spondyloarthritis.au · an initiative of BJC Health

Could this be inflammatory back pain?

Most back pain is mechanical and settles with time. But some back pain follows a different pattern, especially when it starts before the age of 45:

Stiff and sore in the morning, easing as you get moving
Better with exercise, worse with rest
Waking you in the second half of the night
Coming and going for months, or years

This pattern can point to inflammatory back pain, a condition many people live with for years before it is recognised. It is worth checking.

Take the 2-minute back pain quiz Free. Anonymous. It won't diagnose you, but it will tell you whether a rheumatology assessment may be worth considering.

Two kinds of back pain, two very different causes

Mechanical back pain comes from the structures of the back: muscles, discs and joints under strain. Inflammatory back pain is different. It happens when the immune system causes inflammation in the joints of the spine and pelvis, most often the sacroiliac joints where the spine meets the pelvis. The two can feel similar, but the pattern usually gives it away.

Mechanical back pain tends to be...

Brought on by lifting, injury or a specific movement
Worse with activity, better with rest
Short-lived, usually settling within days to weeks
Not associated with long morning stiffness

Inflammatory back pain tends to be...

Gradual in onset, often starting before age 45
Better with exercise, worse with rest
Persistent for more than three months, often coming and going
Accompanied by morning stiffness lasting over 30 minutes, and pain that wakes you in the second half of the night

7+ yearsaverage delay to diagnosis

Inflammatory back pain is easy to miss. It usually starts young, when back pain is common and rarely investigated. Early X-rays often look normal, symptoms come and go, and it gets put down to sport, posture or a desk job. Studies consistently show people wait years, on average seven or more, between their first symptoms and a diagnosis. Recognising the pattern early is the single biggest thing you can do to shorten that wait.

Recognise your own back pain in the right-hand column? The quiz takes two minutes and will help you work out whether an assessment is worth considering.

The bigger picture

Inflammatory back pain is often the first sign of spondyloarthritis

Spondyloarthritis is a family of related inflammatory conditions. When the inflammation mainly affects the spine and the sacroiliac joints, where the spine meets the pelvis, it is called axial spondyloarthritis, or axSpA. Ankylosing spondylitis is the more advanced form, where changes can be seen on X-ray. Earlier on, the changes may only show on MRI, or not on scans at all.

It is not only about the back. Spondyloarthritis can also involve other joints, the points where tendons attach to bone, the skin, the bowel and the eyes. This is why the questions in the quiz above asked about things that might seem unrelated to your back.

The reach of spondyloarthritis

Because it is driven by the immune system, spondyloarthritis can show up well beyond the spine. These features can appear before, alongside or after back symptoms, and noticing them helps with reaching a diagnosis.

EyesUveitis: a painful, red, light-sensitive eye that comes on quickly and needs prompt attention.

SkinPsoriasis: a scaly rash, often on the scalp, elbows or knees.

NailsPitting, ridging or lifting of the nail from its bed.

GutInflammatory bowel disease, such as Crohn’s disease or ulcerative colitis.

A figure with the spine highlighted. Spondyloarthritis is one condition with many signs across the body.

Other jointsSwelling or pain in joints beyond the spine, such as knees, ankles or hips.

Heels & tendonsEnthesitis: pain where tendons and ligaments attach to bone.

Fingers & toesDactylitis: a whole finger or toe swelling up like a sausage.

Whole-body healthLongstanding inflammation can affect energy, and bone and heart health, worth monitoring with your team.

Noticing any of these alongside back pain? Take the quiz or mention them to your GP.

The axial spondyloarthritis spectrum

Axial spondyloarthritis is one condition seen at different stages. It does not always look the same on a scan.

Earlier · inflammationMore established · fusion

Non-radiographic axSpA

Inflammation and symptoms are present, but X-rays still look normal. Inflammation may show on MRI, or not on scans at all yet. This early stage is easily missed.

Ankylosing spondylitis

The more established form, where bony bridges have formed and changes to the sacroiliac joints and spine are visible on X-ray.

Over time, some people’s condition moves along this spectrum, and many do not. Both ends are the same underlying condition, and both are worth diagnosing and treating.

Axial spondyloarthritis

Inflammation centred on the spine and sacroiliac joints. Ankylosing spondylitis is the form with visible X-ray changes.

Psoriatic arthritis

Joint inflammation linked with psoriasis. It can affect the spine, the limbs, or both.

More at psoriaticarthritis.au →

Enteropathic arthritis

Arthritis associated with inflammatory bowel disease, such as Crohn's disease or ulcerative colitis.

Reactive arthritis

Joint inflammation that can follow certain infections, sometimes affecting the spine and other joints.

The axSpA roadmap: a one-page guide showing what to expect from diagnosis onwards, how the care team helps at each step, and what you can do yourself, with movement at the heart of it.

What happens after a diagnosis, on one page

If axial spondyloarthritis is diagnosed, this free one-page guide maps out what typically comes next: getting answers, settling symptoms and staying active for the long term. It shows how your care team helps at each step and what you can do yourself, with movement at the heart of it.

Download the axSpA roadmap (free PDF)

Why it is worth checking

Recognising it early changes what happens next

The long delay to diagnosis is not just frustrating. It is time during which the condition may be active and untreated. Getting an answer earlier opens up options that work best when they are started sooner rather than later.

Treatment can begin

Once inflammatory back pain is recognised, there are effective treatments. These generally work best when inflammation is addressed early, rather than after years of untreated symptoms.

Movement can be guided

Exercise is a core part of managing spondyloarthritis. Knowing what you are dealing with means a physiotherapist can guide the right kind of movement, instead of you guessing or avoiding activity.

The whole picture gets seen

A diagnosis prompts attention to the things that travel with spondyloarthritis, such as eye inflammation, bowel symptoms, and bone and heart health, so they can be watched for and looked after.

An earlier diagnosis will not guarantee any particular outcome, and everyone's experience is different. But it does give you and your doctors the chance to act while there is the most to gain. If the quiz suggested your pattern is worth checking, the sensible next step is a conversation with your GP or a rheumatology assessment.

How it is treated

Spondyloarthritis is very treatable

There is no single fix, and treatment is always tailored to the person. But there is a clear, well-established approach, and it usually combines movement with medicines that calm the underlying inflammation. The aim is to control symptoms, keep you moving, and protect the spine and joints over the long term.

Movement and physiotherapy

Exercise is the cornerstone of managing spondyloarthritis, not an optional extra. Regular stretching, mobility and strengthening help maintain posture and function, and a physiotherapist can tailor a program safely.

See our physiotherapy options →

Anti-inflammatory medicines

NSAIDs (non-steroidal anti-inflammatory drugs) are usually the first medicines tried, and they can work well for the pain and stiffness. COX-2 inhibitors are a type of NSAID that may be gentler on the stomach for some people.

Used safely, these mean the lowest effective dose for the shortest time needed, taken with your doctor's guidance and regular review, keeping an eye on the stomach, kidneys and heart. Always check with your GP or pharmacist before starting them.

Specialised medicines

When symptoms are not controlled by the above, a rheumatologist can prescribe targeted treatments that block specific drivers of inflammation. These include biologic medicines such as TNF inhibitors (TNFi) and IL-17 inhibitors (IL-17i), and targeted tablets such as JAK inhibitors (JAKi).

These are prescribed and monitored by a rheumatologist, and in Australia are subsidised through the PBS for people who meet the eligibility criteria.

The right combination is decided with your rheumatologist, based on how active the condition is and what matters to you. This page is general information and is not a recommendation about any specific medicine.

Movement is medicine

Physiotherapy is central to living well with spondyloarthritis

In spondyloarthritis, the right movement is not just helpful, it is part of the treatment. A physiotherapist who understands the condition can assess how it is affecting you, then guide exercise that keeps your spine mobile and your body strong. At BJC Health, physiotherapists work in the same team as our rheumatologists.

Metrology assessment

A set of careful, standardised measurements of your spinal movement, posture and flexibility. It gives you and your care team an objective baseline, so changes over time can be tracked properly rather than guessed at. Useful whether you are newly diagnosed or have lived with the condition for years.

What does the assessment measure?

A metrology assessment usually draws on three standardised tools used in spondyloarthritis. Together they build a picture of mobility, symptoms and function:

BASMI (Bath Ankylosing Spondylitis Metrology Index) is the physical part: your physiotherapist takes a small set of measurements of how your spine and hips move, such as how far you can bend sideways, turn your neck, reach your head towards a wall, bend forwards, and open your hips. These give an objective mobility score.

BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) is a short questionnaire about how active your symptoms feel, covering fatigue, spinal and joint pain, tenderness, and the amount and length of morning stiffness.

BASFI (Bath Ankylosing Spondylitis Functional Index) is a short questionnaire about how easily you manage everyday physical tasks, such as bending, reaching and standing.

Repeating these over time is how your team sees whether things are holding steady, improving, or need a rethink.

Ankylosing spondylitis exercise program

A guided program built around what the evidence supports for axial spondyloarthritis: stretching, mobility and strengthening tailored to where you are. You learn what to do, how to do it safely, and how to keep it going as part of everyday life.

See our 6-week AS/SpA program →

Book a physiotherapy appointment You do not need a rheumatology diagnosis to see one of our physiotherapists. A GP referral may allow a Medicare rebate under some care plans.

You do not have to wait alone

Join BJC Connect, free

Whether you are still working out what is going on, waiting on an appointment, or already living with spondyloarthritis, BJC Connect is a free online community with practical information and real support. It is open to anyone in Australia, whether or not you are a BJC Health patient.

Live events every fortnight with our clinicians and guests, on topics that matter to people with rheumatic conditions.

A library of recordings, ebooks, videos and recipes you can work through in your own time.

Practical, everyday information on movement, eating well and managing life with a long-term condition.

A community of people who get it, so you are not piecing things together on your own.

Create a free account Free for anyone in Australia. No cost, no obligation.