INFLAMMATORY BACK PAIN
Young, stiff for hours every morning, better with movement. That is not a mechanical back.
Axial spondyloarthritis is typically diagnosed years after symptoms begin, because a young person with back pain is assumed to have strained something. The pattern that separates it is specific and easy to ask about.
The five features that define it
- Onset before age forty-five, and often before thirty.
- Gradual onset rather than a moment you can name.
- Morning stiffness lasting more than thirty minutes, frequently well over an hour.
- Improvement with exercise, not with rest — the reverse of a mechanical back.
- Night pain in the second half of the night, often getting people up to move around.
Four or more of those in someone under forty-five should prompt an inflammatory workup rather than another course of physical therapy. A striking response to anti-inflammatories is further support.
What else travels with it
Ask about these deliberately, because patients rarely connect them to their back: alternating buttock pain, heel pain from Achilles or plantar enthesitis, a swollen finger or toe, painful red eye episodes, psoriasis, and inflammatory bowel symptoms. A family history of any of those matters too.
Those associations are the reason this diagnosis belongs to rheumatology. It is a systemic condition that happens to present in the spine, and it has disease-modifying treatment that changes long-term outcomes.
Why we screen for it here
An interventional pain practice sees a great many young adults with persistent back pain, which makes it exactly the place this diagnosis should be caught. It is also exactly the place it can be missed for years by treating each flare as mechanical.
Injections do not treat axial spondyloarthritis. Recognizing it and routing it is worth more than anything we would otherwise do, and we would rather send someone to a rheumatologist than keep them.
Sacroiliitis on MRI is the finding that supports the diagnosis, and it is different from the degenerative sacroiliac change seen with age. If your imaging mentioned it, that is worth pursuing rather than filing. The mechanical version, for contrast.
What we can still contribute
Symptom control alongside rheumatology, where a specific painful structure is identified. Movement programming, because exercise is genuinely disease-modifying in axial spondyloarthritis rather than merely palliative. And the metabolic work, since systemic inflammatory load and insulin resistance interact with any inflammatory arthropathy.
Common questions
How is this different from ordinary back pain?
Ordinary mechanical back pain is worse with activity and better with rest, with brief morning stiffness. This is the opposite on both counts, and the stiffness is long.
What test confirms it?
There is no single test. It is a combination of pattern, examination, inflammatory markers, HLA-B27 status and MRI of the sacroiliac joints, interpreted together by a rheumatologist.
Is a negative HLA-B27 enough to rule it out?
No. A substantial minority of patients are negative. The clinical pattern carries more weight than any single marker.
Related reading
- Back pain at night
- Sacroiliac joint pain
- What your MRI actually showed
- What happens at the first visit
If you are under forty-five and stiff for an hour every morning, say so
That one sentence redirects the entire workup, and it is the sentence most often never asked for.
12174 Natural Bridge Rd, Suite 301
St. Louis, MO 63044
At DePaul Hospital on Natural Bridge Road, inside the I-270 and I-70 interchange, on the west side of the airport.
Sources
- Bittar M et al. Axial Spondyloarthritis: A Review. JAMA, 2025. PubMed 39630439
- Ramiro S et al. ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Annals of the rheumatic diseases, 2023. PubMed 36270658
- van Gaalen FA et al. Challenges in the diagnosis of axial spondyloarthritis. Best practice & research. Clinical rheumatology, 2023. PubMed 37714776
- Navarro-Compán V et al. Axial spondyloarthritis. Lancet (London, England), 2025. PubMed 39798984