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Axial Spondyloarthritis: Are women being overlooked?

Axial spondyloarthritis back pain

Axial Spondyloarthritis is inflammatory arthritis mainly affecting the back. It is an umbrella term which covers Ankylosing spondylitis (changes in the spine and/or pelvis can be seen on X-ray) and Non-Radiographic Axial Spondyloarthritis (where x-ray changes are not visible but signs of inflammation are picked up on MRI or you have symptoms of Axial SpA). Axial spondyloarthritis forms approximately 0.5-3% of cases of low back pain. It is a painful condition that slowly progresses. Even though it mainly affects the spine and pelvis, it can affect other areas of the body such as:

  • Joints in the body such as the hands and feet (especially in women),

  • The eyes (uveitis), causing redness, soreness and light sensitivity (photophobia)

  • The bowel (such as Irritable Bowel Disease, IBD, Chrohn's disease and Ulcerative Colitis),

  • Tendons or ligaments where they attach to the bone (enthesopathy) for example, the achilles tendon as it attaches to the heel.

As healing occurs, bone replaces soft tissues such as ligaments, forming bony spurs which can cause pain and restricted movement. Eventually this process of ossification can cause joints to fuse together; in the spine, this causes the classic hunch back posture (forward flexion) in ankylosing spondylitis referred to as bamboo spine on x-rays.

Inflammatory Back Pain

Mechanical Back Pain

Slow, gradual onset and present for more than 3 months

Can be acute or chronic

More than 30 minutes of stiffness in the morning

Often gets worse throughout the day

Worse with rest, pain at night (especially second half), improves with movement and exercise

Worse with activity or exercise, improves with rest

Age younger than 40

Affects any age

Can be accompanied with other areas of inflammation systemically, such as eyes, bowel, tendons & ligaments

Only affects a localised area

Axial spondyloarthritis can be diagnosed through a set of criteria or collection of symptoms, that make up a clinical picture of Axial SpA. You can check your symptoms here.

An X-ray or MRI may show signs of inflammation depending on how far the disease has progressed. A blood test may be used to check for inflammatory factors (ESR, CRP) and the HLA-B27 gene. Around half of those with Axial spondyloarthritis will be negative for inflammatory markers (seronegative) and 85% have the HLA-B27 gene, so it is possible to have the condition without a positive blood test (Royal Free, 2022). There is an 8.5 years delay in the diagnosis of Axial Spondyloarthritis in the UK on average, which leads to a delay in effective management and treatment. As it is a progressive disorder, this can lead to irreversible damage (NASS, N.D). It is particularly difficult for women to receive an accurate diagnosis as it often doesn't present in a typical way. Women are more likely to suffer with neck pain, hand and wrist, ankle and foot pain which is easily dismissed as mechanical pain. Women are more likely to have systemic symptoms such as IBD or Ulcerative colitis which are dealt with in isolation rather than as part of a wider clinical picture. This is because historically Ankylosing spondylitis, with the classic inflammation and eventual solidification of the spine and sacroiliac joints, presented more often in men.

Axial SpA usually starts at a young age (less than 40 years old) with the average age being 24. Due to the genetic component it often runs in families. It can be triggered initially by bacterial infection (such as E.Coli or Klebsiella), a change in gut microbiome or sudden change in diet. It progresses through flare ups followed by periods of recovery and can be exacerbated by illness, periods of stress or high inflammation.

It is managed by lifestyle changes and therapies such as:

  • High intensity exercise

  • Breathing exercises

  • Increasing flexibility and mobility - through stretching (passive and active/assisted stretching) massage, chiropractic care and activities such as yoga and tai chi

  • Relaxation and stress reduction

  • Cryotherapy

  • Hydrotherapy

  • Eating healthily and not smoking

  • Improving posture

Systemic conditions such as accompanying IBD, ulcerative colitis or chrohns need to be treated individually alongside Axial SpA management.

Anti-inflammatories (NSAIDS) pain-relief are especially useful during flare-ups and corticosteroids may be used in extremity joints (e.g the shoulder or knee) if affected.

Biologics (a type of Disease-Modifying Antirheumatic drug, DMARD) target certain proteins and processes within the body and are self-injected or given as an infusion. The most commonly used are tumour necrosis factor (TNR) and interleukin (IL-17) inhibitors (Arthritis Foundation, N.D).

For Further information and support at NASS

Arthritis Foundation (N.D). Ankylosing Spondylitis & Non-Radiographic Axial Spondyloarthritis [Online] Accessed 11.06.24. Available at:Axial Spondyloarthritis: Symptoms, Diagnosis, and Treatment | Arthritis Foundation

NASS (N.D). What is Axial SpA? [online], Accessed 10.06.24. Available at:What is axial SpA? | National Axial Spondyloarthritis Society (

Royal Free (2022). Axial Spondyloarthritis [online], Accessed 10.06.24, Available at:Symptoms Checker - Act on axial SpA

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