Ankylosing Spondylitis Musculoskeletal manifestations Iraj Salehi-Abari MD., Internist Rheumatologist salehiabari@sina.tums.ac.ir

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.

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.

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.

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.

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.

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.

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.

Initial presentation*: Iraj Salehi-Abari Initial presentation*: History: A male (75%) with age of 35 + 10 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.

Initial presentation*: Iraj Salehi-Abari Initial presentation*: A Positive FH: In first-degree relatives: Increases the risk of AS by 75-94 folds In second-degree relatives: Increases the risk of AS by 20-25 folds *Iraj Salehi-Abari, Early diagnosis of AS, Rheumatol Int. 2012, table 3 Amir Alam Hosp.

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.

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.

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.

Iraj Salehi-Abari Amir Alam Hosp.

Iraj Salehi-Abari Amir Alam Hosp.

Iraj Salehi-Abari Amir Alam Hosp.

Iraj Salehi-Abari Amir Alam Hosp.

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

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.

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.

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.

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

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.