Axial Spondyloarthritis
Not All Back Pain Has Musculoskeletal Origins: Axial Spondyloarthritis (AxSpA)
Not All Back Pain Has Musculoskeletal Origins: Axial Spondyloarthritis (AxSpA)
Back pain is incredibly common. In primary healthcare and chiropractic practices, back pain is one of the most common reasons patients present — in both GP surgeries and clinics like ours. For most, the cause is purely musculoskeletal (MSK) such as muscle strains, lumbar facet joint irritation, or mechanical overload.
However, back pain occasionally follows a distinct pattern — one that suggests an underlying systemic condition rather than a simple mechanical injury. In these instances, clinical care extends beyond short-term symptom relief. Chiropractors are equipped to obtain a comprehensive clinical history, evaluate spinal movement, screen for non-mechanical red flags, and ensure timely referral for specialist medical evaluation.
At Right Track Chiropractic, we take a full clinical history with every new patient — partly because conditions like AxSpA are exactly why a thorough case history matters. Knowing how your pain behaves, when it started, and what makes it better or worse tells us far more than any quick assessment ever could.
One key condition to screen for when back pain displays an inflammatory pattern is Axial Spondyloarthritis (AxSpA) — a chronic, immune-mediated inflammatory arthritis that predominantly targets the sacroiliac (SI) joints and the spine.
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Why AxSpA Is Frequently Missed (and Why Screening Matters)
Axial Spondyloarthritis can be challenging to identify early because its initial presentation often mimics common "wear and tear" or mechanical back strains.
A major healthcare challenge is the significant diagnostic delay associated with AxSpA - patients globally experience an average delay of several years before receiving a definitive diagnosis. During this interval, management often focuses solely on symptomatic relief using over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) or physical modalities without addressing the underlying driver.
Early identification in primary care settings is essential. Timely referral to a rheumatologist allows for earlier intervention, minimizing chronic pain and preserving long-term mobility and quality of life. First-contact clinicians play a vital screening role by evaluating symptom behavior over time, identifying inflammatory red flags, and advising patients when medical imaging and specialist investigation are warranted. Patient advocacy organizations, such as the National Axial Spondyloarthritis Society (NASS), actively champion early referral pathways to shorten this diagnostic delay.
Recognising the Inflammatory Back Pain Pattern
Unlike mechanical back pain, which typically worsens with physical exertion and improves with rest, AxSpA exhibits a classic inflammatory back pain pattern
Age of Onset: Symptoms typically begin gradually in early adulthood (onset under 45 years of age).
Insidious Onset: Symptoms develop gradually over weeks or months rather than following an acute trauma.
Morning Stiffness: Prominent stiffness lasting longer than 30 minutes upon waking.
Aggravated by Rest, Relieved by Exercise: Discomfort worsens during prolonged inactivity or rest (often waking the patient during the second half of the night) and improves markedly with physical movement.
Reduced Spinal Mobility: A progressive reduction in range of motion across the lumbar or thoracic spine over time.
While the presence of these features does not guarantee an AxSpA diagnosis, they serve as clinical indicators that warrant further investigation.
Beyond the Spine: Extra Musculoskeletal Manifestations
AxSpA is a systemic inflammatory condition, meaning its clinical manifestations often extend beyond the lower back and sacroiliac joints:
Enthesitis: Inflammation at bone-tendon attachment sites, most commonly presenting as plantar fasciitis or Achilles tendinopathy.
Peripheral Joint Involvement: Swelling or pain in larger peripheral joints such as hips, knees, or shoulders.
Associated Inflammatory Conditions: Co-occurrence with Inflammatory Bowel Disease (Crohn’s disease or Ulcerative Colitis), psoriasis, or anterior uveitis (eye inflammation).
Evaluating these associated features helps paint a complete clinical picture when screening for spondyloarthritis.
How Primary Care Clinicians Assess and Refer
While Chiropractors do not make a definitive medical diagnosis of AxSpA, clinical screening involves:
Detailed clinical history taking focused on symptom behavior over time.
Targeted physical examination evaluating spinal and chest expansion mobility.
Use of validated inflammatory back pain screening tools.
When an inflammatory presentation is suspected, patients are directed to their general practitioner or directly referred to a rheumatologist for definitive diagnostic workup.
How Axial Spondyloarthritis Is Diagnosed
A formal medical diagnosis requires a synthesis of clinical evaluation, specialized imaging, and laboratory findings:
Magnetic Resonance Imaging (MRI): Highly sensitive for detecting active bone marrow edema and sacroiliac inflammation prior to structural changes becoming visible on conventional X-rays.
Blood Biomarkers: Evaluation of genetic markers (such as HLA-B27) alongside systemic inflammatory markers like C-reactive protein (CRP).
Evidence-Based Management Options
International management guidelines recommend a dual strategy combining pharmacological control and structured physical activity:
First-Line Pharmacotherapy: Non-steroidal anti-inflammatory drugs (NSAIDs) prescribed at the lowest effective dose are recommended as initial first-line medication for active symptomatic AxSpA. For non-responders, advanced medication may be prescribed by a rheumatologist.
Structured Exercise and Rehabilitation: Daily physical exercise and targeted spinal mobility programs are core components of non-pharmacological management to maintain spinal flexibility, posture, and physical function over the long term (Ramiro et al., 2023).
A Collaborative Approach to Back Health
Differentiating mechanical back pain from inflammatory conditions like Axial Spondyloarthritis highlights the vital role of thorough clinical screening in primary care. By recognizing these subtle patterns early, chiropractors and primary care practitioners can work alongside general practitioners and rheumatologists to shorten diagnostic delays.
Early detection opens the door to effective, targeted management - ensuring patients receive the exact combination of medical care and structured movement they need to thrive.
Experiencing back pain that fits this pattern?
If your back pain is worse in the mornings, eases with movement, and has been going on for months without a clear cause, it is worth getting a proper assessment. At Right Track Chiropractic in Paddington, we take a full history with every new patient, screen for inflammatory patterns, and refer on if needed.
You will always get an honest answer.
References
Garrido-Cumbrera, M., Navarro-Compán, V., Bundy, C., Mahapatra, R., Makri, S., Correa-Fernández, J., Christen, L., Delgado-Domínguez, C. J., & Poddubnyy, D. (2021). Identifying parameters associated with delayed diagnosis in axial spondyloarthritis: data from the European map of axial spondyloarthritis. Rheumatology, 61(2), 705–712. https://doi.org/10.1093/rheumatology/keab369
Ramiro, S., Nikiphorou, E., Sepriano, A., Ortolan, A., Webers, C., Baraliakos, X., Landewé, R. B. M., Van den Bosch, F. E., Boteva, B., Bremander, A., Carron, P., Ciurea, A., van Gaalen, F. A., Géher, P., Gensler, L., Hermann, J., de Hooge, M., Husakova, M., Kiltz, U., … Nissen, M. J. (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
Rudwaleit, M., van der Heijde, D., Landewé, R., Listing, J., Akkoc, N., Brandt, J., Braun, J., Chou, C. T., Collantes-Estevez, E., Dougados, M., Huang, F., Gu, J., Khan, M. A., Kirazli, Y., Maksymowych, W. P., Mielants, H., Sørensen, I. J., Ozgocmen, S., Roussou, E., … Sieper, J. (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), 777–783. https://doi.org/10.1136/ard.2009.108233
Sieper, J., & Poddubnyy, D. (2017). Axial spondyloarthritis. The Lancet, 390(10089), 73–84. https://doi.org/10.1016/S0140-6736(16)31591-4
