GPAtlas🧭 When to suspect
Suspect axial spondyloarthritis (axSpA) in any adult with low back pain and stiffness lasting longer than 3 months that began before the age of 45.
• axSpA includes ankylosing spondylitis (radiographic axSpA) and non-radiographic axSpA.
• The hallmark is inflammatory back pain: pain that improves with movement and worsens with rest, prominent morning stiffness and night pain, distinct from ordinary mechanical back pain.
In primary care, axSpA is routinely missed.
• The average delay from first symptom to diagnosis is around 8 years, because inflammatory back pain is mislabelled as "mechanical" back pain.
• axSpA is not simply a young man's disease – it affects women in similar numbers, who tend to wait even longer for a diagnosis.
| Feature | Inflammatory (suggests axSpA) | Mechanical |
|---|---|---|
| Age at onset | < 45 years (often < 35) | Any age |
| Onset | Insidious, gradual | Often acute, after activity or strain |
| Effect of rest | Worse with rest and in the morning | Improves with rest |
| Effect of movement | Improves with exercise | Worsens with activity |
| Night pain | Characteristic – wakes in the second half of the night | • Uncommon • Little diurnal rhythm |
| Morning stiffness | Prolonged, > 30 minutes | Brief, < 30 minutes |
| Response to NSAIDs | Good, often within 48 hours | Variable |
| Duration | Chronic, > 3 months | Often self-limiting |
Suspicion is strengthened by extra-articular and associated features:
• acute anterior uveitis (a painful red eye), psoriasis or inflammatory bowel disease
• enthesitis (e.g. Achilles or plantar fascia) or dactylitis (sausage digit)
• alternating buttock pain
• a first-degree relative with spondyloarthritis
• a recent genitourinary/GI infection (reactive pattern).
NICE provides a clear referral rule. In a person with low back pain that started before 45 and has lasted > 3 months:
• Refer to rheumatology if 4 or more of the following are present.
• If exactly 3 are present, perform HLA-B27 and refer if positive.
| NICE NG65 – additional referral criteria (need ≥ 4, or 3 + HLA-B27 positive) |
|---|
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• Low back pain that started before the age of 35 |
|
• Waking during the second half of the night because of symptoms |
|
• Buttock pain |
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• Improvement with movement |
|
• Improvement within 48 hours of taking NSAIDs |
|
• A first-degree relative with spondyloarthritis |
|
• Current or past arthritis |
|
• Current or past enthesitis |
|
• Current or past psoriasis |
Source: NICE NG65 · NICE QS170
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