Expertise Details




• Ankylosing spondylitis is a seronegative chronic inflammatory arthritis that primarily affects the axial skeleton with a predilection for lumbar spine and sacroiliac joints.

• 90% of the affected people carry the histocompatibility antigen HLA-B27.

• It is also associated with inflammatory bowel disease.

• The disease usually occurs in the second and third decades with a male to female ratio of 4: 1.


Clinical Features

• Involvement of the lumbar spine results in low back pain with nocturnal exacerbations. Characteristically, this is associated with low back morning stiffness that improves with activity. Low-back stiffness may be precipitated by inactivity.

Early physical signs include failure to obliterate the lumbar lordosis on forward· flexion and restriction of the movements of lumbar spine in all directions. The limitation of forward flexion of lumbar spine can be measured by the Schober test:

   • Mark points on the spine 5 cm below and 10 cm above the posterior superior iliac spines.

   • Ask the patient to bend forward maximally.

   • The distance between the two marks should increase by 5 cm or more in normal persons. An increase of less than 5 cm suggests decreased range of motion of the lumbar spine.

• Involvement of the sacroiliac joints causes low back pain. Pain in the sacroiliac joints may be elicited either by direct pressure or by manoeuvres that stress the joint-e.g. "figure of 4 test" (Patrick's test).

   • One limb is guided into "figure of 4" position with the ipsilateral ankle resting across the contralateral thigh.

   • The ipsilateral knee is then pressed downwards with one hand, while providing counterpressure with the other hand on the contralateral anterior superior iliac spine.

   • This manoeuvre tends to stress the sacroiliac joint on the side being tested.

• Enthesitis is common. Inflammation at the Achilles tendon and plantar fascia calcaneal insertions is particularly common, and manifests as heel pain. Like arthritis, enthesitis typically is aggravated by rest and improved with activity. Other areas of enthesitis include superior and inferior aspects of patella, metatarsal heads and spinal ligament insertions on vertebral bodies.

• Involvement of the thoracic spine, costovertebral joints and costostemal joints result in chest pain, diminished chest expansion (<5 cm) and thoracic kyphosis.

• Involvement of the cervical spine results in neck pain and a forward stoop of the neck.

• Peripheral arthritis is usually late and asymmetric. Involvement of hips and shoulders result in pain and limitation of movement. Hip involvement may lead to flexion contractures, compensated by flexion at knees.



• Erythrocyte sedimentation rate (ESR) is raised. Tests for rheumatoid factor (RF) are negative.

• HLA-B27 is present in >90% cases.

• MRI and bone scan can pick up early sacroiliitis.

• Ultrasonography can be useful in detecting enthesitis.


Radiological Manifestations

• Blurring of sacroiliac joint margins followed by erosions and sclerosis

• Erosion and sclerosis at the anterior corners of vertebrae

• Syndesmophyte (ossification of annulus fibrosus) formation, marginal

• "Squaring" of lumbar vertebrae (due to enthesitis involving spine)

• Bamboo spine (multiple syndesmophytes bridging the intervertebral spaces)

• Diffuse osteoporosis of spine

• Atlanta-axial subluxation and vertebral fractures • Erosive changes in symphysis pubis, ischial tuberosities and peripheral joints



• Regular exercises, active and passive physiotherapy



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