Ankylosing Spondylitis(AS)
Seronegative Spondyloarthropathy – Chronic Inflammatory Axial
Disorder
BY/ Mahmoud Salim
🚨 Ankylosing Spondylitis (AS)
Seronegative Spondyloarthropathy – Chronic
Inflammatory Axial Disorder
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🔵 Definition
AS is a progressive autoimmune inflammatory disorder primarily
affecting the axial skeleton, especially the sacroiliac joints and spine,
leading to pain, stiffness, and progressive spinal fusion.
In severe cases, it can cause a “bamboo spine” appearance due to
syndesmophyte formation.
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🔴 Etiology / Risk Factors
Genetic predisposition: Strong association with HLA-B27
Gender: Male > Female (2-3:1)
Age of onset: Typically 15–40 years
Family history
Environmental/immune triggers
🔵 Pathophysiology
Chronic inflammation at entheses (where ligaments/tendons attach to
bone)
Leads to fibrosis → ossification → ankylosis
Mainly affects: SI joints, spine, costovertebral joints
Extra-articular: Uveitis, aortic root inflammation, pulmonary fibrosis
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🔶 Signs & Symptoms
1. Chronic low back pain >3 months, insidious onset
2. Morning stiffness >30 minutes
3. Improves with exercise, worsens with rest
4. Alternating buttock pain
5. Loss of spinal mobility and chest expansion
6. Enthesitis (Achilles, plantar fascia)
7. Fatigue and systemic symptoms
8. Uveitis (25–40%) – painful red eye, photophobia
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🔵 Clinical Examination
Inspection:
Flattened lumbar lordosis
Thoracic kyphosis
Stooped posture
Palpation:
Tender SI joints
Paraspinal tenderness
Range of Motion:
↓ Lumbar and cervical spine mobility
↓ Chest expansion (<5 cm abnormal)
Muscle Testing:
Often weak spinal extensors, glutes, and core
✅ Clinical Tests
1. Schober’s Test – Assesses lumbar spine mobility
2. FABER (Patrick’s Test) – SI joint pain provocation
3. Gaenslen’s Test – SIJ stress test
4. Chest Expansion Test – <2.5–5 cm is abnormal
5. Occiput-to-wall distance
6. Modified Thomas Test – Check hip flexor tightness
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Investigations
Radiographs: Bilateral sacroiliitis (early), “bamboo spine” (late)
MRI: Detects early sacroiliitis and active inflammation
Blood tests: ↑ ESR, CRP; Positive HLA-B27
Pulmonary Function Test (for chest wall involvement)
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➡️Differential Diagnosis
Mechanical LBP
Rheumatoid arthritis
Psoriatic arthritis
SIJ dysfunction
DISH (Diffuse idiopathic skeletal hyperostosis)
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✅✅✅Physical Therapy Role
1. Patient Education
Disease process & importance of postural training
Emphasize movement, daily exercise, smoking cessation
2. Stretching (Key for maintaining spinal and hip mobility)
Hamstring Stretch
Hip Flexor Stretch (Modified Thomas)
Quadratus Lumborum Stretch
Upper Trapezius & Levator Scapulae Stretch (for postural control)
Pectoralis Major Stretch (open thorax)
Thoracic Extension Stretch over foam roller
Cervical Stretch (chin tuck with overpressure)
3. Strengthening & Mobility Exercises
Deep core activation (transversus abdominis, multifidus)
Glute bridges, clamshells
Scapular stabilization
Postural correction drills
Wall angels
Chin tucks, cervical retraction
Segmental spine mobilization with breathing
Swimming, walking, Pilates
4. Advanced Manual Therapy Techniques
SI joint mobilizations (Grade I–II if painful)
Maitland & Mulligan mobilizations (especially thoracic spine)
Myofascial release (paraspinals, QL, lats)
Rib mobilizations
Muscle energy techniques for pelvic correction
5. Respiratory Therapy
Diaphragmatic breathing
Lateral costal expansion exercises
Incentive spirometry if chest expansion reduced
6. Postural Training / Gait Correction
Emphasis on upright posture
Wall posture correction
Gait drills if kyphotic stoop affects function
Nerve Gliding / Neural Mobilization (If
radicular symptoms are present)
While AS itself is not a neural entrapment, neural tension symptoms due
to postural changes or inflammation may benefit from:
Sciatic Nerve Gliding
Femoral Nerve Gliding
Brachial Plexus Sliders (if thoracic outlet suspected)
Perform gently and avoid excessive provocation
Prognosis & Outcomes
Progressive but manageable with early detection & consistent PT
Surgery (THR, spinal osteotomy) for advanced cases
Exercise > Medication for long-term function
Early physical therapy improves outcomes, reduces deformity risk
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Bonus Clinical Insight
Exercise is the cornerstone of AS management — even more than
NSAIDs in the long-term. Stretching, posture correction, and breathing
exercises prevent disability.
