Ankylosing spondylitis (AS) usually starts as back pain and stiffness that creep in over months or years, ease with movement and get worse with rest. According to the NHS, it can also bring pain and swelling elsewhere in the body, and extreme tiredness. The clue is the pattern, not the pain level: stiffness that is worst first thing in the morning or in the night, in a younger adult, that loosens up once you get moving.
This guide explains that pattern in plain English, the symptoms people don’t connect to their back, what NICE tells UK clinicians to look for, and who you should see first. We are a chiropractic clinic, not a rheumatology service, so we will also be clear about where our role ends.
TL;DR
- AS typically starts gradually, with lower back or buttock pain and stiffness that improves with exercise and gets worse with rest.
- Waking in the second half of the night, morning stiffness and deep fatigue are classic signs. A normal blood test does not rule it out.
- Heel pain, tendon pain, red painful eyes, psoriasis or bowel disease can all be part of the same picture.
- Your GP is the right first stop for suspected inflammatory back pain, and a rheumatology referral is how it is confirmed.
- Early diagnosis and regular movement are what protect your spine in the long run.
Table of Contents
- What ankylosing spondylitis actually is
- The core symptoms: back pain and stiffness
- Symptoms beyond the spine
- What NICE tells UK clinicians to look for
- Who to see first
- What treatment and self-management look like
- Our perspective at Elaris
- Book an assessment in Great Totham
- Practical tips while you wait for answers
- FAQ
- Sources
What ankylosing spondylitis actually is
AS is a long-term condition in which the spine and other areas of the body become inflamed. It is one form of axial spondyloarthritis. In AS, changes in the spine can be seen on an X-ray. NICE describes spondyloarthritis as a group of inflammatory conditions with a range of manifestations, split into axial forms (ankylosing spondylitis, which is radiographic, and non-radiographic axial spondyloarthritis) and peripheral forms.
The Royal Free London explains that axial SpA was previously known as ankylosing spondylitis. If your doctor uses either term, or “inflammatory back pain”, they are talking about the same family of conditions.
Two things surprise many people:
- It is not only a condition of men in their twenties. A UK clinical pathway notes that axial spondyloarthritis affects as many women as men and is commonly missed or diagnosed late.
- It is not the same as the wear-and-tear or muscle strain behind most back pain. That difference is why the symptoms matter.
The core symptoms: back pain and stiffness
The NHS describes AS symptoms as developing slowly over several months or years, and as able to come and go, improve or worsen over many years. That slow, patchy start is one reason it gets missed.
What inflammatory back pain feels like
Compare it with the mechanical back pain most of us get from lifting, sitting or a bad night on the sofa.
| Typical mechanical back pain | Typical inflammatory (AS-type) back pain | |
|---|---|---|
| Onset | Often sudden, after a movement or strain | Gradual, over weeks, months or years |
| Effect of rest | Often eases | Often worse, with stiffness after inactivity |
| Effect of exercise | Often aggravates | Often improves with movement |
| Time of day | Worse after activity or at the end of the day | Worse in the morning or at night |
| Sleep | May ache when you roll over | May wake you in the second half of the night |
| Typical age at start | Any | Often before 35 |
The NHS notes that AS pain and stiffness get worse with rest and improve with exercise, and may be worse in the morning or at night, sometimes waking people in the second half of the night. The pain often sits low in the back and buttocks, and may spread up the spine over time.
Buttock pain and sacroiliitis
Deep, vague pain in one or both buttocks, sometimes swapping sides, is a hallmark. It comes from inflammation of the sacroiliac joints, where the base of the spine meets the pelvis. This is called sacroiliitis. The NHS says it is a key feature of AS, and diagnosis usually involves imaging, either X-ray or MRI, of those joints.
Buttock pain on its own has plenty of other causes, including nerve irritation and muscle weakness. If yours is on one side and travels down the leg, our guide to lumbar radiculopathy symptoms explains the difference. For a sore, achy backside after long sitting, see dead butt syndrome. Neither of those typically wakes you at 4am with stiffness that eases when you get up and walk around.
Symptoms beyond the spine
Because AS is an inflammatory condition, it does not stay politely in your back. Many people see a physio or a podiatrist for a symptom that is actually part of the same story.
Heels, tendons and joints
The NHS lists pain and swelling in other parts of the body as a main symptom, caused by inflammation of the joints and by enthesitis, which is inflammation where a tendon joins a bone. In practice that can mean:
- Heel pain that does not behave like plantar fasciitis, particularly first thing in the morning.
- Tendon pain around the elbows, knees or ribs with no injury to explain it.
- Pain and stiffness in the hips, shoulders or neck.
- Chest tightness or pain when breathing in deeply, which can reflect stiffness where the ribs meet the spine.
The Versus Arthritis information booklet on ankylosing spondylitis covers these symptoms in more detail and includes first-hand accounts from people living with the condition.
Fatigue
Extreme tiredness is listed by the NHS as one of the three main symptoms, and many people with AS say it is the hardest part. It is not simply the tiredness of a poor night: pain and stiffness break up sleep, and inflammation itself is draining.
If you are waking unrefreshed, it is worth looking at your sleep set-up as well as your medical care. This piece on why you can wake up tired covers how a tired mattress can contribute. It will not treat inflammation, but it is one factor you can control while you wait for answers.
Eyes, skin and bowel
AS can come with related conditions. The NHS complications page describes uveitis, inflammation of the eye, as one of them. If you have a diagnosis or suspected inflammatory back pain and your eye becomes red, painful or sensitive to light, treat it as urgent. Do not wait for a routine GP slot: contact your GP urgently, NHS 111, or an eye casualty department the same day. Eye symptoms can happen even when your back is quiet.
Psoriasis and inflammatory bowel disease (Crohn’s disease or ulcerative colitis) also raise suspicion. Mention them, and any family history of them, to your GP, even if they seem unrelated to your back.
What NICE tells UK clinicians to look for
NICE guidance NG65 gives a practical referral framework. Under NICE’s recommendations, clinicians should think about axial spondyloarthritis in people with back pain lasting more than three months who first had symptoms before the age of 45. They should then check for these features:
- Back pain that began before the age of 35.
- Waking in the second half of the night because of symptoms.
- Buttock pain.
- Improvement with movement.
- Improvement within 48 hours of taking NSAIDs.
- A first-degree family history of spondyloarthritis.
- Current or past arthritis, enthesitis or psoriasis.
If four or more are present, NICE advises referral for a rheumatology assessment. If exactly three are present, an HLA-B27 blood test is recommended, and a positive result leads to referral. This is a framework for clinicians, not a self-diagnosis checklist. But if you tick several boxes, take the list to your GP and ask directly whether inflammatory back pain has been considered.
Why a normal blood test is not the end of it
Many people are reassured by normal blood tests and then spend years without answers. According to the Royal Free London, inflammatory markers such as CRP and ESR are normal in roughly half of people with axial spondyloarthritis. A normal result therefore cannot rule it out. If your story fits the pattern, ask whether an MRI of the sacroiliac joints is appropriate.
Who to see first
If the pattern above sounds like you, your GP is the right first call. Say plainly what you have noticed: age at onset, duration, night waking, morning stiffness, what helps, and any heel, eye, skin or bowel history. Ask whether you meet the criteria for a rheumatology referral. Diagnosis in the UK is made by rheumatology, usually with imaging and sometimes HLA-B27 testing.
See a doctor urgently, and do not book a routine appointment of any kind, if you have:
- A red, painful eye or sensitivity to light.
- New numbness around the groin or genitals, or difficulty controlling your bladder or bowel, with back pain. This needs emergency care.
- Back pain with fever, unexplained weight loss, or a history of cancer.
The delay in diagnosis is the main problem. Versus Arthritis describes diagnostic delay as common because the symptoms mimic everyday mechanical back pain, so being persistent with your GP is reasonable, not pushy.
What treatment and self-management look like
AS cannot be cured, and the NHS says damage already caused cannot be reversed. It is, though, very manageable. The Royal Free’s patient leaflet stresses that regular exercise is central to managing axial SpA, alongside medication, and that staying mobile is the best defence against long-term stiffness. Typical care involves a rheumatology team, NSAIDs, physiotherapist-guided exercise and, for some people, biologic medicines prescribed by a specialist.
On diet, there is no evidence that any specific diet cures AS, and Versus Arthritis advises against cutting out whole food groups. A balanced diet and a healthy weight help to reduce strain on the spine.
Our perspective at Elaris
We see a lot of people with long-standing low back pain, and we take the question “is this really mechanical?” seriously at the first visit. It is the reason our first consultation is a full examination, not a quick look at your spine.
When we assess someone, we listen for the pattern in this article: how the pain began, what it does at night and first thing in the morning, whether movement helps, and what else is going on in the body. We combine a hands-on exam and neurological testing with a detailed history, because the structure of the spine is only part of the picture. Neurological and emotional factors matter too, and years of being told it is “just a bad back” take their toll.
Here is what we think is important:
- We do not diagnose or treat AS. That is for your GP and rheumatology. If what we find fits an inflammatory pattern, we will tell you plainly and write to or advise you to go back to your GP, rather than carrying on with treatment that is not the right answer.
- Mechanical pain and inflammatory pain can co-exist. Someone with AS can also have a stiff joint, a tight muscle or an irritated nerve. Where chiropractic care is suitable, it should sit alongside medical care, not replace it.
- You deserve an explanation. Our patients see the same two practitioners at every visit, with a treatment plan explained in detail and progress measured at each stage. That continuity is how a pattern that has been missed for years gets noticed.
If your symptoms ring true after reading this, do not wait for the next flare to see someone.
— steve
Book an assessment in Great Totham
If you are in Maldon, Tiptree, Witham or the villages around Great Totham and have back pain that has dragged on, our first consultation and examination costs £105 one-off. It includes a hands-on exam and neurological testing, and you leave with a clear explanation of what we found and a written plan if chiropractic care is suitable. If we suspect something that needs a doctor, we will say so.
You can read more about how we approach low back pain or sciatica and leg pain, or browse our articles, including one on tailbone pain when sitting. If you are closer to Maldon, see our Maldon clinic page.
Practical tips while you wait for answers
- Keep a symptom diary for two weeks. Note when the pain wakes you, how long morning stiffness lasts, and what eases it. It makes your GP appointment far more productive.
- Keep moving. Gentle walking and mobility work usually feel better than rest in inflammatory pain. Stop and seek advice if anything gives you new nerve symptoms.
- Write down your family history. Include psoriasis, bowel disease, eye inflammation and spondyloarthritis.
- Mention heel and tendon pain. It looks unrelated, but it can be a clue.
- Do not rely on one normal test. Ask what else could be done if your symptoms keep fitting the pattern.
FAQ
What are the first signs of ankylosing spondylitis?
The earliest sign is usually gradual lower back or buttock pain with stiffness that is worse in the morning or at night and eases with movement. Some people first notice heel pain, or fatigue that seems out of proportion. If this has lasted more than three months, speak to your GP.
Can you fly with ankylosing spondylitis?
Most people with AS can fly, but long periods of sitting tend to make stiffness worse. Stand, walk the aisle and do gentle stretches regularly, and ask your rheumatology team for advice if you have significant spinal stiffness, heart or lung involvement, or recent eye inflammation.
Can ankylosing spondylitis cause kidney problems?
AS itself mainly affects the spine, joints and tendons, but the NHS complications page lists several possible effects elsewhere in the body, and long-term anti-inflammatory use can affect the kidneys in some people. Your rheumatology team will monitor your blood tests while you are on medication, so report any new symptoms to them.
What is sacroiliitis?
Sacroiliitis is inflammation of the sacroiliac joints, where the spine meets the pelvis. It usually shows as deep buttock pain and morning stiffness, and is a hallmark of AS. It is confirmed with imaging, usually an X-ray or an MRI.
Sources
- NHS: Ankylosing spondylitis overview
- NHS: Ankylosing spondylitis symptoms
- NHS: Ankylosing spondylitis complications
- NICE NG65: Spondyloarthritis in over 16s, recommendations
- NICE NG65: Spondyloarthritis in over 16s, guidance PDF
- Royal Free London: Axial spondyloarthritis patient leaflet
- Royal Free London
- Versus Arthritis
- Versus Arthritis: Ankylosing spondylitis and related conditions booklet
- Gloucestershire NHS clinical pathway: Axial spondyloarthritis