Back Pain Doctor
Ankylosing Spondylitis (Axial Spondyloarthritis)
Ankylosing spondylitis is an autoimmune condition in which the immune system attacks the bones, ligaments and joints of the spine and pelvis. The sacroiliac joints, where the base of the spine meets the pelvis, are often where changes appear first. Over time, ongoing inflammation can cause vertebrae to fuse, reducing movement. It is roughly twice as common in men, tends to run in families, and is strongly associated with the HLA-B27 gene — though most people who carry that gene never develop the disease. It also affects structures beyond the spine: the entheses where tendons attach to bone, most recognisably at the heel, and the eye, in the form of anterior uveitis.
Assessment focuses on identifying the inflammatory pattern early, because this is the diagnosis most often missed in a back pain practice. A young adult with months of morning-predominant back stiffness that improves with exercise is a very different problem from a mechanical strain, and treating it as one delays effective care. Examination looks at spinal movement in all directions and at the entheses; investigation combines inflammatory markers, HLA-B27 and imaging. Because this condition also causes osteoporosis, a sudden increase in spinal pain after even minor trauma warrants prompt assessment for fracture.
First-line care is exercise and physiotherapy to preserve spinal flexibility, together with anti-inflammatory medication. Where symptoms are not controlled, referral to a rheumatologist is the appropriate next step, as biologic and targeted therapies are prescribed and monitored in that setting. The role of a musculoskeletal GP here is recognition, initial investigation, timely referral, and shared ongoing care — including monitoring for the associated problems of osteoporosis, uveitis and cardiovascular risk. A sudden red, painful, light-sensitive eye needs same-day assessment.
This page is general educational information and does not replace individual medical advice. Please speak with your GP about your own circumstances.
Common symptoms
- Back or buttock pain and stiffness starting before age 45, often over months
- Marked morning stiffness that eases with movement rather than rest
- Pain that wakes you in the second half of the night
- Heel pain, or a red, painful, light-sensitive eye
Evidence for twelve treatment options in ankylosing spondylitis (axial spondyloarthritis)
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation — diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Core care
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan — with weight management where that is clinically relevant.
What the evidence shows
Exercise and education sit alongside medical disease control, not instead of it. Both the ASAS-EULAR recommendations and the American College of Rheumatology guideline place education, regular exercise and physical therapy as core non-pharmacological management in axial spondyloarthritis, escalating to a biologic where disease activity stays high (Ramiro, Ann Rheum Dis 2023; Ward, Arthritis Rheumatol 2019).
Pairing reviewed 2026-09-02.
Where it fits for you
The critical point is sequencing: this does not replace rheumatological treatment, and a delay in getting disease control is the thing that causes lasting damage. Assessment here is aimed at recognising the pattern early and getting you to the right treatment, with exercise supporting it throughout.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Only if relevant
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with 0.02-0.08% lignocaine is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling — the same technique with nothing injected — is not offered here.
What the evidence shows
No trial evidence in axial spondyloarthritis. Secondary muscular pain around a stiff spine is common, and is treated as muscular pain rather than as the disease.
Pairing reviewed 2026-08-30.
Where it fits for you
Occasionally helpful for a specific tender band that is limiting the exercise programme. The exercise programme is the treatment.
Ultrasound-guided injections Guidance means we can see the needle reach the target. What goes into the needle depends on the diagnosis. Only if relevant
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis — and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
Injection has no role in controlling the spinal disease. Where a separate peripheral joint, bursa or tendon sheath is symptomatic, ultrasound guidance improves needle placement at those targets, and corticosteroid is used sparingly in inflammatory disease because repeated doses can undermine tendon and bone.
Pairing reviewed 2026-08-30.
Where it fits for you
Occasionally useful for a specific peripheral problem, in discussion with the treating rheumatologist. Never a substitute for disease-modifying treatment.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Plausible — no studies
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
No published clinical trial of this device in this condition. It is a vibration handpiece delivered from the same console as radial shockwave, and the rationale is myofascial rather than tendon- or bone-directed.
Pairing reviewed 2026-08-30.
Where it fits for you
A comfort measure used within a session where muscular tightness is limiting movement. Never the reason for the appointment, and not a substitute for the treatments that do have evidence.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. Only if relevant
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue — including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
Same position as focused shockwave. The one randomised trial in axial spondyloarthritis treated co-existing plantar fasciitis, not the spondyloarthritis (Caner, Rheumatol Int 2022, n=22). Nothing addresses the axial disease.
Pairing reviewed 2026-08-30.
Where it fits for you
Only for a co-existing peripheral enthesopathy, and only alongside proper disease control.
Focused shockwave (ESWT) A true shock wave converging at depth — for tendon, joint, ligament and bone. Only if relevant
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form we use for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
Shockwave is not a treatment for the spinal disease itself. Disease control in axial spondyloarthritis is exercise, education and anti-inflammatories first, then a biologic where disease activity stays high (ASAS-EULAR 2022; ACR/SAA/SPARTAN 2019) — no guideline lists shockwave. The only randomised evidence in this population treats a co-existing problem: 22 patients with axial spondyloarthritis and chronic plantar fasciitis, shockwave against sham, with better pain and foot function in the shockwave group (Caner, Rheumatol Int 2022). The trial is small, and an earlier conference report of the same cohort described no difference between groups, so we hold it loosely.
Pairing reviewed 2026-08-30.
Where it fits for you
Considered only where a separate peripheral enthesopathy — a plantar fascia or Achilles — is the thing actually hurting, and treated on its own merits. It does nothing for the sacroiliac or spinal disease, and it is not a reason to delay rheumatology review.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Painless, no contact. Plausible — no studies
What it involves
You sit with the applicator positioned over the area for a short session. Painless, no gel or contact required, and usually delivered as a course — commonly alongside shockwave.
What the evidence shows
There are no published randomised trials of EMTT in this condition, or in any musculoskeletal condition, that we can point to. The supporting work is laboratory work: EMTT increased tenocyte proliferation, migration and collagen expression in cultured human tendon cells (Mancini, Int J Mol Sci 2025). The nearest human evidence for a related electromagnetic therapy is negative — a randomised trial of pulsed electromagnetic field therapy added to eccentric exercise for Achilles tendinopathy found no improvement in outcome scores or tendon neovascularity over eccentric exercise alone (Ko, Orthop J Sports Med 2024).
Pairing reviewed 2026-08-30.
Where it fits for you
Not part of managing inflammatory spinal disease. Offered only as an adjunct alongside treatment that does have evidence, never as the plan itself, and only after that gap is explained. Much of the EMTT literature is manufacturer-affiliated, which is part of why we describe it this way.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Plausible — no studies
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
No randomised trial of platelet-rich plasma in axial spondyloarthritis. This is an immune-mediated inflammatory disease, and the treatments with evidence are systemic.
Pairing reviewed 2026-08-30.
Where it fits for you
Not offered as a treatment for this condition.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Plausible — no studies
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
A PubMed search for prolotherapy or dextrose injection in ankylosing spondylitis or axial spondyloarthritis returns no trials — the published material is single case reports.
Pairing reviewed 2026-08-30.
Where it fits for you
Not part of managing this diagnosis. If a separate mechanical problem is present it is assessed on its own terms, not as treatment for the spondyloarthritis.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Not offered for this
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
Hyaluronic acid is a treatment for an arthritic peripheral joint, not for inflammatory spinal disease.
Pairing reviewed 2026-08-30.
Where it fits for you
Not used for this condition.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve—not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Plausible — no studies
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
No trial evidence for perineural injection in axial spondyloarthritis.
Pairing reviewed 2026-08-30.
Where it fits for you
Not part of managing this condition.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Plausible — no studies
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
No trial evidence for nerve hydrodissection in axial spondyloarthritis.
Pairing reviewed 2026-08-30.
Where it fits for you
Not part of managing this condition.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. Evidence in tendon problems suggests early relief can be followed by worse outcomes at a year than exercise alone, and repeated injections into a joint have been associated with cartilage loss. It does not repair anything.
So we do not build treatment plans around it. Where an injection is the right call, we review the specific diagnosis and target, discuss what is being injected and why, keep the number low, and pair it with the loading work that changes the longer-term course.
When we would still consider it
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal — a trip, a procedure, a return to work
- Diagnostic use, where the response tells us where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other back conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Frequently asked questions
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