1. Ankylosing Spondylitis
Musculoskeletal manifestations
Iraj Salehi-Abari MD., Internist Rheumatologist

2. Iraj Salehi-Abari
Definition:
Ankylosing Spondylitis (AS) is a chronic inflammatory disease of the axial skeleton manifested by inflammatory LBP and progressive stiffness of the spine accompanied by enthesitis and/or arthritis
Amir Alam Hosp.

3. Definite inflammatory LBP:
Iraj Salehi-Abari
Definite inflammatory LBP:
LBP lasting for > 3 months and at least 4 out of 5 below parameters:
Age at onset < 40 years
Insidious onset
Improvement with exercise
No improvement with rest
Pain at night (with improvement upon getting up)
Amir Alam Hosp.

4. Probable inflammatory LBP type I*:
Iraj Salehi-Abari
Probable inflammatory LBP type I*:
LBP lasting for < 3 months and at least 4 out of 5 below parameters:
Age at onset < 40 years
Insidious onset
Improvement with exercise
No improvement with rest
Pain at night (with improvement upon getting up)
* [Defined by Iraj Salehi-Abari, Rheumatol Int, 2012]
Amir Alam Hosp.

5. Probable inflammatory LBP type II*:
Iraj Salehi-Abari
Probable inflammatory LBP type II*:
LBP lasting for > 3 months and 2–3 out of 5 below parameters:
Age at onset < 40 years
Insidious onset
Improvement with exercise
No improvement with rest
Pain at night (with improvement upon getting up)
* [Defined by Iraj Salehi-Abari, Rheumatol Int, 2012]
Amir Alam Hosp.

6. Clinical Features: Axial joint involvement;
Iraj Salehi-Abari
Clinical Features:
Axial joint involvement;
Spondylitis and Sacroiliitis
Peripheral joint involvement:
Root joints (Hip, Shoulder), other
Enthesitis:
Plantar fasciitis, Achille tendinitis
Extra-articular involvement
Amir Alam Hosp.

7. Initial presentation:
Iraj Salehi-Abari
Initial presentation:
History:
Inflammatory LBP
Buttock pain
Heel pain
Back pain
Cervical pain
Articular pain (Shoulder, Hip, Knee, Ankle)
Chest pain
Amir Alam Hosp.

8. Initial presentation:
Iraj Salehi-Abari
Initial presentation:
Physical examination:
Spondylitis:
Axial tenderness
Limitation of motion in all directions
Sacroiliitis:
Positive Sacral push test
Enthesitis:
Plantar fasciitis, Achille tendinitis, …
Arthritis:
Shoulder, Hip, Knee, Ankle, …
Amir Alam Hosp.

9. Initial presentation*:
Iraj Salehi-Abari
Initial presentation*:
History:
A male (75%) with age of years
Definite inflammatory LBP: #65%
Probable inflammatory LBP: 25%
Buttock pain
(+) Family history (FH) of AS #10%
*Iraj Salehi-Abari, Early diagnosis of AS, Rheumatol Int. 2012, table 3
Amir Alam Hosp.

10. Initial presentation*:
Iraj Salehi-Abari
Initial presentation*:
A Positive FH:
In first-degree relatives:
Increases the risk of AS by folds
In second-degree relatives:
Increases the risk of AS by folds
*Iraj Salehi-Abari, Early diagnosis of AS, Rheumatol Int. 2012, table 3
Amir Alam Hosp.

11. Initial presentation*:
Iraj Salehi-Abari
Initial presentation*:
Physical examination:
Lumbar LOM in all direction: 75%
Positive sacral push test: > 20%
Enthesitis: #30%
Arthritis: 40%
Limited chest expansion: < 2%
No systemic manifestations
*Iraj Salehi-Abari, Early diagnosis of AS, Rheumatol Int. 2012, table 3
Amir Alam Hosp.

12. Axial involvement: Sacroiliitis: Spondylitis: Buttock pain
Iraj Salehi-Abari
Axial involvement:
Sacroiliitis:
Buttock pain
Sacral push test
Spondylitis:
Inflammatory LBP
Back pain
Neck pain
Spinal limitation of motion
Limited chest expansion
Amir Alam Hosp.

13. Spinal limitation of motion:
Iraj Salehi-Abari
Spinal limitation of motion:
Schober sign: 10 cm above S1 (5. 1-2)
Ott sign: 30 cm below C7 (2-4, 1-2)
Fingertips-to-floor distance test
Occiput to wall test
Chest expansion test
Amir Alam Hosp.

14. Iraj Salehi-Abari
Amir Alam Hosp.

15. Iraj Salehi-Abari
Amir Alam Hosp.

16. Iraj Salehi-Abari
Amir Alam Hosp.

17. Iraj Salehi-Abari
Amir Alam Hosp.

18. Enthesitis: Inflammation of Enthesis Chest and spinal enthesitis
Iraj Salehi-Abari
Enthesitis:
Inflammation of Enthesis
Chest and spinal enthesitis
Extraspinal enthesitis
Amir Alam Hosp.

19. Chest and spinal enthesitis:
Iraj Salehi-Abari
Chest and spinal enthesitis:
Costosternal
Costovertebral
Spinous processes
Paraspinal
Iliac crests
Ischial tuberosities
Sternoclavicular
Manubriosternal
Amir Alam Hosp.

20. Extraspinal enthesitis:
Iraj Salehi-Abari
Extraspinal enthesitis:
Heels:
Achilles tendonitis
Plantar fasciitis
Shoulder tendonitis
Greater Trochanters
Tibial tubercles, Others
Differentiated with FMS by dramatic response to NSAIDs
Amir Alam Hosp.

21. Peripheral arthritis:
Iraj Salehi-Abari
Peripheral arthritis:
Limb arthritis
Upper limb joints
Lower limb joint
Root joint: Hip & shoulder
Extra-limb arthritis
TMJ arthritis
Sternoclavicular arthritis
Amir Alam Hosp.

22. Peripheral arthritis:
Iraj Salehi-Abari
Peripheral arthritis:
Root joints arthritis: 25-35%
Other joints: 30%
Early hip arthritis: worse prognosis
Amir Alam Hosp.

23. Peripheral arthritis:
Iraj Salehi-Abari
Peripheral arthritis:
Asymmetric > symmetric arthritis
Lower limb > upper limb
Large > small
Acute > chronic
Non-erosive non-deforming > erosive-destructive
Mono > oligo > polyarthritis
It is in opposite point of RA
Amir Alam Hosp.