Ankylosing Spondylitis Knee Pain

Ankylosing Spondylitis Knee Pain

Ankylosing spondylitis, a chronic inflammatory condition primarily affecting the spine, can extend its grasp to other joints as well. One such area frequently affected is the knees. This article delves into the relationship between ankylosing spondylitis and knee pain, exploring its implications, symptoms, management strategies, and more.

Understanding Ankylosing Spondylitis

Ankylosing Spondylitis Knee Pain

Ankylosing spondylitis is an autoimmune disorder characterized by inflammation of the spine and other joints. It’s often associated with stiffness and pain, particularly in the lower back.

This condition primarily strikes young adults, with men being more susceptible. The inflammatory nature of ankylosing spondylitis is a crucial factor in comprehending its impact on knee joints.

The Connection to Knee Pain

While ankylosing spondylitis (AS) primarily affects the spine and sacroiliac joints, it can also have an impact on other joints, including the knees. Knee pain and involvement of the knee joints can be a part of the broader picture of AS. Here’s how AS can be connected to knee pain:

  • Enthesitis: Enthesitis refers to inflammation where tendons or ligaments attach to bones. This is a common feature of AS. Inflammation at the sites where tendons or ligaments attach to the knee joint can lead to knee pain and swelling. The patellar tendon, which connects the kneecap to the shinbone, is one such area that can be affected.
  • Secondary Arthritis: AS is an inflammatory arthritis, and the inflammation associated with the condition can extend beyond the spine and sacroiliac joints to other joints in the body, including the knees. This can lead to secondary arthritis in the knee joints, causing pain, swelling, and stiffness.
  • Inflammatory Cascade: The underlying inflammatory process in AS can contribute to a systemic immune response, which may affect various joints including the knees. The immune system’s reaction can result in pain, warmth, and swelling in the affected joints, including the knees.

Symptoms and Diagnosis

The symptoms of ankylosing spondylitis can vary widely among individuals, but some common signs include:

  • Chronic Back Pain: The most characteristic symptom is persistent, chronic pain and stiffness in the lower back, which can extend to the upper back and neck over time.
  • Morning Stiffness: Stiffness and pain are often more pronounced in the morning or after prolonged periods of inactivity, and they improve with movement and activity.
  • Reduced Spinal Flexibility: As AS progresses, inflammation can lead to the fusion of spinal vertebrae, reducing flexibility and mobility. This can result in a stooped or forward-leaning posture.
  • Enthesitis: Inflammation, where tendons and ligaments attach to bone (enthesitis), can cause pain, swelling, and tenderness at these attachment sites.
  • Fatigue: Many people with AS experience fatigue, which can be related to the body’s immune response and chronic inflammation.
  • Peripheral Joint Pain: Joints other than the spine can also be affected, such as the hips, knees, shoulders, and ankles. This can cause pain, swelling, and limited mobility in these joints.
  • Chest Pain: In some cases, inflammation can affect the joints between the ribs and the breastbone, leading to chest pain or discomfort.
  • Eye Inflammation: About 30% of individuals with AS develop inflammation in the eyes (uveitis or iritis), causing redness, pain, and light sensitivity.

Diagnosis of Ankylosing Spondylitis


Diagnosing AS can be challenging due to its variable presentation and the overlap of symptoms with other conditions. A combination of medical history, physical examination, imaging tests, and laboratory tests are usually used for diagnosis.

Medical History and Physical Examination: Your healthcare provider will ask about your symptoms, family history, and medical history. They will also conduct a physical examination to assess joint movement, tenderness, and signs of inflammation.

Imaging Tests:

  • X-rays: X-rays can show changes in the spine, such as fusion of vertebrae or other structural abnormalities.
  • MRI (Magnetic Resonance Imaging): MRI can detect inflammation in soft tissues and early signs of AS before structural changes appear on X-rays.

Blood Tests:

  • HLA-B27 Test: While not definitive, the presence of the HLA-B27 gene is often associated with AS. However, many people with AS do not have this gene, and its absence does not rule out the diagnosis.
  • Inflammation Markers: Blood tests such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) can indicate the presence of inflammation.

Clinical Criteria: The Assessment of Spondyloarthritis International Society (ASAS) has established criteria for diagnosing axial spondyloarthritis (which includes AS) based on specific clinical and imaging features.

Causes of Ankylosing Spondylitis Knee Pain

The exact cause of ankylosing spondylitis (AS) is not fully understood, but it’s believed to result from a combination of genetic and environmental factors. Here’s an overview of the potential causes and contributing factors:

Genetic Factors:

  • HLA-B27 Gene: The most significant genetic factor associated with AS is the presence of the HLA-B27 gene. People who carry this gene have an increased risk of developing AS. However, having the HLA-B27 gene does not guarantee that an individual will develop the condition, as many carriers never develop AS. Conversely, not all individuals with AS carry the HLA-B27 gene.
  • Other Genes: While HLA-B27 is a major genetic risk factor, other genes and genetic variations are also believed to play a role in susceptibility to AS. These genes are involved in the regulation of the immune system and the body’s response to inflammation.

Immune System Dysregulation: AS is classified as an autoimmune disease, which means the immune system mistakenly attacks the body’s tissues. In AS, immune cells are thought to target the joints, leading to inflammation and tissue damage. The HLA-B27 gene might play a role in triggering this immune response.

Environmental Factors:

  • Infections: Some researchers suggest that certain infections could trigger or contribute to the development of AS in genetically predisposed individuals. Infections might lead to an immune response that mistakenly targets joint tissues.
  • Gut Microbiome: Emerging research suggests a potential link between the gut microbiome and AS. Alterations in the gut microbiota composition might influence the immune response and inflammation in susceptible individuals.

Treatment Options for Ankylosing Spondylitis

Treatment Options for Ankylosing Spondylitis

The treatment approach may vary depending on the severity of the disease and individual patient factors. Here are some common treatment options for AS:

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs):

  • NSAIDs such as ibuprofen, naproxen, and diclofenac are often the first-line treatment for AS. They help relieve pain, reduce inflammation, and improve mobility.
  • Regular use of NSAIDs may help manage symptoms and prevent long-term damage, but potential side effects should be considered.

Physical Therapy and Exercise:

  • Physical therapy plays a crucial role in maintaining joint flexibility, improving posture, and preventing further limitations caused by AS.
  • Regular exercise, especially low-impact activities like swimming and yoga, can help maintain joint mobility, strengthen muscles, and improve overall fitness.

Biologic Disease-Modifying Antirheumatic Drugs (bDMARDs):

  • Biologics are a class of medications that target specific molecules in the immune system responsible for inflammation. Tumor necrosis factor (TNF) inhibitors such as etanercept, adalimumab, and infliximab are commonly used to treat AS.
  • Other types of biologics, such as interleukin inhibitors, may also be prescribed for those who do not respond to TNF inhibitors.

Conventional Disease-Modifying Antirheumatic Drugs (cDMARDs):

  • Methotrexate and sulfasalazine are examples of cDMARDs that can be used to manage AS. They are often used in combination with other treatments, particularly in cases where biologics are not indicated or effective.

Pain Management Techniques:

  • Heat and cold therapy, massage, and relaxation techniques can provide relief from pain and stiffness.
  • Supportive devices like orthotic insoles and back braces may be recommended to improve posture and reduce strain on the spine.


  • In severe cases where AS has caused significant spinal fusion and deformity, surgical interventions might be considered to correct the alignment of the spine and improve mobility.
  • Surgery is typically considered a last resort when other treatments have not provided adequate relief.

Managing Ankylosing Spondylitis Knee Pain

Managing Ankylosing Spondylitis Knee Pain

Managing knee pain in ankylosing spondylitis (AS) requires a comprehensive approach that focuses on both addressing the underlying inflammatory condition and providing relief for the specific knee symptoms. Here are some strategies to help manage AS-related knee pain:

Consult a Healthcare Professional: If you’re experiencing knee pain related to AS, consult your rheumatologist or healthcare provider. They can assess the severity of the pain, determine whether it’s specifically related to AS, and recommend appropriate treatment options.

Physical Therapy and Exercise:

  • Consult a physical therapist who is experienced in working with AS patients. They can design an exercise program tailored to your needs, focusing on improving knee strength, mobility, and overall flexibility.
  • Low-impact exercises like swimming, stationary cycling, and gentle yoga can help maintain joint health without putting excessive strain on the knees.

Knee-Specific Exercises: Incorporate knee-specific exercises to improve knee stability and flexibility. Your physical therapist can guide you in performing exercises that target the muscles around the knee joint.

Proper Posture and Movement: Maintain good posture and body mechanics to reduce strain on the knee joints. Avoid positions that may aggravate knee pain.

Hot and Cold Therapy: Applying heat or cold to the knees can help reduce pain and inflammation. Experiment with both methods to see which provides more relief.

Orthotic Support: Consider using orthotic insoles or inserts in your shoes to provide better support for your feet and knees. Proper footwear can also play a role in managing knee pain.


Ankylosing spondylitis knee pain is a facet of a complex condition that requires multifaceted management. Early detection, a holistic approach to treatment, lifestyle adjustments, and emotional well-being collectively shape the journey toward improved quality of life for individuals grappling with this challenge.

If you’re experiencing Knee pain, physical therapy for knee pain at PhysioMantra can help: Book an online physical therapy session.