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Ankylosing Spondylitis (AS) - Detailed Orthopaedic Clinical Notes

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1. DEFINITION & OVERVIEW

• Part of the seronegative spondyloarthritides group (Moll & Wright, 1970s) - includes AS, psoriatic arthritis, reactive arthritis, IBD-associated arthritis
• Also termed r-axSpA (radiographic axial spondyloarthritis) in modern classification
• Campbell's Operative Orthopaedics 15th Ed, p. 2420

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2. EPIDEMIOLOGY

• Campbell's Operative Orthopaedics, p. 2420; Harrison's 22E, p. 2926

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3. PATHOLOGY & PATHOGENESIS

Key Mechanism: Enthesitis

Progression:

1. Inflammation at enthesis → periarticular osteopenia
2. Inflammatory bone resorption → "squaring off" of vertebral bodies (Romanus lesions - sclerotic shiny corners)
3. Ossification of annulus fibrosus (Sharpey fibres) → syndesmophytes (vertical, thin, marginal)
4. Sparing of anterior longitudinal ligament initially
5. Fusion of posterior elements - facet joints, interspinous/supraspinous ligaments, ligamentum flavum
6. Final result: Bamboo spine appearance
7. Progression: caudal to cephalad (sacroiliac joints → lumbar → thoracic → cervical)

Pathological features:

• Sacroiliitis (bilateral, symmetrical) - synovial portion of SIJ first
• Costovertebral joint involvement → restricted chest expansion
• Hip involvement ("root joint") - diffuse joint space loss, entheseal new bone at femoral head
• Andersson lesion - inflammatory pseudarthrosis at mobile unfused segments (can mimic infection)
• Grainger & Allison's Diagnostic Radiology, p. 1119-1121; Campbell's p. 2420

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4. CLINICAL FEATURES

4a. Spinal Symptoms

• Inflammatory back pain (cardinal symptom): insidious onset, worse in morning/after rest, improves with activity
• Morning stiffness - lasting >30 min, improves with exercise
• Buttock pain (sacroiliac joint origin) - may alternate sides
• Progressive loss of lumbar lordosis → thoracic and cervical kyphosis
• Inability to look above the horizon ("stooped" posture)
• Inability to lie flat in bed

4b. Peripheral Manifestations

• Hip joint - most common peripheral joint (second most after SIJ overall); diffuse joint space loss
• Shoulder, knee (asymmetric, oligoarticular, lower limb predominant)
• Heel pain (calcaneal enthesopathy, Achilles enthesitis)

4c. Extra-articular (Extra-spinal) Features - "3 A's"

4d. Clinical Examination Signs

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5. DIAGNOSTIC CRITERIA

Modified New York Criteria (1984) - Gold Standard for AS

1. Low back pain for ≥3 months, improved by exercise, not relieved by rest
2. Limitation of lumbar spine motion in sagittal AND frontal planes
3. Chest expansion reduced relative to normal for age and sex

• Sacroiliitis grade ≥2 bilaterally, OR grade 3-4 unilaterally

Sacroiliitis Grading (Modified New York Criteria):

• Harrison's Principles 22E, p. 2926-2927; Firestein & Kelley's Rheumatology

ASAS Criteria (2009) - for Axial SpA (broader, includes nr-axSpA):

• Imaging arm: Sacroiliitis on MRI or X-ray + ≥1 SpA feature
• Clinical arm: HLA-B27 positive + ≥2 SpA features

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6. INVESTIGATIONS

MRI Findings (Grainger & Allison's Radiology):

• T1W: Erosions, joint space loss (damage)
• T2 fat-suppressed / STIR: Subchondral edema (active inflammation)
• Romanus lesion MRI equivalent = corner bone edema of vertebral bodies
• Costovertebral joint edema on STIR sagittal

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7. RADIOLOGY - KEY FEATURES

Plain X-ray Progression:

• Periarticular osteopenia
• Loss of SIJ definition / blurring of cortical margins
• Romanus lesion ("shiny corners") - sclerosis at anterior vertebral corners
• Squaring of vertebral bodies (erosion + reactive sclerosis)

• Syndesmophytes - thin, vertical, marginal bone outgrowths (annular ossification)
• Facet joint fusion
• SI joint erosions + sclerosis

• Bamboo spine - complete vertebral body fusion + posterior element fusion
• Complete bilateral SIJ ankylosis
• "Trolley track" sign (posterior element fusion on AP view)
• "Dagger sign" (fused interspinous ligament on AP view)

Distinguishing Syndesmophytes from Osteophytes:

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8. DIFFERENTIAL DIAGNOSIS

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9. MANAGEMENT

9a. Non-operative Treatment

• Daily stretching exercises for hip flexors and hamstrings
• Spinal extension exercises to prevent kyphosis
• Deep breathing exercises to maintain chest expansion
• Swimming is ideal (reduces axial loading)
• Sleeping supine on firm mattress with one pillow to maintain sagittal alignment
• Avoid hip flexion contractures

9b. Operative Management

Types of Spinal Osteotomy:

• Type I: Apex lumbar
• Type II: Apex thoracolumbar
• Type III: Apex thoracic
• Type IV: Apex cervical / cervicothoracic junction
• Campbell's Operative Orthopaedics 15th Ed, p. 2420-2421

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10. COMPLICATIONS & SPECIAL CONSIDERATIONS

Spinal Fractures in AS - HIGH RISK

• Osteopenic + fused spine = highly susceptible to fracture from minor trauma
• Most common site: lower cervical spine
• Often missed on plain X-rays (distorted anatomy from ossification)
• Key sign: Widened anterior disc space (hyperextension injury through disc)
• Always immobilize in position found - do NOT extend (risk of sudden neurological deficit)
• Image entire spine (associated fractures at multiple levels possible)
• CT/MRI/bone scan often needed

Atlantoaxial Instability

• 25-90% of AS patients have atlantoaxial instability
• Must be assessed pre-operatively
• Cervical spine deformity can cause disabling functional deficits

Cauda Equina Syndrome (late)

• Rare; due to arachnoid adhesions from chronic inflammation

Heterotopic Ossification after THA

• Increased risk in AS patients
• Prophylaxis: NSAIDs (indomethacin) or low-dose radiation

Andersson Lesion (Spondylodiscitis)

• Inflammatory pseudarthrosis at mobile segment in otherwise fused spine
• Mimics infection; distinguish by lack of systemic features and MRI pattern

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11. ASSESSMENT TOOLS (Orthopaedic/Rheumatology)

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12. PROGNOSIS

• After ankylosis occurs: pain often improves (burnt-out phase)
• Progressive kyphosis → fixed sagittal imbalance is the main disabling outcome
• Hip involvement → adds significantly to functional loss
• Uveitis: requires regular ophthalmology follow-up to prevent vision changes
• Renal amyloidosis: serious late complication
• Spinal fractures: frequently life-threatening

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SUMMARY TABLE

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• Campbell's Operative Orthopaedics 15th Ed (2026), pp. 2316, 2420-2421
• Grainger & Allison's Diagnostic Radiology, pp. 1119-1121
• Harrison's Principles of Internal Medicine 22E (2025), pp. 2926-2928
• Miller's Review of Orthopaedics 9th Ed, p. 63
• Firestein & Kelley's Textbook of Rheumatology (2-Volume Set)

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Physiotherapy Management of Ankylosing Spondylitis (AS / axSpA)

Evidence-Based Clinical Notes

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1. RATIONALE FOR PHYSIOTHERAPY IN AS

• Inflammation leads to progressive ankylosis - mobility must be actively maintained
• Fused spine can still develop kyphotic deformity; posture must be trained
• Drug therapy (even biologics) does not restore lost mobility - only exercise does
• Functional disability, fatigue, and quality of life are exercise-responsive outcomes
• Evidence confirms: exercise improves BASDAI, BASFI, BASMI, pain, and QoL

Key paradox (Perrotta et al., RMD Open 2021, PMID: 33547227): Biomechanical stress at entheses may theoretically promote inflammation, yet exercise programmes consistently demonstrate therapeutic benefit. The net benefit of structured exercise outweighs any theoretical entheseal risk. Exercise is recommended, not avoided.

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2. PHYSIOTHERAPY GOALS (Outcome Domains)

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3. EVIDENCE SUMMARY

Level 1 Evidence - Meta-Analyses & Systematic Reviews

RCT Level 1 Evidence

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4. PHYSIOTHERAPY ASSESSMENT

4a. Subjective Assessment

• Pain: site, character, onset, duration, radiating, aggravating/relieving factors
• Morning stiffness: duration and severity
• Functional limitations: ADL, work, recreation
• Sleep quality (pain-related)
• Fatigue level
• Psychological status (depression/anxiety common in AS)
• Smoking status (reduces exercise tolerance)
• Medications (NSAIDs, biologics)

4b. Objective Assessment (BASMI - 5 components)

Additional Objective Tests

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5. PHYSIOTHERAPY INTERVENTIONS

5a. THERAPEUTIC EXERCISE (Core Intervention)

PRINCIPLE: Exercise is ALWAYS recommended. The type, setting, and intensity should be individualized.

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A. STRETCHING & FLEXIBILITY EXERCISES

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B. STRENGTHENING EXERCISES

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C. AEROBIC EXERCISE

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D. BREATHING EXERCISES

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E. POSTURAL TRAINING

• Sleeping position: Supine on firm mattress, one flat pillow only (prevents cervical kyphosis)
• No prone sleeping initially if severe kyphosis is present
• Standing posture: Wall standing exercises - head, shoulders, buttocks touching wall
• Ergonomic advice for work (raise monitor height, avoid flexed posture)
• Avoid sitting in deep flexion for prolonged periods

• Brügger posture correction
• Mirror/wall feedback training
• Thoracic extension mobilizations before posture exercises

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F. SPINAL MOBILITY / RANGE OF MOTION EXERCISES

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5b. GROUP vs. HOME vs. SUPERVISED EXERCISE

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5c. MIND-BODY EXERCISE (Tai Chi, Yoga, Pilates, Qigong)

• BASFI improvement: MD -0.76 (P<0.00001)
• BASDAI improvement: MD -0.76 (P<0.00001)
• VAS pain: MD -0.89 (P<0.00001)
• BASMI: MD -0.44 (P=0.0006)
• QoL (ASQoL): MD -2.14 (P=0.003)
• No serious adverse events in any included study
• Tai Chi had the most pronounced pain-reduction effect vs. Qigong

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5d. AQUATIC THERAPY / HYDROTHERAPY

• Aquatic exercise superior to home exercise for pain
• Improved disease activity vs. land-based and control groups
• Improved physical function

• Water buoyancy reduces joint loading
• Warm water (32-35°C) reduces muscle spasm and pain
• Water resistance provides gentle resistance training
• Facilitates movement in patients with severe stiffness or pain

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5e. MANUAL THERAPY & ELECTROPHYSICAL AGENTS

Important: Spinal mobilization/manipulation is contraindicated in severely fused spine due to risk of chalk-stick fracture. Only gentle, graded mobilization techniques should be used in early/inflammatory disease.

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5f. PATIENT EDUCATION (Cornerstone - Equal Status with Exercise)

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6. PHYSIOTHERAPY ACROSS DISEASE STAGES

Stage 1 - Early / Active Inflammatory Phase

• Gentle ROM exercises within pain tolerance
• Hydrotherapy (warm water reduces pain)
• Deep breathing exercises
• Postural education and sleeping position advice
• NSAID timing before exercise (take 30-60 min before morning exercises)
• Avoid aggressive stretching into pain; work in pain-free range
• 10-15 min of gentle daily activity initially; build up gradually

Stage 2 - Established / Progressive Phase

• Full structured exercise programme: flexibility + strength + aerobic
• Supervised group exercise or individual physiotherapy
• Intensive chest expansion programme
• Postural correction programme
• Spinal mobility exercises (all planes)
• Aquatic therapy if land-based exercise limited

Stage 3 - Advanced / Ankylosed Phase

• Focus shifts to maintaining what is left of mobility
• Peripheral joint exercises become more important
• Fall prevention and balance training
• Respiratory physiotherapy (diaphragmatic breathing, incentive spirometry)
• Gait training; walking aids if needed
• Pre/post-operative rehabilitation if osteotomy or THA planned

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7. POST-OPERATIVE PHYSIOTHERAPY

After Total Hip Arthroplasty (THA)

• Pre-op: Assess and optimize hip ROM and strength; respiratory physiotherapy
• Day 1-2 post-op: Bed exercises, deep breathing, transfers
• Week 1-2: Gait training (walking frame → stick); hip precautions (no forced adduction/internal rotation)
• Heterotopic ossification (HO) prevention: NSAIDs (indomethacin 25mg TDS × 6 weeks) or low-dose radiation within 72 hrs
• 6-week programme: progressive ROM, strength, functional training
• HO risk is high in AS - monitor; aggressive physio of hip may worsen HO; balance needed

After Spinal Osteotomy

• Pre-op: Chest physiotherapy, breathing exercises, strengthen paravertebral muscles
• Post-op: Respiratory physiotherapy (vital capacity may be reduced postoperatively)
• Gradual mobilization in brace/orthosis
• Progressive core and postural re-education
• Gait retraining in corrected posture

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8. SPECIAL CONSIDERATIONS

Flare Management

• Do NOT stop exercise during mild-moderate flare
• Reduce intensity; shift to gentle ROM, hydrotherapy
• Swimming / pool walking ideal during flares
• Use ice/heat for symptomatic relief
• Maintain breathing exercises even during severe flares

Fatigue

• Fatigue is the most disabling symptom for many patients
• ASAS/EULAR SLR 2023 confirms non-pharmacological interventions (exercise, cognitive-behavioural approaches) moderately effective for fatigue
• Pacing strategies; sleep hygiene; aerobic exercise shown to reduce fatigue

Kinesiophobia (Fear of Movement)

• Common in AS (Ertem, 2025 PMID: 39959836)
• Graded exposure to movement; reassurance that exercise is safe
• CBT-based pain neuroscience education effective

Osteoporosis

• Common in AS (paradox: despite osteoproliferation, systemic osteoporosis occurs)
• Weight-bearing exercise (recommended as per ASAS/EULAR)
• Co-manage with rheumatologist (DEXA scan, calcium/vitamin D)

Pregnancy

• Continue low-impact exercise (swimming, walking, pelvic floor)
• Avoid prone exercises after 1st trimester
• Aquatic therapy preferred
• NSAIDs avoided in 3rd trimester; exercise even more important

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9. FREQUENCY / INTENSITY / DURATION - PRESCRIPTION SUMMARY

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10. OUTCOME MONITORING

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11. ASAS/EULAR 2022 - PHYSIOTHERAPY RECOMMENDATIONS (Key Points)

1. Non-pharmacological management should be offered to all patients at all stages
2. Education and exercise are consistently confirmed efficacious
3. Both supervised and home exercise are effective; supervised preferred for technique acquisition
4. Smoking cessation is recommended (smoking = worse outcome)
5. Physical therapy should be personalised and ongoing - not time-limited
6. Patient self-management (home exercise, lifestyle modification) is essential

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SUMMARY TABLE - Evidence-Based Physiotherapy Hierarchy in AS

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• ASAS-EULAR 2022 Recommendations - Ramiro et al., Ann Rheum Dis 2023
• ASAS/EULAR SLR 2022 - Non-pharmacological - Ortolan et al., Ann Rheum Dis 2023
• Cochrane Review: Exercise in AS - Regnaux et al., 2019
• Meta-analysis: Exercise types in AS - Boudjani et al., Disabil Rehabil 2023
• RCT: Long-term supervised exercise - van Wissen et al., Rheumatology 2025
• Meta-analysis: Mind-body exercise in axSpA - Wang et al., J Orthop Surg Res 2024
• Systematic review: Aquatic exercise in inflammatory arthritis - Medrado et al., Rheumatol Int 2022
• Physiotherapy effectiveness SR/MA in AS - Gravaldi et al., Healthcare 2022
• Paradoxical role of exercise review - Perrotta et al., RMD Open 2021
• Goldman-Cecil Medicine, Chapter on AS

Physiotherapy Management of Ankylosing Spondylitis

Clinical Notes

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GOALS OF PHYSIOTHERAPY

• Reduce pain and stiffness
• Maintain/improve spinal and peripheral joint mobility
• Prevent fixed deformity (kyphosis, hip flexion contracture)
• Strengthen postural muscles
• Maintain chest expansion and respiratory function
• Improve functional ability and quality of life
• Patient education and self-management

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1. PATIENT EDUCATION

• Explain nature of disease - inflammatory, progressive, but manageable
• Stress that daily exercise is non-negotiable - "use it or lose it"
• Sleeping position: supine on firm mattress, one flat pillow - prevents cervical kyphosis and hip flexion contracture
• Avoid soft mattress, high pillows, and prolonged sitting in flexed posture
• Ergonomics: raise monitor height, avoid forward-bending posture at work
• Take NSAIDs 30-60 min before morning exercise session
• Smoking cessation - worsens disease and reduces lung function
• Warn about fracture risk - any trauma, even minor, needs medical attention
• Teach self-monitoring using BASDAI and BASFI

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2. POSTURAL TRAINING

• Wall standing exercise daily - head, shoulders, buttocks touching wall; hold for 10 min
• Mirror feedback posture correction
• Thoracic extension drills before daily activities
• Train "chin tuck" habit to counter cervical kyphosis
• Brügger postural relief position (sit upright, chest open, shoulders back)
• Ergonomic advice for work, driving, and sleeping

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3. SPINAL MOBILITY EXERCISES

• Forward flexion - seated reach or standing wall slide
• Extension - prone press-up (McKenzie)
• Lateral flexion - standing side lean, both sides
• Rotation - supine hook-lying knee roll, both sides

• Extension over foam roller / rolled towel placed across thoracic spine
• Seated thoracic rotation with arms crossed
• Thread-the-needle stretch

• Chin tuck + slow extension
• Lateral flexion - ear toward shoulder
• Rotation left and right
• All movements slow, within pain-free range

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4. FLEXIBILITY / STRETCHING

• Hip flexors - Thomas position stretch (prevents hip flexion contracture)
• Hamstrings - supine straight leg raise or seated reach
• Piriformis - figure-4 stretch
• Pectorals - doorway stretch (counters thoracic kyphosis)
• Quadratus lumborum - lateral trunk stretch
• Calf / Achilles - standing wall stretch (enthesitis at heel)
• Spinal extensors - child's pose (gentle; not held long in flexion)

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5. STRENGTHENING EXERCISES

• Prone "Superman" extension
• Bird-dog (opposite arm/leg)
• McKenzie extension in lying

• Dead bug
• Plank (progress from knees to toes)
• Side plank
• Pallof press

• Prone Y-T-W
• Seated rows / band rows
• Wall angels

• Glute bridges
• Prone hip extension
• Step-ups

• Chin tuck with light resistance band

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6. BREATHING EXERCISES

• Diaphragmatic breathing - hand on belly; breathe in to expand belly, not chest
• Lateral costal expansion - hands on lower ribs; breathe into the hands sideways
• Anterior chest expansion - hands on upper chest; expand toward hands
• Maximal deep breaths - slow inhale to maximum, hold 3-5 sec, slow exhale
• Combine with trunk extension - inhale during extension, exhale during flexion
• Incentive spirometry - daily; objective tracking of progress
• Target: maintain chest expansion ≥ 2.5 cm

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7. AEROBIC EXERCISE

• Swimming - preferred; non-impact, full body, improves breathing
• Cycling (stationary or outdoor) - low impact, maintains hip mobility
• Walking - accessible, safe, effective
• Elliptical trainer

• High-impact running or contact sports
• Any activity with high risk of fall or spinal impact (fused spine = fracture risk)

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8. AQUATIC THERAPY / HYDROTHERAPY

• Pool temperature: 32-34°C
• 3 sessions per week, 30-45 min each
• Combine flexibility, ROM, gentle strengthening, and aerobic in water
• Best during flares or when land-based exercise is poorly tolerated
• Buoyancy reduces joint loading; warm water relieves morning stiffness

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9. MIND-BODY EXERCISE

• Tai Chi - best evidence for pain reduction
• Yoga - flexibility + breathing + relaxation
• Pilates - core, posture, mobility
• Qigong - gentle movement + breathing

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10. HEAT & PHYSICAL MODALITIES (Adjunctive)

• Warm shower or hot pack before morning exercises - reduces stiffness, aids warm-up
• Ice/cold pack post-exercise - reduces post-activity inflammation
• TENS - short-term pain relief; improves compliance with exercise
• Therapeutic ultrasound - adjunctive for local enthesitis sites
• Manual therapy: gentle peripheral joint mobilization (hip, shoulder) is acceptable; spinal manipulation is CONTRAINDICATED in fused spine - chalk-stick fracture risk

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11. GROUP vs. HOME EXERCISE

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12. MANAGEMENT BY DISEASE STAGE

• Gentle ROM within pain-free range
• Hydrotherapy; diaphragmatic breathing
• Postural education; sleeping position
• Short sessions (10-15 min) daily; build gradually
• NSAIDs timed before exercise

• Full programme: flexibility + strength + aerobic + breathing
• Group exercise class
• Intensive chest expansion
• All planes of spinal mobility daily

• Maintain remaining peripheral joint mobility
• Respiratory physiotherapy - key to prevent complications
• Fall prevention and balance training
• Gait training; walking aids if needed
• Pre/post-operative rehabilitation (THA or spinal osteotomy)

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13. FLARE MANAGEMENT

• Do NOT stop exercise during a flare
• Reduce intensity, not frequency
• Shift to hydrotherapy / pool walking
• Gentle ROM and breathing exercises maintained
• Apply heat before, ice after
• Return to full programme as flare settles

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14. POST-OPERATIVE REHABILITATION

• Day 1-2: Bed exercises, breathing, transfers
• Week 1-2: Gait training (frame → stick); hip precautions (no forced adduction/IR)
• 6 weeks: Progressive hip ROM, strength, functional training
• Monitor for heterotopic ossification (HO) - if developing, avoid aggressive hip physio

• Pre-op: Chest physio + breathing exercises + core strengthening
• Post-op: Respiratory physio; mobilize in orthosis/brace
• Gradual core and postural re-education
• Gait retraining in corrected posture

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15. OUTCOME MEASURES

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QUICK SUMMARY

Physiotherapy Assessment of Ankylosing Spondylitis

Clinical Notes

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A. SUBJECTIVE ASSESSMENT (History)

1. Patient Profile

• Name, age, sex, occupation, dominant hand
• Body weight and BMI
• Duration of symptoms and diagnosis

2. Chief Complaint

• Site of pain - low back, buttocks, neck, chest
• Character - dull ache, stiffness, burning
• Onset - insidious (typical of AS)
• Duration - chronic (>3 months)
• Radiation - buttocks, posterior thigh (referred from SIJ)

3. Pain Assessment

• VAS / NRS (0-10) at rest, activity, night
• Morning stiffness:
  • Duration (>30 min = inflammatory)
  • Improves with activity? (Yes = inflammatory back pain)
  • Worsens with rest? (Yes = inflammatory)
• Night pain - wakes from sleep? (Inflammatory feature)

4. Inflammatory Back Pain Features (ASAS Criteria - ≥4/5 = positive)

• Age of onset < 40 years
• Insidious onset
• Improvement with exercise
• No improvement with rest
• Pain at night (improves on getting up)

5. Functional History

• ADL: dressing, bathing, bending, reaching overhead
• Work: desk/manual; prolonged sitting or standing
• Mobility: walking distance, stairs, transfers
• Sleep: position, pillows used, quality
• Driving ability

6. Extra-articular Features - Screen for:

• Eye: redness, pain, blurred vision (uveitis)
• Skin: rashes, psoriasis
• Bowel: diarrhoea, blood in stool (IBD)
• Heel pain (enthesitis)
• Chest tightness or shortness of breath (costovertebral fusion)

7. Past Medical & Treatment History

• When diagnosed; by whom
• Previous physiotherapy - what helped, what didn't
• Medications: NSAIDs, DMARDs, biologics (TNF-i, IL-17i)
• Surgical history - THA, osteotomy
• Imaging: latest X-ray, MRI, DEXA (osteoporosis)
• Comorbidities: cardiovascular, respiratory, osteoporosis

8. Social History

• Living situation (alone/family)
• Exercise habits before and after diagnosis
• Smoking status (worsens disease)
• Alcohol
• Recreational activities, sports

9. Patient's Goals

• What does the patient want to achieve from physiotherapy?

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B. OBJECTIVE ASSESSMENT

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1. OBSERVATION

• Gait - antalgic gait, reduced arm swing, trunk stiffness
• Transfers - getting up from chair or plinth (rigid en bloc movement)
• Undressing - difficulty reaching behind, putting on shoes

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2. SPINAL MOBILITY ASSESSMENT

BASMI - Bath AS Metrology Index (5 components)

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3. CHEST EXPANSION

• Measured at 4th intercostal space / nipple level
• Maximum inspiration minus maximum expiration
• Normal: ≥5 cm
• < 2.5 cm = significantly restricted (costovertebral fusion)

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4. PERIPHERAL JOINT ASSESSMENT

• Active and passive ROM: flexion, extension, abduction, adduction, IR, ER
• Thomas test - hip flexor tightness (angle of hip flexion contracture)
• FABER test (Flexion, ABduction, External Rotation) - SIJ provocation
• Trendelenburg test - gluteus medius weakness
• Pain at end range and groin pain

• FABER (Patrick's test) - hip flexion, abduction, external rotation; SI pain = positive
• Gaenslen's test - hyperextension of one hip; SI pain = positive
• Posterior pelvic pain provocation (P4 / thigh thrust) - axial load through femur
• Distraction test - ASIS pushed laterally; SIJ pain = positive
• Compression test - iliac crests compressed toward midline; SIJ pain = positive
• Sacral thrust test - prone; downward pressure on sacrum

• Active ROM: flexion, abduction, rotation
• Often restricted with upper thoracic involvement

• Knee and ankle ROM if symptomatic
• Heel: tenderness at Achilles insertion and plantar fascia (enthesitis sites)

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5. NEUROLOGICAL ASSESSMENT

• Sensation: light touch and pinprick - lower limbs (check for cauda equina involvement)
• Reflexes: knee jerk (L3/4), ankle jerk (S1)
• Power: hip flexors, knee extensors/flexors, ankle dorsiflexion/plantarflexion
• Babinski sign (rule out myelopathy - especially with cervical involvement)
• Bladder/bowel function - cauda equina red flag

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6. MUSCLE ASSESSMENT

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7. RESPIRATORY ASSESSMENT

• Breathing pattern at rest: diaphragmatic vs. accessory muscle breathing
• Chest expansion (as above)
• Respiratory rate
• Auscultation if respiratory symptoms present
• SpO2 if clinically indicated
• Incentive spirometry reading (baseline FEV1/FVC if available)

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8. FUNCTIONAL TESTS

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9. OUTCOME MEASURES (Baseline Score - Record and Reassess)

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10. RED FLAGS - Screen Before Starting Physiotherapy

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C. ASSESSMENT SUMMARY FORMAT

1. Demographics + diagnosis duration
2. Dominant symptoms: pain site + VAS score + stiffness duration
3. Postural findings
4. BASMI components (individual scores)
5. Chest expansion measurement
6. SIJ provocation test results
7. Peripheral joint ROM (esp. hip)
8. Neurological screen result
9. Functional test results
10. BASDAI and BASFI scores
11. Outcome measure baseline
12. Short-term and long-term goals
13. Physiotherapy plan

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QUICK ASSESSMENT CHECKLIST

• Inflammatory back pain features confirmed
• VAS / NRS recorded
• Morning stiffness duration noted
• Posture analyzed (lateral view)
• BASMI completed (all 5 tests)
• Chest expansion measured
• SIJ provocation tests done
• Hip ROM assessed (Thomas test)
• Neurological screen done
• 6MWT / functional test done
• BASDAI + BASFI scored
• Red flags screened
• Patient goals identified