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Ankylosing Spondylitis

A long-term inflammatory arthritis of the spine and the joints where the spine meets the pelvis. It often starts in young adults as back pain and stiffness that ease with movement. There is no cure, but exercise and modern medicines can control it well.

What is ankylosing spondylitis?

Ankylosing spondylitis (AS) is a type of arthritis that causes inflammation in the joints and ligaments of the spine (NIAMS). It usually starts in the sacroiliac joints, where the base of the spine meets the pelvis, and can spread up the spine (Cleveland Clinic). Doctors now group it under axial spondyloarthritis (axSpA): AS is the form whose damage shows on X-rays, while “non-radiographic” axSpA causes changes that may not be visible on X-rays (Arthritis Foundation). Over time, new bone can grow in the spine and fuse sections of it in a fixed position (Spondylitis Association of America), though not everyone reaches that stage (SAA).

Inflammatory back pain: how it feels different

Most back pain comes from strain and gets better with rest. The back pain of AS tends to behave the other way round:

Low back, buttock and hip pain are usually the first symptoms (Arthritis Foundation). AS can also affect the shoulders, ribs, knees, heels and feet, make deep breaths difficult when the rib joints are involved, and cause tiredness (NIAMS, SAA, MedlinePlus). Symptoms often come and go in flares (SAA).

Who gets it, and the HLA-B27 gene

Eye inflammation (uveitis or iritis)

Up to half of people with spondylitis have at least one bout of eye inflammation. It usually affects one eye at a time, causing redness, pain, sensitivity to light and blurred or distorted vision (SAA, NHS).

Why diagnosis takes so long

Spondyloarthritis is often missed or misdiagnosed; the Spondylitis Association of America says it takes an average of 7–10 years from first symptoms to an accurate diagnosis (SAA). There is no single test (Arthritis Foundation, Cleveland Clinic). Doctors put together your symptoms, a physical exam, and personal and family history (SAA) with:

Get help fast for these.

  • A painful red eye, light sensitivity or a change in vision: iritis is a medical emergency that needs immediate attention — untreated, it can permanently damage sight (SAA, NHS). See an eye doctor the same day.
  • New or worse neck or back pain after a fall or jolt — even a minor one: a fused, stiff spine is brittle. Fusion plus thinning bones gives many people with spondyloarthritis a much higher risk of spinal fracture, and even minor falls and jolts can break the spine (SAA, SAA). Very little force is needed, and many people can’t recall a specific injury; emergency doctors advise strongly considering spine imaging for anyone with AS and new or unusual neck or back pain (Western Journal of Emergency Medicine, 2009). Get emergency evaluation and tell staff right away that you have AS.
  • Weakness or numbness in both legs, numbness around the genitals or bottom, or trouble controlling your bladder or bowels: these can signal cauda equina syndrome, a rare complication that needs emergency care (NHS).

The American College of Rheumatology advises people with a fused or curved spine to wear a medical alert bracelet so first responders know about the fracture risk (ACR/SAA/SPARTAN, 2026); the SAA also offers a wallet card for first responders (SAA).

When to see a doctor: if you have back pain and stiffness that is worse after rest and better with movement, especially if it began before 45, ask about a referral to a rheumatologist (an arthritis specialist). If you already have AS, report new symptoms during treatment (MedlinePlus).

Side by side

Six approaches compared

For every condition we look at the same six approaches: what each involves, what it typically costs, and what a patient can realistically expect.

ApproachWhat it involves Estimated costWhat to expect
Conventional medicine (AMA) Physical therapy and daily exercise plus medicine: NSAIDs first, then a biologic (TNF or IL-17 inhibitor) or a JAK inhibitor if needed. Eye, bone and fall-risk checks; hip replacement for severe hip damage. Biologics are expensive — one TNF inhibitor listed at about $7,100 for a 30-day supply before Medicare negotiation. Physical therapy about $50–$350+ a session without insurance. Assistance programs exist. No cure, but most people function well unless the hips or spine are badly damaged. Biologics may slow spinal damage in some people; exercise is lifelong.
Chiropractic Not a treatment for AS. Rheumatology guidelines strongly advise against spinal manipulation. Gentle mobility work only with your rheumatologist’s OK. About $50–$200 a visit without insurance ($15–$75 with); first evaluations $100–$250. Manipulating a fused or thinned spine risks fracture. A chiropractor who suspects inflammatory back pain should refer you to a rheumatologist.
Acupuncture A course of needle treatments alongside, not instead of, rheumatology care. About $125–$230 for a first visit and $90–$185 for follow-ups; community clinics about $50–$90. Pooled trials report less pain and stiffness, but the trials are small and often poorly blinded. Guidelines give it a weak (conditional) recommendation.
Herbal medicine Turmeric and fish oil are the supplements most often tried. None is proven to treat AS. Cost estimate being researched. Little or no AS-specific evidence. Some herbs interact with medicines or may stir up the immune system; the 2026 guideline advises against alternative-medicine systems. Check with your rheumatologist or pharmacist first.
Massage therapy Gentle massage for comfort and relaxation, with your rheumatologist’s OK — no forceful work on the spine. About $60–$120 for 45–60 minutes with a private therapist, or $50–$90 at clinics, gyms and spas. One small pilot trial suggests short-term pain relief. Guidelines prefer active exercise over passive treatments such as massage.
MBHA Wellness Coach Building a daily exercise and posture routine, quitting smoking, sleep, fatigue and stress, pacing work, fall-proofing and finding a support group. Cost estimate being researched. Quitlines (1-800-QUIT-NOW) are free. Supports — never replaces — your rheumatologist. Exercise and not smoking are two of the most powerful things you control.

Approach 1 of 6

Conventional medicine (AMA)

There is no cure for AS, but there are many ways to control symptoms (NIAMS). U.S. care follows guidelines from the American College of Rheumatology (ACR), the Spondylitis Association of America (SAA) and the SPARTAN research network. Their 2026 update (a summary approved in May 2026, with full papers still to be published) replaces the 2019 guideline, and stresses shared decision-making because much of the evidence is low quality (ACR/SAA/SPARTAN, 2026, ACR).

1. Physical therapy and daily exercise — the foundation

2. NSAIDs

Anti-inflammatory pain relievers (NSAIDs) are the usual first medicine, and the guideline strongly recommends them (ACR/SAA/SPARTAN, 2026, MedlinePlus). Some are sold over the counter, but check with your provider before using them for more than 10 days in a row (Cleveland Clinic). People who also have inflammatory bowel disease need special care in choosing them (ACR/SAA/SPARTAN, 2026).

3. Biologics and JAK inhibitors

  • If NSAIDs aren’t enough, the guideline strongly recommends a TNF inhibitor or an IL-17 inhibitor (both biologics, given by injection or infusion) and treats the two classes as equal first choices. JAK inhibitors (tablets) are also strongly recommended, but the biologics are preferred ahead of them (ACR/SAA/SPARTAN, 2026).
  • For people at high risk of poor outcomes, a biologic or JAK inhibitor may be started first. If one medicine doesn’t work, switching to a different class is recommended, and stopping these medicines suddenly is not advised (ACR/SAA/SPARTAN, 2026).
  • Your other conditions shape the choice: repeated uveitis or inflammatory bowel disease favors TNF-inhibitor antibodies, and psoriasis favors IL-17 inhibitors (ACR/SAA/SPARTAN, 2026).
  • Newer biologics may slow disease progression in some people (SAA, MedlinePlus).

Steroid tablets and other whole-body steroids are generally not recommended, though a steroid injection into an inflamed sacroiliac joint may be (ACR/SAA/SPARTAN, 2026). We don’t list doses; your rheumatologist will tailor any medicine to you.

4. Eyes, bones, heart and mood

5. Surgery

Surgery is rarely needed (Cleveland Clinic). A hip replacement may help advanced hip arthritis, and an operation to straighten the spine is an option for severe forward curvature. Anyone with neck involvement who needs general anesthesia should make sure the anesthesiologist knows (ACR/SAA/SPARTAN, 2026).

What it costs

  • Biologics: very expensive. For example, one TNF-inhibitor biologic used for AS (ACR/SAA/SPARTAN, 2019) had a list price of about $7,106 for a 30-day supply; Medicare’s negotiated price for it is $2,355 from 2026 (CMS fact sheet). What you pay depends on your insurance.
  • Help paying: charities such as the PAN Foundation and the NeedyMeds clearinghouse list help for AS medicines, and the Arthritis Foundation helpline (1-800-283-7800) can point you to programs (Arthritis Foundation). With Medicare drug coverage, out-of-pocket costs for covered Part D drugs are capped at $2,100 in 2026, and Extra Help is available for people with limited income (Medicare.gov).
  • Physical therapy: about $50–$350 or more a session without insurance, or a $10–$75 copay or 10%–50% coinsurance with it (cost guide: CostHelper). Medicare Part B covers medically necessary outpatient PT; you pay 20% of the approved amount after the deductible (Medicare.gov).
  • Over-the-counter NSAIDs: MBHA cost estimate being researched.

What to expect

The course of AS is hard to predict, with flares and quieter periods, but most people do well unless the hips or spine are badly damaged (MedlinePlus). Some people have periods of remission with fewer or milder symptoms (Cleveland Clinic).

Find a medical doctor in our directory

Approach 2 of 6

Chiropractic

Chiropractic care doesn’t treat the inflammation behind AS, and for this condition the key issue is safety.

What the guidelines say about spinal manipulation

  • The 2019 ACR/SAA/SPARTAN guideline strongly recommends against spinal manipulation for adults with AS who have spinal fusion or advanced spinal osteoporosis (ACR/SAA/SPARTAN, 2019).
  • The 2026 update goes further, strongly recommending against spinal manipulation for adults with axSpA in general, and also advising against traction (ACR/SAA/SPARTAN, 2026). These recommendations rest on very low-quality evidence, but the possible harm is serious.

Why: a brittle spine

Fusion makes the spine rigid and more likely to break under impact, and the bone formed during fusion is weak (SAA). The SAA says people with AS may have an 11-times-higher risk of spinal fracture (SAA). More generally, serious problems after spinal manipulation are rare, but the risk may be greater in people with health problems that raise their risk of injury (NCCIH).

Spotting AS early

The SAA trains chiropractors to recognize inflammatory back pain — pain that is worse with rest and better with exercise — and refer those patients to a rheumatologist, because undiagnosed axSpA can leave someone highly prone to spinal fracture (SAA). If a chiropractor suspects AS, a referral rather than an adjustment is the right next step.

If you still want chiropractic care

As a precaution, MBHA suggests: get your rheumatologist’s clearance first; tell the chiropractor you have AS, whether any part of your spine is fused, and about any osteoporosis; and accept only gentle, non-thrust mobility and exercise coaching — never high-velocity adjustments or neck manipulation. Supervised exercise from a physical therapist has the strongest support (ACR/SAA/SPARTAN, 2026).

What it costs

Find a chiropractor in our directory

Approach 3 of 6

Acupuncture

Acupuncture is sometimes used for AS pain and stiffness alongside standard treatment. The 2026 ACR/SAA/SPARTAN guideline gives acupuncture a conditional (weak) recommendation (ACR/SAA/SPARTAN, 2026).

What the research says

  • A 2026 review pooled 35 randomized trials with 2,591 people. Acupuncture (including electro-acupuncture and warm-needle styles) was linked to lower disease-activity, pain and function scores and lower blood markers of inflammation (meta-analysis, Frontiers in Neurology, 2026).
  • But the trials were small, results varied widely between them, blinding was poor, and only one study was judged at low risk of bias overall. The authors themselves call for large, high-quality trials (meta-analysis).

In short: acupuncture may offer some extra pain relief, but the evidence is weak. It does not replace exercise or medicines that control inflammation.

Safety

Relatively few complications have been reported. Problems have come from non-sterile needles and poor technique; in the U.S., needles must be sterile and single-use, and most states license acupuncturists (NCCIH). In the review above, no serious acupuncture-related side effects were reported (meta-analysis). MBHA suggests telling your acupuncturist about a fused spine and asking for gentle handling and positioning.

What it costs

Published examples run about $125–$230 for a first private visit and $90–$185 for follow-ups; community clinics about $50–$90 a visit (The Pricer).

Find an acupuncturist in our directory

Approach 4 of 6

Herbal medicine

No herb or supplement has been shown to treat AS or stop spinal fusion. The 2026 ACR/SAA/SPARTAN guideline recommends against alternative-medicine systems such as naturopathic, homeopathic and ayurvedic treatment for axSpA, and against microbiome-targeted therapies (ACR/SAA/SPARTAN, 2026).

Turmeric (curcumin)

Early evidence for turmeric in knee osteoarthritis is positive, but better studies are needed (NCCIH); we found no NIH information on turmeric for AS. It can upset the stomach, liver injury has been reported with highly absorbable curcumin products, and supplements may be unsafe in pregnancy (NCCIH).

Fish oil (omega-3s)

For rheumatoid arthritis, diets rich in omega-3s may ease joint pain and swelling, but the evidence is low quality and concerns food rather than supplements (NCCIH). We found no NIH information on omega-3s for AS. Side effects of supplements are usually mild, such as an unpleasant taste and stomach upset (NCCIH).

The bigger concern: interactions and the immune system

  • Cat’s claw may interact with immune-suppressing medicines and might make the immune system more active, which could worsen autoimmune symptoms (NCCIH).
  • Asian ginseng may worsen autoimmune disorders and interfere with blood clotting, and St. John’s wort has a high overall risk of drug interactions (NCCIH).

Before you take any supplement, show it to your rheumatologist or pharmacist — especially if you take a biologic, a JAK inhibitor or another immune-suppressing medicine, or are pregnant (NCCIH, NCCIH). Never stop or change a prescribed medicine on your own (NCCIH). We don’t list doses here.

Approach 5 of 6

Massage therapy

Many people with AS find gentle massage soothing for tight back and neck muscles. It is a comfort measure, not a treatment for the inflammation.

What the research and guidelines say

  • The 2026 ACR/SAA/SPARTAN guideline gives massage therapy a conditional (weak) recommendation, but within physical therapy it prefers active, supervised exercise over passive treatments such as massage, ultrasound and heat (ACR/SAA/SPARTAN, 2026).
  • A small 2017 pilot trial in 27 men with AS compared two styles of back massage over two weeks. Deep-tissue massage lowered low-back pain and disease-activity scores more than relaxation-style massage, but there was no untreated comparison group and the authors call for more research (pilot trial, Evid Based Complement Alternat Med, 2017).
  • For low-back pain in general, evaluations have found only weak evidence that massage helps (NCCIH).

Safety

The risk of harm from massage appears to be low, but rare serious problems — including a broken bone — have been reported, sometimes with vigorous or deep-tissue work (NCCIH). Because a fused or thinned spine fractures more easily (SAA), MBHA suggests:

  • Ask your rheumatologist first, especially if part of your spine is fused or you have osteoporosis.
  • Choose gentle work; no forceful pressure on the spine and no neck manipulation or cracking.
  • Tell the therapist about your AS and ask for positioning that is comfortable for your back and neck.
  • Don’t use massage to put off seeing a doctor about new pain (NCCIH).

What it costs

Find a massage therapist in our directory

Approach 6 of 6

MBHA Wellness Coach

An MBHA Wellness Coach can help you turn your rheumatologist’s and physical therapist’s advice into daily habits — alongside, never instead of, your medical care.

A daily exercise routine

Exercise is essential with axSpA. Swimming, Pilates, yoga and tai chi help with mobility, and cardio and strength training are recommended too; a physical therapist can design a full program (Arthritis Foundation). The 2026 guideline also supports home back exercises and recreational exercise (ACR/SAA/SPARTAN, 2026). A coach can help you schedule it, track it and keep going through flares. The guideline also suggests counseling about the dangers of contact sports (ACR/SAA/SPARTAN, 2026), so ask your team which activities suit you.

Posture

Quitting smoking

Smoking can make axSpA symptoms worse, speed up joint damage and make treatment less effective (Arthritis Foundation); the SAA says smoking is absolutely contraindicated in all forms of spondylitis (SAA). Free, confidential coaching is available at 1-800-QUIT-NOW, and using counseling and medicine together gives the best chance of quitting for good (CDC).

Sleep, fatigue and stress

Fatigue is common with AS (MedlinePlus), and poor sleep can make you more sensitive to pain. Helpful habits include taking medicines as directed, avoiding late-day caffeine, limiting screens before bed and exercising during the day; meditation, yoga, walks in nature and music can ease stress (Arthritis Foundation). Tell your doctor if sleep doesn’t improve.

Weight, work and driving

The guideline suggests counseling on reaching and keeping a healthy weight, on heavy physical labor, and on changes that make driving safer, plus group or one-to-one self-management education (ACR/SAA/SPARTAN, 2026). A coach can help you plan work breaks, pace physical jobs and bring questions to your care team.

Preventing falls

Because even minor falls can fracture a fused spine (SAA), a coach can help with practical fall-proofing at home and with the fall check your doctor should offer (ACR/SAA/SPARTAN, 2026). Consider a medical ID and an “ICE” (in case of emergency) contact in your phone (SAA).

Support groups

The SAA runs virtual peer support groups open to people with spondyloarthritis and their families wherever they live, with California groups listed for Los Angeles and Oakland/San Francisco (SAA). Depression screening is part of good AS care (ACR/SAA/SPARTAN, 2026) — if your mood is low, tell your doctor.

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This page is for education only and is not medical advice. Costs are typical U.S. ranges and estimates; yours will depend on your provider, location and insurance. Talk with your doctor before starting, stopping or combining any treatment. In an emergency, call 911. See our disclaimer.

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