Inflammatory Back Pain: Could It Be Spondyloarthritis?

Lower back pain is incredibly common. Most presentations do not involve serious disease, and many people improve with time, appropriate activity and individualised management.

But occasionally, someone presents with back pain that does not behave quite as expected.

Perhaps the symptoms have continued for months. They feel particularly stiff in the morning, wake during the night and actually feel better after moving around.

There may also be symptoms in other parts of the body that initially seem unrelated to the back.

These are some of the clues that should make us consider inflammatory back pain and the possibility of a condition called axial spondyloarthritis.

At RHP Physiotherapy in Kelvin Grove, Brisbane, our physiotherapists assess a broad range of lower back pain presentations. An important part of that assessment is recognising when physiotherapy alone may not be the appropriate starting point and when further medical investigation is needed.

This article explains what spondyloarthritis is, the clinical features that may raise suspicion, when rheumatology referral is appropriate and how physiotherapy can contribute to longer-term management.

A Clinical Case: When Lower Back Pain Doesn't Quite Fit

Some time ago, a patient presented to our clinic with lower back pain that had continued for more than three months.

Initially, the complaint sounded like many other presentations of persistent back pain.

However, as we explored the history in greater detail, some features did not fit neatly with the more common musculoskeletal presentations we encounter.

The patient also described discomfort in other areas of the body, and discussion of a recent illness raised the possibility of a broader inflammatory or systemic process.

At this point, the most useful decision was not simply which exercise or manual treatment to prescribe.

It was whether the overall presentation required medical investigation.

Following specialist assessment by a rheumatologist, a diagnosis within the spondyloarthritis group was established, and the patient subsequently reported a positive response to treatment.

This case highlights one of the most important responsibilities of a physiotherapist.

Our role is not simply to provide physiotherapy. It is to determine whether physiotherapy is appropriate for the person in front of us, and to recognise when another healthcare professional needs to be involved.

The individual details of this case are deliberately limited. The useful lesson is the clinical reasoning process, rather than suggesting that this particular combination of symptoms always indicates inflammatory disease.

What Is Spondyloarthritis?

Spondyloarthritis, sometimes called spondyloarthropathy, describes a group of related inflammatory rheumatic conditions.

These conditions can involve:

• The spine and sacroiliac joints.
• Other joints throughout the body.
• Entheses, where tendons and ligaments attach to bone.
• The skin.
• The eyes.
• The gastrointestinal system.

The condition can therefore present with symptoms that extend well beyond ordinary lower back pain.

This is one reason recognition can be challenging in primary care and musculoskeletal practice.

Axial Spondyloarthritis

Axial spondyloarthritis, or axSpA, primarily involves the spine and sacroiliac joints.

The sacroiliac joints connect the sacrum at the base of the spine to the pelvis.

Inflammation in these regions may contribute to persistent back or buttock pain and stiffness.

Axial spondyloarthritis includes two main presentations:

• Radiographic axial spondyloarthritis: Sometimes referred to as ankylosing spondylitis, where characteristic structural changes can be identified on X-ray.
• Non-radiographic axial spondyloarthritis: Where the person has an axial spondyloarthritis presentation without the characteristic structural changes being visible on plain X-ray.

Non-radiographic disease is not necessarily mild or insignificant.

Symptoms and functional limitations can still be substantial.

It is also important to recognise that not everyone with non-radiographic disease will progress to radiographic changes.

Peripheral Spondyloarthritis

Other forms of spondyloarthritis predominantly affect joints outside the spine or the sites where tendons and ligaments attach to bone.

Related conditions include psoriatic arthritis and reactive arthritis.

Some people have both axial and peripheral symptoms.

This overlap matters because a person presenting with persistent back pain may also describe heel pain, swelling in a knee or ankle, or a history of skin or bowel symptoms.

Those complaints may be clinically connected rather than independent problems.

Inflammatory Back Pain vs Mechanical Back Pain: What's the Difference?

The term mechanical back pain is often used to describe symptoms influenced by movement, loading or position.

Inflammatory back pain refers to a characteristic symptom pattern that may suggest an underlying inflammatory condition.

The distinction can be useful, but it is not perfectly reliable.

Many people with ordinary lower back pain feel stiff in the morning or better after moving.

Likewise, someone with axial spondyloarthritis may still experience pain during particular physical tasks.

We therefore need to look at the overall presentation rather than interpreting any single symptom as a diagnosis.

These are tendencies rather than diagnostic rules. The presence or absence of one feature cannot reliably confirm or exclude axial spondyloarthritis.

What Other Symptoms Can Suggest Spondyloarthritis?

One of the most valuable parts of assessing possible inflammatory back pain is asking questions beyond the back itself.

Spondyloarthritis can involve several body systems, and some symptoms may initially appear unrelated.

1. Pain or Swelling in Other Joints

Some people experience inflammatory symptoms in peripheral joints such as the knees, ankles or hips.

These may include:

• Joint swelling.
• Stiffness following inactivity.
• Pain involving more than one body region.
• Episodes of joint symptoms that change over time.

2. Enthesitis: Pain Where Tendons Attach to Bone

Enthesitis describes inflammation involving an enthesis, the region where a tendon or ligament attaches to bone.

Common locations include:

• The Achilles tendon insertion at the heel.
• The underside of the heel.
• Other tendon and ligament attachment sites.

This can resemble common musculoskeletal presentations such as Achilles tendinopathy or plantar heel pain.

However, not every painful tendon attachment represents inflammatory enthesitis.

The wider history and other clinical features are important when considering whether there may be a systemic inflammatory condition.

3. Psoriasis

Psoriasis is an inflammatory skin condition that can be associated with psoriatic arthritis and other spondyloarthritis presentations.

Sometimes the skin symptoms are relatively subtle, or a person may have a previous history rather than an active flare.

Nail changes can also provide useful clues.

4. Inflammatory Bowel Disease

Crohn's disease and ulcerative colitis are associated with spondyloarthritis.

A history of inflammatory bowel disease may therefore be important when someone presents with persistent back or joint symptoms.

This does not mean that all gastrointestinal symptoms indicate inflammatory bowel disease.

But established diagnoses and relevant symptoms are worth discussing during assessment.

5. Eye Inflammation: Uveitis

Acute anterior uveitis is an inflammatory eye condition associated with spondyloarthritis.

Symptoms may include:

• A painful red eye.
• Sensitivity to light.
• Blurred vision.

A new painful red eye with light sensitivity or visual changes requires urgent same-day medical and ophthalmological assessment.

It should not be managed as an ordinary musculoskeletal symptom.

6. Family History and Previous Infection

A family history of spondyloarthritis or related inflammatory conditions can increase clinical suspicion.

Some spondyloarthritis presentations may also occur following particular gastrointestinal or genitourinary infections.

However, a recent infection does not by itself establish the diagnosis of reactive arthritis or another spondyloarthritis condition.

When Should Someone With Back Pain Be Referred to a Rheumatologist?

The National Institute for Health and Care Excellence (NICE) published guideline NG65 to support recognition and management of spondyloarthritis.

Although it is a UK guideline, it provides a useful, clearly defined referral framework for clinicians.

It is important to understand that the criteria are used to help decide when further assessment is warranted.

They are not a checklist that independently diagnoses axial spondyloarthritis.

NICE Referral Criteria for Suspected Axial Spondyloarthritis

For a person whose lower back pain started before age 45 and has lasted longer than three months, NICE recommends rheumatology referral when at least four of the following nine additional features are present:

• Back pain began before age 35.
• Waking during the second half of the night because of symptoms.
• Buttock pain.
• Symptoms improve with movement.
• Symptoms improve within 48 hours of taking an NSAID.
• A first-degree relative has spondyloarthritis.
• Current or previous arthritis.
• Current or previous enthesitis.
• Current or previous psoriasis.

If exactly three additional criteria are present, the guideline recommends HLA-B27 testing, with referral if the test is positive.

However, NICE also makes an important qualification:

If the referral threshold is not met but clinical suspicion remains, the possibility of spondyloarthritis should not simply be dismissed.

Further assessment may become appropriate if additional features develop, especially in someone with inflammatory bowel disease, psoriasis or uveitis.

What Does Queensland Health Recommend?

Queensland Health also provides specific referral criteria for suspected axial spondyloarthritis and ankylosing spondylitis.

Its rheumatology criteria recognise suspected axial spondyloarthritis with or without peripheral joint symptoms or manifestations involving other body systems.

Information recommended for referrals includes:

• The duration and progression of back pain and stiffness.
• Inflammatory features such as morning stiffness, night pain and response to anti-inflammatory medication.
• Peripheral joint symptoms.
• Psoriasis, inflammatory bowel disease or uveitis.
• Relevant examination findings and previous treatment.
• Blood tests and imaging as appropriate to the referral pathway.

These are considerations for clinicians arranging a specialist referral, rather than investigations every patient needs to organise independently.

You can read the Queensland Health Axial Spondyloarthritis Referral Criteria.

Why Is Axial Spondyloarthritis Sometimes Diagnosed Late?

One of the difficulties with axial spondyloarthritis is that the early symptoms can resemble more common lower back pain presentations.

Symptoms may begin gradually in a young adult.

The person may remain physically active, and early medical investigations may be inconclusive.

They might also seek care for separate problems, such as heel pain or joint discomfort, without those symptoms initially being recognised as potentially connected.

Unfortunately, delays in diagnosis are well documented.

A systematic review and meta-analysis published in 2021 examined 64 studies and found a pooled average delay between symptom onset and diagnosis of approximately 6.7 years.

There was substantial variation between studies and countries.

These findings should not be interpreted as the expected delay for an individual Australian patient.

Nevertheless, they illustrate why greater awareness among both patients and healthcare professionals is valuable.

Why Early Recognition Matters

A delayed diagnosis may mean that someone spends years trying to manage a systemic inflammatory condition without access to appropriate specialist treatment.

That can contribute to ongoing pain, stiffness, fatigue, limitations in physical activity and disruption to work or everyday life.

Early recognition creates an opportunity for appropriate investigation, specialist management and support.

It does not guarantee that every symptom will disappear or that future disease progression will be prevented.

But it gives the person access to a more informed and individualised treatment pathway.

How Is Axial Spondyloarthritis Diagnosed?

There is no single blood test, movement test or scan that independently establishes the diagnosis in every patient.

A rheumatologist considers the overall clinical picture, including:

• The age at which symptoms began.
• The pattern of back pain and stiffness.
• Associated joint and tendon symptoms.
• Psoriasis, inflammatory bowel disease or uveitis.
• Family history.
• Blood tests.
• Imaging findings when indicated.
• Other possible explanations for the symptoms.

What Is the HLA-B27 Blood Test?

HLA-B27 is a genetic marker associated with axial spondyloarthritis.

People who carry HLA-B27 have a greater likelihood of developing certain spondyloarthritis conditions than people who do not carry it.

However, many people with HLA-B27 never develop inflammatory arthritis.

A positive test does not establish the diagnosis.

Equally, a negative HLA-B27 result does not exclude axial spondyloarthritis.

What About CRP and ESR?

C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are blood tests used to help assess inflammation.

They can provide useful information, but neither test is specific to axial spondyloarthritis.

Importantly, people with active spondyloarthritis may have normal inflammatory markers.

Normal blood results therefore do not automatically rule out the condition.

Can an X-Ray Be Normal in Axial Spondyloarthritis?

Yes.

Early or non-radiographic axial spondyloarthritis may be present without the characteristic structural changes appearing on plain X-ray.

MRI may be useful in selected circumstances because it can identify some inflammatory changes that are not visible on X-ray.

However, MRI findings also require careful interpretation, as some changes can occur for other reasons.

The diagnosis should be made by an appropriately qualified clinician using the whole clinical picture rather than one test result.

What Is the Treatment for Axial Spondyloarthritis?

Management usually involves a combination of medical treatment, education, physical activity and individualised rehabilitation.

International recommendations emphasise multidisciplinary care coordinated by a rheumatologist.

The specific treatment depends on disease activity, the parts of the body involved, other health conditions and the person's goals.

Medical Treatment

Anti-inflammatory medication is commonly considered in the treatment of axial spondyloarthritis.

Non-steroidal anti-inflammatory drugs, known as NSAIDs, are among the first-line medication options discussed in international treatment recommendations.

For people with ongoing active disease, rheumatologists may also consider targeted medications such as biological therapies or other disease-modifying treatments where clinically appropriate.

Medication selection and monitoring require medical assessment, particularly because some treatments carry important risks or are unsuitable for certain individuals.

Physiotherapy is not a replacement for appropriate rheumatological management.

Exercise and Physiotherapy

Regular exercise is an important component of managing axial spondyloarthritis.

The ASAS-EULAR management recommendations encourage patient education, regular exercise and consideration of physiotherapy.

Depending on the person's presentation, an exercise program might include:

• Spinal mobility exercises.
• Progressive strength training.
• Aerobic exercise.
• Postural and functional movement activities where relevant.
• Exercises directed towards specific activity limitations.

The aim is to improve and maintain physical capacity, mobility and participation in everyday life.

Exercise selection should consider disease activity, current symptoms, fatigue, physical capacity and any associated joint or tendon problems.

There is no single exercise program that is best for every person with axial spondyloarthritis.

Can People With Spondyloarthritis Continue Sport?

Many people can continue participating in physical activity and sport.

The appropriate amount and type of activity depend on the condition, current symptoms and any structural or functional limitations.

For some people, maintaining strength and fitness alongside medical management is an important part of maintaining their quality of life.

For others, activity may need to be modified during periods of more active symptoms.

Our Sports Physiotherapy and Exercise Physiology services can support individual physical-capacity goals as part of the person's wider healthcare plan.

What Is the Physiotherapist's Role in Recognising Spondyloarthritis?

For physiotherapists, this topic highlights the value of a thorough subjective examination.

When someone presents with lower back pain, it is easy to become focused on the painful movement, joint or muscle.

However, the most important information may come from questions about symptoms outside the original area of complaint.

Our responsibilities include:

• Recognising when a presentation may be inconsistent with common non-specific back pain.
• Asking appropriate screening questions about inflammatory symptoms.
• Considering associated skin, bowel, eye and peripheral joint symptoms.
• Recognising when medical investigation may be appropriate.
• Communicating relevant findings to the patient's GP.
• Supporting physical rehabilitation once an appropriate management plan is established.

When Should You Speak to Your GP About Possible Inflammatory Back Pain?

Consider discussing the possibility of inflammatory back pain with your GP if you have:

• Back pain lasting longer than three months.
• Symptoms that began at a younger age, particularly before 45.
• Significant morning stiffness.
• Pain that improves after moving but becomes worse during prolonged rest.
• Back or buttock pain that repeatedly wakes you during the second half of the night.
• Other symptoms such as psoriasis, peripheral joint swelling, persistent heel pain or inflammatory bowel disease.
• A relevant family history.

These symptoms can also occur in people without inflammatory arthritis.

The purpose of raising them is not to self-diagnose, but to help determine whether a rheumatological assessment is appropriate.

A GP can consider the history, relevant investigations and the need for specialist referral.

Frequently Asked Questions About Spondyloarthritis

Lower Back Pain Assessment and Physiotherapy in Kelvin Grove, Brisbane

At RHP Physiotherapy in Kelvin Grove, we recognise that not all lower back pain is explained by a local joint, disc or muscle problem.

Our assessment considers how symptoms behave, the person's broader health history and whether their presentation indicates a need for further medical investigation.

For someone with suspected inflammatory back pain, our role may include identifying relevant clinical features, recommending GP or specialist assessment and supporting appropriate physical activity.

Once a medical management plan has been established, exercise-based rehabilitation may help someone maintain their physical capacity and participation in everyday life.

Relevant RHP services include:

• Lower Back Pain Physiotherapy for assessment of persistent, recurring or otherwise unusual back pain presentations.
• Physiotherapy for musculoskeletal assessment, exercise guidance and coordination with other healthcare professionals where appropriate.
• Chronic Pain Physiotherapy for people whose persistent symptoms affect physical function and everyday participation.
• Exercise Physiology for structured physical activity and longer-term strength and fitness goals.

Our clinic is located at AMA Place, 88 L'Estrange Terrace, Kelvin Grove, Brisbane.

If you are experiencing persistent or unexplained lower back pain, an appropriate assessment can help determine whether physiotherapy, medical investigation or a combination of care is the most suitable next step.

This article is intended for general education and does not replace individual medical advice. Suspected inflammatory or systemic disease should be assessed by an appropriately qualified healthcare professional.

Author in the know

Sam Donaldson

Director, APA titled Sports and Exercise Physiotherapist. Sam loves to treat athletes with lower limb injuries and has a special interest in knees of all ages; adolescent knee pain, athlete with knee pain, ACL injuries, ACL rehabilitation, Knee Osteoarthritis and Knee Replacement recovery. He is a Dad, Football enthusiast and loves to move. BAppSci (HMS), MPhtyStudies, MPHTY (Sports)