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Finding the Right Treatment for Axial Spondyloarthritis

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7 Symptoms of Non-Radiographic Axial Spondyloarthritis

Medically Reviewed By Stella Bard, MD

When joint damage doesn’t show up on X-rays, these symptoms can help your doctor make a diagnosis and suggest treatment.


Axial spondyloarthritis is a chronic inflammatory condition that affects joints of the spine, chest, and pelvis. It’s an umbrella term that includes two types:

  • Radiographic axial spondyloarthritis (r-AxSpA): This type causes lower back pain and limits movement. Your doctor can see evidence of damage to the sacroiliac joints on your X-rays where your lower spine and pelvis meet. Ankylosing spondylitis is another name for this type.
  • Non-radiographic axial spondyloarthritis (nr-AxSpA): This type also causes lower back pain, but sacroiliac joint damage isn’t visible on X-rays.

You can have symptoms, even if no signs of joint damage are visible on your X-rays. The symptoms can be very similar to those of r-AxSpA, which makes the two conditions hard even for rheumatologists to tell apart. 

Your doctor can use a combination of your symptoms, blood tests, and imaging tests to make a diagnosis. MRI is a more sensitive test for diagnosing nr-AxSpA since it may reveal joint inflammation that may not be visible on X-rays.

The most common symptoms of nr-AxSpA can include the following:

1. Joint pain 

Nr-AxSpA inflames the joints. Inflammation causes chronic pain, especially in the lower back, buttocks, and hips. Pain is usually the first symptom of axial spondyloarthritis. You may feel it only on one side or alternating from side to side.

Axial spondyloarthritis pain usually feels like a dull ache, and sometimes it can be severe.

The pain develops slowly over weeks or months, lasting longer than 3 months. You may also have swelling, discoloration, and warmth in the affected joints. 

Pain can also affect other body parts, including your:

  • arms and legs
  • heels
  • knees
  • neck
  • rib cage
  • shoulders

Sometimes, pain starts in one of these joints instead of the back. According to the Spondylitis Association of America, men may have pain in their lower back, while women can feel it in other joints first. Pain in other joints can make it hard to tell whether you have axial spondyloarthritis or another type of arthritis.

2. Morning stiffness

Like other forms of inflammatory arthritis, axial spondyloarthritis pain can get better with activity and worse with rest. Your joints may hurt most when you get up in the morning. The pain should improve after you exercise or take a warm shower.

3. Fatigue

Your body uses a lot of energy to manage the inflammation from nr-AxSpA. Chemical messengers called cytokines that your immune system releases during the inflammatory process may also tire you. Pain can make it hard for you to sleep.

Fatigue from axial spondyloarthritis can be severe. The exhaustion may affect your relationships, work, social life, and mental health.

4. Eye problems

Axial spondyloarthritis can inflame the iris (colored part of the eye), a condition called iritis. It can also cause inflammation in the uvea (middle layer), which is called uveitis. Symptoms include eye pain, redness, light sensitivity, and blurred vision. Iritis is a medical emergency that needs immediate treatment.

5. Enthesitis

Other symptoms of nr-AxSpA are pain and swelling in the entheses. These are the areas where tendons attach to the bones in your heel, rib cage, and spine.

6. Bowel symptoms

Abdominal pain, diarrhea, and weight loss are symptoms of inflammatory bowel disease (IBD). According to some studies in a 2021 research review Trusted Source PubMed Central Highly respected database from the National Institutes of Health Go to source , up to 12% of people with axial spondyloarthritis also had IBD, and up to 50% had some inflammation in their gastrointestinal tract.

7. Scaly skin rash

The studies in the 2021 review above showed that 10% Trusted Source PubMed Central Highly respected database from the National Institutes of Health Go to source  of people with axial spondyloarthritis also had psoriasis.

Treatment options

Treatments for nr-AxSpA and r-AxSpA are similar. Doctors often start with nonsteroidal anti-inflammatory drugs like ibuprofen (Advil, Motrin), naproxen (Aleve), indomethacin (Indocin), or celecoxib (Celebrex). Physical therapy may also be part of treatment.

In some cases, certain medications may be ineffective at relieving inflammation and pain. Other options that may be effective include tumor necrosis factor inhibitors or disease-modifying antirheumatic drugs such as methotrexate (Rheumatrex), sulfasalazine (Azulfidine), or tofacitinib (Xeljanz).


The two types of axial spondyloarthritis are radiographic and non-radiographic. Symptoms like back pain, morning stiffness, and fatigue are common with both types. Your doctor can use a combination of your symptoms, blood tests, and MRI to make a diagnosis and treat you.

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  1. Ankylosing spondylitis & nonradiographic axial spondyloarthritis. (n.d.).
  2. Deodhar A. (2019). What is non-radiographic axial spondyloarthritis?
  3. Evans J, et al. (2021). Prevalence of axial spondyloarthritis in patients with inflammatory bowel disease using cross-sectional imaging: A systematic literature review.
  4. Lucasson F, et al. (2022). Prevalence and consequences of psoriasis in recent axial spondyloarthritis: An analysis of the DESIR cohort over 6 years.
  5. Symptoms of non-radiographic axial spondyloarthritis. (n.d.)
  6. Ward MM, et al. (2019). 2019 update of the American College of Rheymatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations for the treatment of ankylosing spondylitis and non-radiographic axial spondyloarthritis.

Medical Reviewer: Stella Bard, MD
Last Review Date: 2024 Jan 5
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