Ankylosing Spondylitis & Nonradiographic Axial Spondyloarthritis

Axial spondyloarthritis (axSpA) mostly affects the spine. It can cause damage visible on X-ray (ankylosing spondylitis) or damage that doesn’t show up on X-rays (nonradiographic axSpA).

Axial spondyloarthritis (axSpA) is a form of arthritis that mostly causes pain and swelling in the spine and the joints that connect the bottom of the spine to the pelvis (sacroiliac joint). Other joints can be affected as well. It is a systemic disease, which means it may affect other body parts and organs. AxSpA tends to run in families. 
There are two types of axSpA:

  • Ankylosing spondylitis, or AS, also known as radiographic axSpA, because the damage it can cause to the sacroiliac joints and spine can be seen on X-rays.
  • Nonradiographic axSpA (nr-axSpA) causes damage that may not be visible in X-rays but it may show up on magnetic resonance images (MRIs).

The disease can occur at any age, but typically begins between ages 20 and 40. AS is more common in men than in women. However, nr-axSpA may be just as common in women as in men. It is less common among African Americans than people of other racial backgrounds.    



The exact cause of axSpA is not clear. Researchers believe that people with certain genes develop axSpA when they are exposed to a virus, bacteria or another trigger. Many people with axSpA have a gene called HLA-B27. But most people that have the gene never develop axSpA.  


Low back, buttocks and hip pain are usually the first symptoms. Children, however, may have pain in the hips, knees or heels before the back. 

Symptoms of axSpA include:

  • Pain in the low back, buttocks and hips that develops slowly over weeks or months.
  • Pain, swelling, redness and warmth in the toes, heels, ankles, knees, rib cage, upper spine, shoulders and neck. 
  • Stiffness when first waking up or after long periods of rest.
  • Back pain during the night or early morning. 
  • Fatigue.
  • Appetite loss. 

Health Effects

Joints. Over time, the joints and bones of the spine may grow together (fuse). This usually happens at the base of the spine first. This causes the back to become stiff and hard to move. The rib cage may also fuse, making chest expansion difficult. 

Eyes. Chronic eye inflammation (uveitis) causes dryness, pain, redness, sensitivity to light and vision problems. The white part of the eye may also get inflamed and red (called scleritis).

Digestive Tract. Inflammation may cause abdominal pain and diarrhea.

Heart. Though uncommon, inflammation may affect the largest artery that leads to the heart (aorta). People with axSpA also have an increased risk for heart attack and stroke.
Lungs. Complications affecting the lungs are rare. Inflammation may cause shortness of breath and impaired lung function


It’s important to see a doctor early to get an accurate diagnosis. A primary care doctor may be the first person to assess your joint pain. A doctor that specializes in arthritis (a rheumatologist) should be seen if axSpA is suspected. 
There is no single test to diagnose axSpA. The doctor will talk with you, perform a physical exam and order a few tests to rule out other causes of back and hip pain.  

  • Medical history. The doctor will ask about symptoms, when they started, if they come and go, current medical conditions, medication use and whether family members have arthritis.
  • Physical examination. The doctor will look for signs of tenderness, swelling and pain in your spine, pelvis and hips. They will watch how your joints move and may check your eyes. 
  • Blood tests. The doctor may order a test for the HLA-B27 gene. Having this gene doesn’t mean you have axSpA, but it can help with diagnosis. Other tests will check for body-wide inflammation. 
  • Imaging tests. The doctor may order X-rays, ultrasound, MRI or CT scans of the pelvis and spine to look for damage.  


There is no cure for axSpA, but treatment aims to:

  • Relieve pain and stiffness in the back and affected areas.
  • Keep your spine straight.
  • Prevent joint and organ damage.
  • Preserve joint function and mobility.
  • Improve quality of life.

Early, aggressive treatment is the key to preventing long-term complications and joint damage. A well-rounded treatment plan includes medication, nondrug therapies, healthy lifestyle habits and rarely, surgery. 


  • Nonsteroidal anti-inflammatory drugs. NSAIDs are the most commonly used drugs to treat axSpA and help relieve pain. They include over-the-counter drugs, such as ibuprofen (Advil) and naproxen (Aleve), as well as the prescription drugs indomethacin, diclofenac or celecoxib.
  • Analgesics. In addition to NSAIDs, the doctor may recommend acetaminophen (Tylenol) for pain relief.
  • Disease-modifying antirheumatic drugs (DMARDs). Conventional DMARDs are not usually used in people with axSpA that effects just the back. Sulfasalazine, however, may be used for joints other than those in the back and pelvis.
  • Biologics. A type of DMARD, biologics target certain proteins and processes in the body to control disease. Biologics are self-injected or given by infusion at a doctor’s office. The ones that work best for axSpA are tumor necrosis factor (TNF) inhibitors and interleukin (IL-17) inhibitors.
  • Corticosteroids. These powerful drugs are not often used for spinal disease in axSpA. However, injecting steroids into a knee or shoulder can provide quick relief.

Regular physical activity is a critical part of managing axSpA. It helps prevent stiffness and preserves range of motion in the neck and back. Walking, swimming, yoga and tai chi can help with flexibility and posture. It’s also important to strengthen your core and legs. Talk to a physical therapist to put together a total exercise plan.  

Physical Therapy and Assistive Devices
A physical therapist  will teach you to strengthen and stretch your muscles to help keep you mobile and reduce your pain. Occupational therapists can prescribe assistive devices and give tips for protecting joints and making daily tasks easier.

Most people with axSpA will never need surgery. But joint replacement can help people with severe pain or joint damage. Surgery may also help straighten a severely bent forward spine.

Self Care

Eat a healthy diet. There’s no special diet for axSpA. But, eating anti-inflammatory foods, like the ones found in the Mediterranean diet may help. Eat plenty of fatty fish, fruits, vegetables, whole grains and extra virgin olive oil. Limit red meat, sugar, and processed foods.

Avoid smoking. Smoking worsens overall health, and it can speed up disease activity and joint damage. It can also make it harder to breathe. Talk to your doctor about ways to help you quit. 

Practice good posture. Good posture can help ease pain and stiffness. Adjust the height of the computer monitor or desk so the screen is at eye level. Plant your feet firmly on the ground. Avoid staying in cramped or bent positions. Alternate between standing and sitting, and use a cushion to support your back. Be careful of “texting neck” when cellphone use is constant.

Stretch. Stretching exercises, especially after a warm bath or shower, can help ease pain and relieve stiffness.

Pace yourself.  On tough days, pace your activities and take short breaks throughout the day to manage fatigue.   


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