Axial Spondyloarthritis Explained

Released July 21, 2026 

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Julie Eller Olson: Hi, everyone, and welcome to the Live Yes! With Arthritis podcast. I'm Julie Eller Olson, and I'm thrilled to be hosting today's episode. Arthritis has been a part of my life for as long as I can remember. I grew up with juvenile arthritis, and it shaped my personal experiences navigating healthcare, and also the career that I've gotten to build advocating for patients. I spent six really awesome years working at the Arthritis Foundation, where my purpose there was to ensure voices of people with living with arthritis were reflected in healthcare and policy decisions. Ultimately, that led me to pursue a master's degree in public health and dedicate my career to advocating for patient-centered health policy. So, I'm really thrilled to be back hosting a few episodes of the podcast and reconnecting with this community that just means so much to me. 

Today we're going to be touching on a 101 on axial spondyloarthritis. Axial spondyloarthritis is also known as axSpA, and it refers to several types of inflammatory arthritis diseases that primarily affect the spine. They can also affect other joints, as well as organs. AxSpA is one of more than a hundred different types of arthritis, which, all told, affect nearly 60 million people in the U.S. Today, we're doing a deep dive on axSpA. We're so glad to have an expert to come back and teach us about this condition, the different types, what causes it, how it affects your joints and other parts of your body, and how to manage it, and more. 

Dr. Philip Mease is the director of rheumatology research at the Providence Swedish Medical Center and clinical professor at the University of Washington School of Medicine. His clinical practice is based in Seattle Rheumatology Associates. He is considered an international key opinion leader, researcher, educator and clinician regarding spondyloarthritis, including psoriatic arthritis (PsA), ankylosing spondylitis and non-radiographic ankylosing spondyloarthritis, as well as rheumatoid arthritis, lupus and fibromyalgia. Dr. Mease is the past president and founding organizer of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. He is a master of the American College of Rheumatology. He's also co-chair of the PsA Task Force of the National Psoriasis Foundation, which in 2019 awarded him a lifetime achievement award for his work in advancing the field of PsA. He's certainly an expert and has had a long career to develop so many relationships with amazing patients. And we're so excited to have your expertise with us again today. Dr. Mease, welcome to the podcast. 

Dr. Philip Mease: Thank you so much, Julie, for having me. 

Julie Eller Olson: Tell us a little bit about yourself and your experiences with axSpA. 

Dr. Philip Mease: I've had a longstanding interest in the field of spondyloarthritis, which is like a big umbrella that includes conditions like psoriatic arthritis; what we're going to talk about today, axial spondyloarthritis; but also other forms of spondyloarthritis that include infection-related, the type of arthritis that's associated with inflammatory bowel disease. And all of these are linked genetically. And by having certain common clinical features and many of the responses to therapies are similar across these different forms of the spondyloarthritis condition. So, I've been researching this area since the late '90s, when I conducted the first investigator-initiated trial with the drug etanercept in the treatment of psoriatic arthritis. And since that time, I've had the honor of being in the role of helping design, and conduct, and then publish, clinical trials in relation to all of these spondy conditions, like PsA and axial spondyloarthritis. 

I've also seen a significant evolution, over that time, in our understanding about the basic biology and immunology of these diseases, and as a consequence of deeper understanding about the immunology, we've now got a bunch of terrific treatments that can potentially put the disease into either a low hum, so that the patient is barely able to be aware that they have the condition, or even in remission in some cases. And so, it's been a really exciting time over the last two-and-a-half decades to be part of the research and education about these conditions. 

Julie Eller Olson: That's absolutely incredible. I love the way you talk about that low hum. If we can't quite get to remission, a low hum feels like a great aspiration, especially when it comes to back pain. Tell me a little bit more about axial spondyloarthritis, or axSpA. Give me the clinical factors that we should know about, especially when it comes to the spondys, as you called them. 

Dr. Philip Mease: Axial spondyloarthritis is, as the name implies, a condition which primarily occurs in the spine. All parts of the spine, from the lumbar spine up to the cervical spine, but also including the joints where the spine meets the pelvis. And these are called the sacroiliac joints. They're kind of like an important telltale for the existence of the disease. If we dial way back to 1984, that's when the first classification criteria for what was then called ankylosing spondylitis was published. And in that classification criteria, a requirement was to have evidence on X-ray of damage to the sacroiliac joints. You could also have other features in the spine, such as these bony bridges called syndesmophytes that ultimately, in the worst-involved patients, would lead to what we call ankylosis of the spine, a gradual ossification and turning into, like, a stick of bamboo. 

Julie Eller Olson: Wow. 

Dr. Philip Mease: And at that time, we thought this was predominantly a male disease. I've seen statistics, even 5:1 male, in those days, but generally 2:1 male versus female. With the advent of MRI technology, so not X-rays, but instead this magnetic resonance imaging technique, which is able to give us a much more granular detail about the involvement of the spine and sacroiliac joints, and it can pick up inflammation. It's a particular characteristic change in the bone, immediately adjacent to the sacroiliac joints, or in the spine. And we were able to tell when lymphocytes had invaded the bone and were having a party inappropriately. (laughter) 

This was occurring in young males certainly, but we were also seeing this in women who did not have evidence on X-ray of damage to the sacroiliac joint. So, we were realizing, "Oh, we're missing a whole segment of the axSpA population." And, indeed, what's happened over the last 15 years or so is that we've become much more sensitive about looking into why a young man or young woman — and when I say, use the word "young," I mean many of these patients are in their 20s, 30s — when they first started having symptoms and signs of the disease. 

And a typical story is that they've been going from their primary care physician to an orthopedist or a physiatrist or a  physical therapist, and they've sort of been bouncing around in the medical arena, with ongoing back pain that can be pretty severe and disabling, and stiffness. And generally, because back pain is common in humans, it was assumed that it was related to degenerative arthritis, or the condition fibromyalgia, and the non-rheumatologists that were seeing the patients weren't tumbling to the possibility that this could be an immunologic inflammation. But once we began to see more of these on MRI scan, even when X-ray changes had not developed, we began to realize, "Oh, we're missing a bunch of patients." The other thing that we've come to realize is that there's a particular gene marker, called HLA-B27, that is present in people with axial spondyloarthritis. This gene marker is present in about 6%, 7% of normal individuals, but there's a significant proportion of these B27-positive individuals who have evidence of spondyloarthritis. 

So, if there are some characteristic clinical features, like a history of uveitis, inflammation of the eye, or  back pain has been really chronic, or there's prominent morning stiffness, then we began to realize, "Oh, this is really significant." So, now, instead of thinking that axSpA occurs in 0.5% of the U.S. population, we now think of it occurring in 1% of the U.S. population, and half of the patients being MRI- or HLA-B27-positive and not X-ray-positive. And we now think of the condition as being equigender between males and females. And it's really opened the door to our ability to diagnose the problem and then get it treated effectively. 

So, what we're going to see is the older phrase, "ankylosing spondylitis," which implied that most people went on to have this ossification of the spine and were mostly males, we've changed the name so that it alludes to the spine and inflammation, as well as an arthritis condition, but it's not quite as severe in terms of some of these changes as we used to think. And I think, in the future, what we'll see is the whole phrase "ankylosing spondylitis" will go away, to be replaced by "axial spondyloarthritis." 

Julie Eller Olson: It's kind of incredible to think about your history, as a clinician, watching the evolution of how you detect something like this. I would imagine, for a lot of patients listening, it's a validating narrative to hear of, "Oh, you know, I've experienced this pain for many, many years. I've been shuttled between provider to provider to provider, and no one's really had an answer for me." But really, clinicians have been learning about what makes this diagnosis significant and all the different features and facets that make it new. And so, we're much more able to identify it today. But I'd imagine there are a good handful of patients who maybe have been dealing with this for a long time, have not had their pain addressed or their spondy addressed, and maybe aren't pursuing an option anymore. What would you say to those folks? And how would you encourage them to find a rheumatologist? 

Dr. Philip Mease: So, I think the first step is becoming educated, becoming more knowledgeable. And so, if you're a patient with a certain amount of agency and have persistent back pain that's not responding to traditional, conservative treatment for back pain, or simple medications, see if you can get referred to your local friendly rheumatologist. And what that rheumatologist will do is do several things. First of all, they'll take a careful history and hear about the nature of the back pain. For example, one key element is that people with axial SpA may be awakened by their back pain, and even have to get up out of the bed and move about. And once they start moving about, then the pain will lessen. So, if you have degenerative arthritis in the spine, that pain tends to get worse with activity, but the axSpA pain tends to get better with activity. 

Another important set of elements is: Is there a family history of a spondyloarthritis? Does the patient have any evidence of inflammatory bowel disease or uveitis, which are important associated conditions that are genetically linked? And then there's some examination that will be done, and some of that may include measurement of movement of the spine, to see how limber the person is or not. Then there's important laboratory blood testing, looking for evidence of the B27 gene marker, looking for elevation of inflammation markers in the blood, like, what's called sedimentation rate, or C-reactive protein, CRP. And then, critically, is imaging. 

And one of the things that we will often do is obtain X-rays of the pelvis to look at the sacroiliac joints. Those are often missed by orthopedists or other clinicians who get lumbar spine films of the lower back, but they don't go lower and look at the sacroiliac joints, which is critically important. And then getting images of the lumbar spine, or cervical spine, if they're symptomatic in those areas. And then moving on from there, especially if the X-rays are normal or nearly normal, or just show degenerative arthritis changes, then it's important to get an MRI scan of the pelvis and of the spine, to look for any evidence of inflammation in those areas. And that's a pretty full workup and can help us cinch in the diagnosis. But sometimes it still takes a little bit of time and effort before you can really see all the evidence for it. 

Notice that I've used the phrase "normal" or "not normal" or "nearly normal" X-ray. In this interim period, where we're moving from just using the single term "axial spondyloarthritis," the regulatory agencies, like the FDA and approval of drugs, are still using two different categories. One is called radiographic axial SpA, or ankylosing spondylitis, and many of the legacy drugs, like the TNF inhibitors, have been approved under that label. But the newer category is non-radiographic axSpA. That means people who have a positive MRI scan, or elevated CRP, and we're seeing some of the newer medicines running clinical trials in both subsets. But in the future, we're going to see these two subsets disappear, and it'll just be an overarching term, "axial spondyloarthritis." 

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Julie Eller Olson: We asked some of our friends from the Arthritis Foundation's Ankylosing Spondylitis Connect Group, which provides online and in-person support for people with axial spondyloarthritis, to share feedback with us. And one of the things that Chari said was that she really wasn't aware of the different facets of, and features of, axial spondyloarthritis. And so, when she was going into her diagnosis, it was harder for her to be aware of what might be ahead and what might be happening there. Tell me a little bit about the genetic patterns and different aspects of who gets axSpA and what causes axial spondyloarthritis. 

Dr. Philip Mease: This occurs in about 1% of the population. Depending upon the form of spondyloarthritis that we're talking about, up to about 80, maybe 85% of individuals will be HLA-B27 gene marker-positive. It turns out there are also some other genes that are part of the underlying genetic picture. And this gene is important, not only as a marker of who might end up getting spondyloarthritis, but it also appears to play a role in the pathogenesis of the disease. And there are a number of ways in which the B27 gene gets involved, including sometimes something we call misfolding within the cell, causing a surface marker to lead to activation of immune cells. And so, ultimately, it's an immunologic disease. We used primarily the word "autoimmune disease," meaning that the self is attacking itself. Your own immune cells are inappropriately targeting cells in various areas, like the sacroiliac (SI) joints and spine, and causing inflammation. 

And then, in the case of the SI joints, erosions are sort of… These eaten out areas of bone, on the one hand, and then the ankylosis process in the spine, where these bony bridges develop between vertebral bodies and cause impairment of spine mobility. There are also global differences in disease expression. In places where B27 is really increased in the population — for example, just north of where I live in Seattle, the Haida Indian population, or Native American population, has elevated frequency of B27, and so they have more spondyloarthritis. In some parts of the world, including in Japan, for example, there's much less. 

Many of the people who develop classic axSpA are in their 20s and 30s, but it can occur later in life as well. In the spondylitis form of psoriatic arthritis, which occurs in about a quarter of psoriatic arthritis patients, it occurs even later in life, so up into their 40s and 50s. It is now considered to be equal between males and females, but the slightly more severe form of it is in males. These are all important variabilities in the presentation of it and its pathogenesis. Ultimately, what we're going to be trying to do in treatment is improve spinal mobility and decrease inflammation, possibly get rid of inflammation, so that the person is not painful or stiff and has normal motion. And so, we're going to bring to bear a number of treatments, including pharmacologic treatments to reduce inflammation, but also physical therapy and exercise modalities to try to improve physical function. 

Julie Eller Olson: Well, it sounds like there's a lot of underlying genetic cellular activity going on, and I understand a lot of that, but tell me a little bit more about some of the less cellular, more physical/mental components of this disease. I can imagine back pain can really impact your entire life, your entire experience of health and wellness and the world. Tell me a little bit more about that. 

Dr. Philip Mease: This is a typically daily experience.  The person doesn't have a break from having inexorably severe back pain and stiffness. And so, that wears on people emotionally. It impacts their ability to work, especially if they are doing a physical job. It impacts their ability to be with their family and enjoy family activities. It has a huge impact. And one of the things that I have imprinted in me forever is that, when I was a young rheumatologist, back in the 1980s, I had incidences where two young male patients committed suicide. It just was a tragedy that I could not forget, and these were the sole breadwinners for their family. They obviously felt like they couldn't keep up with their responsibility to their family and were terribly disappointed in themselves and depressed. 

This was when we didn't have any effective therapies. Now we have effective therapies, and so we should be not only treating the condition to reduce inflammation or reduce symptoms, but also making sure that if a person is depressed, or has suicidal thoughts, that we need to help them reach out to get some help, not only support within their family, or their church, but also reaching out to, say, a psychologist or psychiatrist or social worker. There's also organizations, like the Arthritis Foundation Helpline, where people can call and get support for this sort of thing. 

Julie Eller Olson: I think it's an incredibly stark image when you think about these two young men that you treated and the families that they left behind. It teaches you to think about the whole experience of someone's pain, their whole person, their whole family, their whole community. I think one of the best things that the Arthritis Foundation offers are the Connect Groups, where people who are experiencing these conditions can meet and see others who are experiencing the same thing they are, not just from that sense of, “Oh, we're in it together, but what tools are you using to manage this pain daily?” One of the members of our Connect Group, Carla, she shared in advance of our podcast that she wished she knew how significantly this disease would impact her physical health, her energy, her sleep, her mood, her daily life, and that axSpA is a marathon, it's not a sprint. That there's rarely a quick fix and that finding the right treatment often takes time, and trial and error. 

And just as important as finding the right healthcare team that listens and understands your goals and works with you, it might take time to find the right support, and that that's OK. She shares that the most important thing that she wished she knew was that she wasn't alone, that some of the best advice, encouragement and coping strategies she received was from others who were living with this condition as well, and that connecting with people who understand the condition, through community and support groups, can really help you feel less isolated, more supported and more empowered. So, as you listen, if you find yourself feeling alone, know that there is this army of individuals all around, working really hard to fight this daily battle, and that they are available to you, to be a part of your team, fighting it with you, through these Connect Groups. 

Dr. Philip Mease: Beautifully said. 

Julie Eller Olson: From a personal vantage point, having people to talk to in my patient experience, really does just transform your ability to cope, because all of a sudden you're not in this isolated battle by yourself. You really do have the people fighting it with you, and it makes a huge difference. And we love the Arthritis Foundation for that. 

PROMO: The Arthritis Foundation’s website is packed with helpful information about various types of arthritis and how to manage them. You can find inspiring stories from people living with arthritis every day, as well as opportunities to connect with others through support groups and community events. Get resources on physical activity with arthritis, nutrition tips that support joint health and so much more. Check us out at arthritis.org. 

Julie Eller Olson: Aside from assembling your team of clinicians, and getting your rheumatologist and your psychologist and your different physical therapists, and your imaging technology individuals, imaging technicians, I should say, I guess? What are some things that we should know about in who typically makes the diagnosis themselves? Is it always a rheumatologist? Could it be a primary care doctor? 

Dr. Philip Mease: Oftentimes, it is a rheumatologist who ultimately makes the confirmed diagnosis. We bring to bear knowledge about symptom signs, how to interpret imaging and so forth. But a knowledgeable and experienced primary care physician can certainly make the diagnosis, potentially. We work a lot with what are called physiatrists. These are rehabilitation specialists that are trained in musculoskeletal medicine. They don't necessarily do surgeries, like orthopedists, but they are very attuned to this, and they often are present in pain clinics, or what are called spine clinics. Orthopedists certainly may well know about this condition and can make the diagnosis. And some very knowledgeable and experienced physical therapists can at least be suspicious and get the patient to us, a rheumatologist. 

There's a bunch of people that have what we end up calling peripheral spondyloarthritis. And those are people that have a few joints, say, in their hands or knees or ankles that are involved. Importantly, they could have tendon inflammation, right? Where the tendons insert into bone, like at the Achilles tendon insertion, or the plantar fascia insertion. This is a phenomenon we call enthesitis. And we see some individuals with peripheral spondyloarthritis as the predominant manifestation. They may or may not be B27-positive. 

Oftentimes, they've had a history of some kind of infection, like they've been traveling in Mexico and gotten a Teresa Salmonella or Shigella infection, and that sometimes triggers what is predominantly a peripheral spondyloarthritis  picture. And then, also, people with what's called inflammatory bowel disease (IBD), Crohn's or ulcerative colitis may have a musculoskeletal inflammation condition, and that often has a peripheral spondy characteristic, maybe sometimes with back pain. This is more nuanced and, in many ways, harder to suss out, but I think we, as rheumatologists, can be savvy to this. And what we're now learning, even though there isn't a formal FDA-approved pathway for drugs for peripheral spondyloarthritis, if the patient has some back pain, or if the patient has another condition like IBD or uveitis, then we can often gain access to our advanced immune-moderating drugs to treat these people as well. This is a field that is still unfolding in front of us. We don't have all the answers, and we're developing new approaches to diagnosing as well as treating. 

Julie Eller Olson: Rheumatologists really are detectives, and they're looking at the full picture and trying to think about, "Well, did you take that trip to Mexico, and did you have an infection, and are there these underlying features of inflammation that might be influencing your condition?" It speaks to the value of getting matched with a good rheumatologist as soon as you have some kind of pain that might fall under the umbrella of arthritis, even if you don't have the idea that it could be an ankylosing spondylitis, or maybe you don't have the language to describe that it's axSpA. You might be able to find someone who can really help you define what your experience is and find those treatment options that maybe can get you to that low hum of disease activity that you mentioned before. Can you talk a little bit more about those treatment options and just kind of hone in on the hope of what might come when you do get paired with the right treatment? 

Dr. Philip Mease: I want to start talking about treatment with non-pharmacologic treatment. So, it turns out that physical therapy is really important for maintaining mobility, maintaining muscle strength, because there tends to be atrophy of muscles adjacent to inflamed areas. The PT that you've got on your team is really important. Another area that people might not even think about: I have one patient who has a completely ankylosed spine, and he works with his car mechanic people and car service people to trick out his car with all kinds of mirrors all over the place. He can't turn his head because he's completely frozen. So, he gets in the car and can look like this at all the mirrors and see in all directions. 

Julie Eller Olson: Wow. 

Dr. Philip Mease: I've driven in his car before. (laughter) It happens to be a fancy BMW. (laughter) And then I've already mentioned that psychological therapy, acupuncturist, that sort of thing, can be helpful. If we turn to pharmacologic treatment, there are just wonderful medications that are available to us. And when I say wonderful, I mean they're highly effective. They're costly, unfortunately, so you need insurance for the most part, to be able to afford them, but these are the medicines that we call biologics. The first ones to be developed for axSpA were the so-called TNF inhibitors, and there are five of those. Examples include adalimumab or etanercept. The other biologics that have been subsequently developed include interleukin-17 inhibitors, both interleukin-17 as well as interleukin-17A and F inhibitors. And there are several of these that are still coming along in the pipeline. There's one, for example, that's coming along that's really long-acting, so you only have to take it about once every six months as an injection. And then others that are pills that can be effective. 

At the very beginning stages of the disease, many patients will try nonsteroidal anti-inflammatory drugs. Two of these are over-the-counter ibuprofen and Aleve, but there are also non-steroidal anti-inflammatory drugs that are prescribed, that can be effective, and these can help not only with pain, but, to a certain extent, with inflammation. We're also looking into the future with new drug mechanisms being tested. TL1A inhibitors would be an example of that, and then even more into the future, the possibility of using what is called cell therapy, where we may use the patient's own cells, to be genetically-engineered to become therapeutic cells within the body, or other approaches to getting rid of certain T lymphocytes that are pathogenic in the disease. So, the future is wide open with newer treatments coming along. It's a good time to be working with your rheumatologist to see what can be effective. Keeping in mind that there can be safety issues, infection, other problems that can arise, but these are ones that we have come to learn and handle quite well in our clinics. 

Julie Eller Olson: I think what I'm hearing is there's a pretty robust toolkit of pharmacologic and non-pharmacologic things that folks who are experiencing this condition really have at their fingertips, especially when they're working with a rheumatologist. So often with back pain, it feels like, "Oh, I'm getting older. My back just hurts. I can deal with it." Maybe you aren't thinking about that toolkit as much. And so, I think it really unlocks something for you when you can work with a rheumatologist who can share these options and help access things that are really potentially curative, or at least get you to that low hum, as you had shared before. I think that's really incredible, and it's not often that you get a story of hope when it comes to chronic pain. 

PROMO: The Arthritis Foundation offers essential resources for newly diagnosed patients, including educational materials to help them better understand their condition. We offer support groups and online communities for patients to connect with others facing similar challenges. Additionally, we can refer you to health care professionals for guidance on treatment options and lifestyle adjustments. Learn more at arthritis.org/newly-diagnosed. 

Julie Eller Olson: When you're hearing this podcast, I hope you're hearing overwhelming hope for the future. Are there other things that you think our listeners should take away, Dr. Mease? What are your top three takeaways for anybody who's listening and thinking about their axSpA? 

Dr. Philip Mease: First, education. Spreading the word, both to patients who might have the condition, but also clinicians, non-rheumatologists, who are every day in their practices encountering people with back pain, and then need to include, as part of their differential diagnosis, the possibility that this treatable autoimmune disease is something that might be present. The more that people around the globe know about the possibility of axial spondyloarthritis in their patient with back pain, the better. 

The second thing is to make sure that the full evaluation is done. So, the blood testing that I spoke about, the careful history and physical, and then, importantly, getting the proper imaging, including MRI scanning. And then, the third take-home message is: This is a highly treatable condition. We now have great medications to get at the inflammation, reduce pain, reduce stiffness, non-narcotic, analgesic medications, as well as physical therapy approaches and getting into physical exercise to treat this. Many different tools can be brought to bear. 

Julie Eller Olson: I just so enjoy talking to you, Dr. Mease, and thinking about the career that you've had and how much you've seen progress in arthritis care, from the days where there really were no options in your toolkit to today, where you're looking around and thinking, "Wow, we're right on the cusp of some incredible curative treatments right around the corner." And as I've come away from this conversation, I'm thinking about access to care, really pursuing and advocating for your care. I think it can be hard, sometimes, in those early diagnostic steps to remember, "All right, I have to get the blood work, I have to get the MRI, I have to have the full history, and I have to have a rheumatologist who's encouraging me to do all three of those things." 

That can be a real challenge, but I hope that this empowers people to say, "All right, I can write my own ticket if I can really say, these are the things that I need in a doctor's office. I can call my insurance company if they're giving me any grief and encourage them to help me gain access to this kind of care," and making sure that you can pursue those things is really important. We talked about how important physical therapists are in this conversation. Physical therapists have fundamentally changed my life. Oftentimes, insurance companies will only cover a certain amount of visits per year, and that can deter people from pursuing physical therapy care. 

But what I would encourage everybody who's listening to do is go and be a student at your physical therapist's office, because they will prepare you with the exercises and materials to take home with you, so that you can practice those exercises at home and do them unassisted. Sometimes, it feels really intimidating to start, but you can go and make the most of those handful of visits that you can get approved for and really benefit from them, whether you're in person, in the office or empowered at your own home. Dr. Mease, thank you so much for sharing your expertise with us. 

Dr. Philip Mease: Always a pleasure to be with you, Julie. 

Julie Eller Olson: Thank you. For more arthritis resources, including information about axial spondyloarthritis, please visit the Arthritis Foundation's website at arthritis.org, and send your questions, comments and thoughts to [email protected]. We'll see you next time. 

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