1 · SNAPSHOT
Who: Onset typically under forty. Often described as male-predominant — read the warning below before you use that.
What: Axial spondyloarthritis — covering radiographic axSpA (what "ankylosing spondylitis" described) and non-radiographic axSpA.
How it behaves: Gradual spinal stiffness and pain over three months. Worse in the morning or after rest; eased by movement. Alternating buttock or posterior thigh pain. May report fatigue or systemic symptoms — eye, bowel, skin.
The one thing to take from this page:
The pattern is reversed. Mechanical back pain is worse with activity and better with rest; this is worse with rest and better with movement. That single question is what shortens a delay measured in years — and physiotherapists ask it before rheumatologists get the chance.
The reverse pattern
| Mechanical back pain | Inflammatory back pain | |
|---|---|---|
| Activity | Worse | Better |
| Rest | Better | Worse |
| Morning | Variable | Stiff, and it takes time to ease |
| Night | Position-related | Second half of the night, gets them up |
| Duration | Any | >3 months |
| Age at onset | Any | Usually <40 |
⚠️ Two warnings. "Male predominance" is a historical description, not a screening rule — diagnostic delay has been examined for sex bias. And the ASAS criteria are classification criteria for research cohorts, not diagnostic criteria.
2 · SE — THE SUBJECTIVE PATTERN (the 70%)
Five stages, in your course's order. The subjective is the whole diagnosis here — and it is a set of questions, not a feeling.
MAIN PROBLEM
"My back's stiff every morning and it takes an hour to loosen."
"It wakes me in the early hours."
"It's better once I get moving."
BODY CHART
- Axial — lumbar, thoracic, cervical, and the buttocks.
- Alternating buttock pain is characteristic. Ask specifically whether it swaps sides.
- Mark the heels and the soles. Enthesitis at the Achilles and plantar fascia is part of the picture.
- Peripheral joints? Ask.
BEHAVIOUR — this is the diagnosis
| Inflammatory | Mechanical | |
|---|---|---|
| Duration | >3 months | Any |
| Age at onset | Usually <40 | Any |
| Onset | Insidious | Often an event |
| Morning stiffness | Prolonged, and it eases with movement | Brief or absent |
| Rest | Worse | Better |
| Exercise | Better | Often worse |
| Night pain | Second half of the night, gets them up | Position-related |
Read further: criteria for inflammatory back pain [1]. Learn the features, ask them all, and don't quote a score — no accuracy figure is verified here.
HISTORY — the systemic screen
- Eyes: any painful red eye, blurred vision, light sensitivity? Uveitis.
- Bowel: any diarrhoea, blood, unexplained weight loss? Inflammatory bowel disease.
- Skin and nails: psoriasis anywhere, including scalp, natal cleft, nails?
- Family history of any of the above, or of spondyloarthritis.
- Any heel pain, plantar heel pain, or swollen digit?
- Response to non-steroidal anti-inflammatories — good response is part of the picture.
- Fatigue. Ask about it properly; it is often the worst symptom.
SPECIAL / SCREENING QUESTIONS
- Any fever, night sweats, weight loss?
- Any progressive neurological symptoms?
- Have they already been told it's mechanical, and for how long?
Assessing this region? Download the Thoracic Spine assessment template →
3 · HYPOTHESIS RANKING
| Competing pattern | The one discriminating feature |
|---|---|
| Mechanical low back pain | Worse with activity, better with rest. The reverse. |
| Non-specific thoracic pain | No morning stiffness pattern, no systemic features, no alternating buttock pain. |
| SIJ dysfunction | Provocation-test positive without the inflammatory time pattern or the systemic features. |
| MRI mimics of sacroiliitis | Inflammatory-back-pain-like symptoms and MRI changes occur in anatomical variants and other conditions [2]. |
| Fibromyalgia and widespread pain | Widespread, non-axial-dominant, without the systemic or enthesial features. |
The one that outranks the table
Malignancy. A published case describes inflammatory back pain and psoriasis where the expected diagnosis was spondyloarthritis and the finding was lymphoma [3]. Night pain, weight loss, fever and systemic illness still get screened even when the pattern looks inflammatory.
And the current terminology
The current term is axial spondyloarthritis, covering radiographic axSpA — which is what "ankylosing spondylitis" described — and non-radiographic axSpA, which has its own current literature [4]. A normal radiograph does not exclude the condition, and that is the single most practical consequence of the change.
4 · RED FLAGS — DON'T MISS THIS
This section is free, on every pattern, forever. Safety is never gated. This whole page is.
| Finding | What it suggests | What you do |
|---|---|---|
| Inflammatory pattern being treated as mechanical for months | Axial spondyloarthritis | Refer to rheumatology. This is the flag |
| Painful red eye, blurred vision, photophobia | Acute anterior uveitis | Same-day ophthalmology |
| Diarrhoea with blood, or unexplained weight loss | Inflammatory bowel disease | Medical review |
| Fever, night sweats, weight loss | Infection, malignancy | Urgent medical review |
| Night pain that does not fit the inflammatory pattern | Malignancy | Medical review |
| Progressive neurological deficit | Cord or root compromise | Urgent medical review |
| New severe spinal pain after minor trauma in established disease | Fracture through an ankylosed spine | EMERGENCY — immobilise, image. Include the neck: cervical was the commonest site (53.0%), and 13.1% broke in more than 1 region (Lukasiewicz et al. 2016) [21] |
| Cardiorespiratory symptoms | Extra-articular involvement | Medical review |
The rule: the inflammatory pattern itself is the flag. A young adult with three months of morning-stiff, movement-relieved back pain who has been managed as mechanical belongs in a rheumatology letter today.
Cross-links: Non-specific low back pain · SIJ dysfunction · Achilles tendinopathy · Plantar fasciopathy
5 · OE — THE OBJECTIVE (the 30%)
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Sections 5 to 7 are for members
The objective exam, management and pearls, plus the six-minute lesson and the debrief. Free with an account.
Sign in or join free6 · MX — MANAGEMENT ESSENTIALS
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The objective exam, management and pearls, plus the six-minute lesson and the debrief. Free with an account.
Sign in or join free7 · CLINICAL PEARLS + RETRIEVAL CHECK
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Sections 5 to 7 are for members
The objective exam, management and pearls, plus the six-minute lesson and the debrief. Free with an account.
Sign in or join freeMembers
The 4-minute lesson is for members
Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.
Sign in or join freeGuideline anchor
No Australian guideline for physiotherapy management. The one Australian guideline, the ARA/ANZMUSC Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis, covers axial SpA but only drug treatment, for prescribers.
More
Anchored to the ASAS-EULAR recommendations for the management of axial spondyloarthritis, 2022 update (Ramiro et al. 2023, PMID 36270658) — a genuine international guideline, which is unusual for these patterns — with the systematic literature review of non-pharmacological and non-biological interventions that informed them (Ortolan et al. 2023, PMID 36261247). Diagnostic framing from the ASAS classification criteria (Rudwaleit et al. 2009, PMID 19297344) and the inflammatory back pain criteria (Sieper et al. 2009, PMID 19147614).
The ASAS-EULAR recommendations are a real management guideline and are cited as such. They are not Australian. Note also that the ASAS criteria are classification criteria for research cohorts — they are not diagnostic criteria and should not be applied as though they were.
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The evidence summary is for members
Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.
Sign in or join freeSources · 20
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Every source on this page resolves and title-verifies against PubMed. Newest first.
- 2009Sieper et al. (2009). New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis international Society (ASAS). Annals of the rheumatic diseases, 68(6), 784-8. https://doi.org/10.1136/ard.2008.101501
- 2026Avcu et al. (2026). Inflammatory back pain-like symptoms and MRI mimics of sacroiliitis in patients with anatomical variants of the sacroiliac joint: a cross-sectional study. Rheumatology international, 46(6). https://doi.org/10.1007/s00296-026-06121-4
- 2024Ullrich et al. (2024). Inflammatory Back Pain and Psoriasis: Expecting Spondyloarthritis, Discovering Lymphoma. Cureus, 16(6), e61593. https://doi.org/10.7759/cureus.61593
- 2026Alexandrov et al. (2026). Non-Radiographic Axial Spondyloarthritis. International journal of rheumatic diseases, 29(4), e70637. https://doi.org/10.1111/1756-185x.70637
- 2009Rudwaleit et al. (2009). The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Annals of the rheumatic diseases, 68(6), 777-83. https://doi.org/10.1136/ard.2009.108233
- 2024Radny et al. (2024). Learning imaging in axial spondyloarthritis: more than just a matter of experience. RMD open, 10(1). https://doi.org/10.1136/rmdopen-2023-003944
- 2024Zimba et al. (2024). Diagnosis, monitoring, and management of axial spondyloarthritis. Rheumatology international, 44(8), 1395-1407. https://doi.org/10.1007/s00296-024-05615-3
- 2025Demeter et al. (2025). Diagnosis and management of axial spondyloarthritis. JAAPA : official journal of the American Academy of Physician Assistants, 38(11), 22-28. https://doi.org/10.1097/01.JAA.0000000000000263
- 2023Ramiro et al. (2023). ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Annals of the rheumatic diseases, 82(1), 19-34. https://doi.org/10.1136/ard-2022-223296
- 2023Ortolan et al. (2023). Efficacy and safety of non-pharmacological and non-biological interventions: a systematic literature review informing the 2022 update of the ASAS/EULAR recommendations for the management of axial spondyloarthritis. Annals of the rheumatic diseases, 82(1), 142-152. https://doi.org/10.1136/ard-2022-223297
- 2025Zhang et al. (2025). Effects of Exercise Therapy in Axial Spondyloarthritis: A Systematic Review, Meta-analysis, and Meta-regression of Randomized Trials. Archives of physical medicine and rehabilitation, 106(1), 113-123. https://doi.org/10.1016/j.apmr.2024.06.005
- 2024Wang et al. (2024). Efficacy and safety of mind-body exercise for patients with axial spondyloarthritis: a systematic review and meta-analysis. Journal of orthopaedic surgery and research, 19(1), 586. https://doi.org/10.1186/s13018-024-05072-5
- 2025Ertem (2025). Ankylosing spondylitis and kinesiophobia. PeerJ, 13, e19034. https://doi.org/10.7717/peerj.19034
- 2026Somer et al. (2026). Sexual function in axial spondyloarthritis: a systematic review and meta-analysis. Rheumatology (Oxford, England), 65(2). https://doi.org/10.1093/rheumatology/keaf578
- 2025Williams et al. (2025). The comparative prevalence of comorbidities across rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis. Rheumatology advances in practice, 9(4), rkaf121. https://doi.org/10.1093/rap/rkaf121
- 2025Poddubnyy & Baraliakos (2025). Understanding the causes of treatment failure is crucial for the management of axial spondyloarthritis. Nature reviews. Rheumatology, 21(6), 309-311. https://doi.org/10.1038/s41584-025-01254-5
- 2021Zhao et al. (2021). Diagnostic delay in axial spondyloarthritis: a systematic review and meta-analysis. Rheumatology (Oxford, England), 60(4), 1620-1628. https://doi.org/10.1093/rheumatology/keaa807
- 2024Bandinelli et al. (2024). Sex Bias in Diagnostic Delay: Are Axial Spondyloarthritis and Ankylosing Spondylitis Still Phantom Diseases in Women? A Systematic Review and Meta-Analysis. Journal of personalized medicine, 14(1). https://doi.org/10.3390/jpm14010091
- 2025Bittar & Deodhar (2025). Axial Spondyloarthritis: A Review. JAMA, 333(5), 408-420. https://doi.org/10.1001/jama.2024.20917
- 2025Navarro-Compán et al. (2025). Axial spondyloarthritis. Lancet (London, England), 405(10473), 159-172. https://doi.org/10.1016/S0140-6736(24)02263-3
Mapped to this pattern
- BASDAI
Bath Ankylosing Spondylitis Disease Activity Index
ankylosing spondylitis disease activity · 6 items · 3 min
- BASFI
Bath Ankylosing Spondylitis Functional Index
ankylosing spondylitis function · 10 items · 3 min
- ASDAS
Ankylosing Spondylitis Disease Activity Score
composite AS disease activity · 5 items · 3 min
- BASMI
Bath Ankylosing Spondylitis Metrology Index
spinal mobility in axial SpA · 5 items · 10 min
- HAQ-DI
Health Assessment Questionnaire Disability Index
functional disability in arthritis · 20 items · 5 min
- Schober
Schober Test
lumbar flexion range · 2 min
Generic measures that also apply
- Borg RPE
Borg Rating of Perceived Exertion Scale (6-20)
perceived exertion · 1 items · 1 min
- GROC
Global Rating of Change Scale
perceived change since baseline · 1 items · 1 min
- NPRS
Numeric Pain Rating Scale
pain intensity · 1 items · 1 min
- PGIC
Patient Global Impression of Change
perceived change since baseline · 1 items · 1 min
- PSFS
Patient-Specific Functional Scale
patient-generated function · 3 items · 2 min
- SANE
Single Assessment Numeric Evaluation
patient-rated function as a percentage of normal · 1 items · 1 min
- VAS
Visual Analogue Scale
pain intensity · 1 items · 1 min
- Borg CR10
Borg Category Ratio 10 Scale
perceived exertion or symptom intensity, ratio scale · 1 items · 1 min
- GAS
Goal Attainment Scaling
individualised goal achievement · 10 min
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