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Consideration of Ankylosing Spondylitis Inflammatory disease is a less common cause of low back pain, but it is nonetheless important to differentiate it from the more common mechanical low back pain. Ankylosing Spondylitis is a chronic inflammatory disease. Clinically more common in men than women, approximately 5% of patients presenting with back pain have ankylosing spondylitis. Characteristic symptoms are low back pain with prolonged early morning stiffness that improves with exercise. It usually occurs in the third decade of life and onset after 45 years of age is exceptional. Information sheet developed by Pennine MSK Partnership, and kindly supplied for inclusion in the toolkit. Clinical suspicion ASAS Criteria 2009 Age at onset < 40yrs Insidious onset Improvement with exercise No improvement with rest Pain in night (with improvement on getting up) Other considerations Clinical Knowledge Summary 2008 suggest Ankylosing Spondylitis should be suspected in anyone with chronic or recurrent low back pain, fatigue and stiffness, especially if: They have current or previous: Buttock pain, felt sometimes on one side and sometimes on the other side — the pain is from sacroiliitis and to be distinguished from sciatica. Arthritis — usually asymmetric, in the lower limbs; occasionally in the upper limbs. Enthesitis: Common sites are Achilles tendon, plantar fasciitis and the tibial tuberosity Costochondritis or epicondylitis Anterior uveitis (iritis): acutely painful red eye and severe photophobia. If treatment is delayed, vision may be lost. Psoriasis or inflammatory bowel disease, or recent infective diarrhoea or sexually transmitted disease (Chlamydia). Physical examination (including Schober’s test) Confident in assessing clinical suspicion of inflammatory back condition YES Examination Spinal examination Investigations ESR, CRP Consider X-ray Start NSAID if no contraindications NO Refer to GPsi if available/ Secondary Care Appointment with Rheumatology consultant To review with results Review NSAID Further investigations, such as MRI & HLA B27 may be considered Refer AS physiotherapist, for BASDAI and Spinal VAS measurements Refer Rheumatology nurse for education and contact if available Information sheet developed by Pennine MSK Partnership, and kindly supplied for inclusion in the toolkit.