Most chronic back pain in Lakewood Ranch is mechanical. A disc pressed against a nerve, a facet joint worn from years of poor posture, muscles that tightened around an old injury and never let go. Mechanical pain generally feels worse when you move and better when you rest. That pattern is so common that when someone walks into the clinic describing it, a disc or joint problem is usually the right first guess.
But roughly one in two hundred adults carries a different diagnosis: ankylosing spondylitis (AS), a form of inflammatory arthritis that targets the spine and sacroiliac joints. The pain looks similar on the surface. The pattern underneath is almost the opposite. AS pain gets worse with rest and better with movement. Mornings are brutal. Anti-inflammatories help more than muscle relaxants. And the longer a diagnosis is delayed, the more irreversible structural damage accumulates.
In our 23-plus years of practice, we have seen AS patients who spent years being treated for "disc problems" with limited progress, then got the right diagnosis and found an entirely different path forward. This article is not a substitute for a rheumatology workup. What it is: a description of the signals that should send you in that direction.
What Ankylosing Spondylitis Actually Is
AS is a seronegative spondyloarthropathy, which is medical shorthand for a form of inflammatory arthritis that does not show up on the standard rheumatoid arthritis (RA) blood panel. It belongs to a family of conditions that includes psoriatic arthritis, reactive arthritis, and inflammatory bowel disease-related arthritis. The inflammation targets the entheses: the points where ligaments and tendons attach to bone.
In the spine, the primary targets are the sacroiliac (SI) joints at the base of the pelvis, then gradually the vertebral joints upward. Over years, uncontrolled inflammation can cause the vertebrae to fuse. A fully fused spine has a characteristic appearance on X-ray called "bamboo spine." That endpoint takes decades to reach and is not inevitable with early treatment, but it is the reason a delayed diagnosis carries real consequences.
The condition strongly favors people who carry the HLA-B27 genetic marker. Around 90 percent of people with AS are HLA-B27 positive, though most HLA-B27 carriers never develop AS. Men are historically more often diagnosed, but research from the last decade suggests AS is more common in women than previously thought, often presenting with more peripheral joint involvement and less dramatic X-ray findings, which contributed to under-diagnosis.
The Classic Symptom Pattern
The 2009 Assessment of SpondyloArthritis International Society (ASAS) criteria formalized what clinicians had observed for decades. Inflammatory back pain, by their definition, meets at least four of five criteria:
- Age of onset under 40
- Insidious onset (gradual rather than following a specific incident)
- Improvement with exercise (not with rest)
- No improvement with rest
- Pain at night, typically waking in the second half of the night
The last two deserve extra attention. Waking at 3 or 4 a.m. with lower back or buttock pain that drives you out of bed, followed by stiffness that takes 30 minutes to an hour to loosen after you start moving: this is not a disc flare. Disc pain tends to ease when you lie still. Inflammatory pain does not, because the inflammation continues whether you move or not, and immobility lets it accumulate.
Morning stiffness lasting more than 30 minutes is a red flag regardless of cause. In mechanical back pain, stiffness after waking is usually gone within 15 minutes. In AS, stiffness often persists for an hour or more and has a strong inflammatory character: joints feel "locked," not simply sore.
Sacroiliac Joint Pain as the Starting Point
The SI joints are the most common first site of AS inflammation. Pain typically presents in one or both buttocks, sometimes radiating down one or both thighs in a pattern that can mimic sciatica. The difference is that true AS-related SI joint pain is rarely the sharp, electric, dermatomal pain that a compressed nerve root produces. It is more often described as a deep, bilateral ache that alternates sides. One week the left buttock hurts, the next the right.
That alternating, bilateral quality is important. A herniated disc at L4-L5 or L5-S1 produces leg symptoms that stay on one side. Bilateral, alternating pain across the SI joints points toward an inflammatory process.
On physical examination, provocative SI joint tests, the FABER test (Flexion, ABduction, External Rotation), and the sacral thrust reproduce pain in the SI region. These tests are not diagnostic on their own, but a positive cluster alongside the symptom pattern warrants imaging. Early AS may not show on plain X-ray; MRI of the SI joints often reveals bone marrow edema (a sign of active inflammation) years before structural changes become visible on X-ray.
"The distinction that matters most in my 23 years of practice is this: if rest makes your back worse and movement makes it better, you are not dealing with a straightforward mechanical problem. The workup needs to go in a different direction." —Dr. Michael Banman, DC
Other Signs That Separate AS from Mechanical Back Pain
Back pain is not the only signal. AS is a systemic inflammatory condition, and it often announces itself through other body systems before a diagnosis is made:
- Uveitis (eye inflammation): Sudden redness, pain, and light sensitivity in one eye, often recurring. Uveitis occurs in roughly 30 percent of AS patients at some point and frequently precedes a spine diagnosis by years.
- Enthesopathy: Pain and swelling where tendons attach to bone. Achilles tendinitis that does not respond to standard treatment, plantar fasciitis that started without an obvious cause, pain at the rib attachments to the sternum (costochondritis-like presentation) are all enthesopathy patterns seen in spondyloarthritis.
- Peripheral joint swelling: Large joint involvement (knees, ankles, hips) sometimes occurs alongside axial symptoms, particularly in women.
- Fatigue disproportionate to activity: Not the tiredness of a hard training week. A bone-deep, persistent fatigue that rest does not resolve is common in active inflammatory disease.
- Inflammatory bowel symptoms: AS and Crohn's disease share genetic risk factors. Chronic diarrhea or bowel irregularity alongside back pain raises the clinical suspicion.
- Family history: HLA-B27 is heritable. A first-degree relative with AS, psoriasis, inflammatory bowel disease, or reactive arthritis increases individual risk.
Why AS Gets Missed for Years
The average delay between symptom onset and AS diagnosis is historically eight to eleven years. That gap has been shrinking with better awareness and MRI accessibility, but it remains long. Several things drive the delay:
First, early AS is invisible on plain X-ray. Structural changes to the SI joints require years of cumulative damage. A normal X-ray report gives a false reassurance that nothing structural is wrong. MRI of the SI joints is far more sensitive for early disease, but it is not the first study ordered when a young person reports back pain.
Second, AS can look exactly like any other low back pain at presentation. Young adults with back pain are often told they "strained" something, given a short course of NSAIDs or physical therapy, and discharged. When NSAIDs work remarkably well (better than they do for most mechanical pain), that finding sometimes gets interpreted as the problem being solved rather than as a diagnostic clue.
Third, the condition is more common in men, and the diagnostic criteria were largely developed on male patients. Women with AS often have more diffuse, less obviously spinal symptoms, which leads to delays in referral.
For context, this is one reason that when patients come to us with back pain that does not respond as expected to conservative mechanical care, we consider whether the working diagnosis needs revisiting. A chiropractor's role here is not to diagnose or treat AS directly. It is to recognize the pattern and facilitate referral to a rheumatologist, who has the imaging, lab tools, and biologic medications that change outcomes. Identifying that something does not fit the mechanical model is clinical value.
The Role of Chiropractic Care in AS Management
Rheumatology is the specialty that leads AS treatment. Biologic medications (TNF inhibitors like adalimumab, IL-17 inhibitors like secukinumab) have transformed the prognosis for many patients and are the cornerstone of disease modification. Nothing in chiropractic care replaces that.
Where chiropractors contribute is in the management of the mechanical and postural consequences that accumulate alongside the inflammatory disease. Patients with controlled AS often develop:
- Reduced thoracic and lumbar mobility from protective muscle guarding
- Hip flexor tightening and reduced hip range of motion
- Forward head posture and reduced cervical mobility
- Pain from myofascial compensation patterns in the paraspinal muscles
Gentle mobilization, soft tissue work, and specific stretching and strengthening can address these secondary changes and improve function in patients whose inflammatory disease is managed medically. In Lakewood Ranch and the broader Bradenton-Sarasota region, we see patients in this situation who benefit from coordinated care between their rheumatologist and our clinic. We treat the mechanical overlay; they treat the underlying inflammation. Both are necessary for best outcomes.
What we do not do: high-velocity thrust manipulation to an acutely inflamed or potentially fused segment. That would be contraindicated. Assessment determines the approach. Patients are always evaluated for contraindications before any spinal work.
For patients dealing with spinal stenosis or structural narrowing that developed alongside longstanding AS, the constellation of conservative options is similar: decompression, gentle mobilization, posture correction, and close monitoring of symptoms. The starting point is always a clear picture of what the spine looks like and how active the disease currently is.
What to Do If This Pattern Sounds Familiar
You do not need to arrive at a chiropractic clinic with a diagnosis already in hand. What matters is describing your symptoms accurately: when the pain is worst, what makes it better or worse, how long morning stiffness lasts, whether you have had eye inflammation, what your family history looks like.
If the pattern points toward inflammatory rather than mechanical back pain, the next step is rheumatology referral, not continued trial of mechanical treatment. A referral requires your primary care physician in most cases, but having a clear clinical narrative, ideally from a provider who has examined you and can describe the pattern in detail, makes that conversation much more direct.
Early referral matters. The biologic medications available today for AS are effective at reducing inflammation, preventing structural damage, and maintaining quality of life. Those outcomes depend on catching the disease early enough that significant fusion has not occurred. The window is real. The delay in diagnosis is not inevitable if the pattern is recognized.
For more context on how morning stiffness specifically differs between mechanical and inflammatory causes, see our article on morning stiffness and inflammatory vs. mechanical spine conditions. For a deeper look at the SI joint and when it drives lower back pain, our SI joint article walks through the mechanics and the diagnostic picture in detail.
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Your back pain deserves an accurate diagnosis
Whether the cause is mechanical, inflammatory, or a combination, the path forward starts with understanding what is actually happening. Dr. Banman has 23-plus years of experience sorting through exactly these patterns at our Lakewood Ranch clinic.
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