Do All Ankylosing Spondylitis Patients Experience Morning Stiffness?

Q: Do All Ankylosing Spondylitis Patients Experience Morning Stiffness?

Hello, thank you for your question. Here are my responses： 1. Morning stiffness is not related to the condition of the L4-5 vertebrae. Morning stiffness is associated with inflammation of the joints, tendons, and ligaments. The reason some individuals experien

Do all patients with ankylosing spondylitis experience morning stiffness?

Hello Doctor: I would like to confirm something with you regarding a question I asked yesterday (#182368, details below).
I am attaching the complete MRI report as follows: MRI of the bony pelvis without contrast enhancement shows: 1.
General bulging discs at L4/5 and L5/S1 with minimal indentation on the thecal sac; no significant spinal stenosis or neural foraminal narrowing is observed.
2.
Patchy bone marrow edema in the left sacral ala and ilium, along the left sacroiliac joint, accompanied by subchondral sclerosis and erosive articular surface, more severe on the iliac side, R/I chronic sacroiliitis; axial spondyloarthritis is highly suggested.
3.
Similar edema in the posteroinferior corner of the right sacroiliac joint is also noted.
IMP: Bilateral sacroiliitis, more severe on the left side, R/O axial spondyloarthritis.

Doctor, I have two questions: 1) Is the reason I do not experience morning stiffness because the MRI report indicates that my spine at L4/L5 is normal, and only the sacroiliac joint is affected? Does this mean I won’t have morning stiffness until the sacroiliac joint involvement progresses to the spine? 2) You believe I "should" have ankylosing spondylitis, but if there is a very small chance that I do not, what other conditions do you think I might have? (I remember the hospital performed serum protein electrophoresis, γ-GT, ALK-P, A/G, etc., at the time of my initial diagnosis.
Each follow-up visit included CRP/ESR, ALT, creatinine, and the first four visits also included complete blood counts and urinalysis.
The doctor did not mention any other diseases, and I have been diagnosed for over two years.
Other than pain in my buttocks, I have not experienced any other unusual symptoms.) I apologize for asking so many questions, thank you, Doctor.

------------------------------------------------------------ (#182368 Full question) Hello Doctor, I am 20 years old, HLA-B27 positive, and MRI of the sacroiliac joint shows inflammation (the following is an excerpt from my MRI report...
R/I chronic sacroiliitis; axial spondyloarthritis is highly suggested...
IMP: Bilateral sacroiliitis, more severe on the left side, R/O axial spondyloarthritis).
My CRP is around 1.8 mg/dL, and my ESR is around 30.
Before my diagnosis, I had physical therapy for sacroiliac joint pain for nearly six months, but it did not fully improve.
My rheumatologist believes I have ankylosing spondylitis, but I have never experienced morning stiffness either before or after my diagnosis.
The only pain I have is in the sacroiliac joint, which does not improve with activity during the day.
I am somewhat skeptical about whether I truly have ankylosing spondylitis, so I would like to ask you: 1) Do all patients with ankylosing spondylitis experience morning stiffness? Does pain in the sacroiliac joint in ankylosing spondylitis patients always improve with activity? 2) Should I consider myself to have ankylosing spondylitis? My responses are as follows: 1) Is morning stiffness a definite symptom in patients with ankylosing spondylitis? Does pain in the sacroiliac joint improve with activity in these patients? --> Morning stiffness is quite common, so not having it is somewhat unusual.
In more severe cases of sacroiliitis, pain may not improve with movement and may require medication.
Your inflammatory markers are relatively high, so I recommend starting medication for a period and combining it with exercise for potential improvement.
2) Should I consider myself to have ankylosing spondylitis? --> Based on your MRI, your age, and elevated inflammatory markers, I believe it is likely correct.

Hao, 20~29 year old female. Ask Date: 2022/05/31

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your question.
Here are my responses:
1.
Morning stiffness is not related to the condition of the L4-5 vertebrae.
Morning stiffness is associated with inflammation of the joints, tendons, and ligaments.
The reason some individuals experience morning stiffness while others do not may be related to each person's perception of pain symptoms.
For example, individuals who exercise regularly may experience milder morning stiffness symptoms.
2.
Diagnosing diseases, especially rheumatic diseases such as ankylosing spondylitis, is challenging and cannot be determined with 100% certainty.
The diagnosis of rheumatic diseases often requires a comprehensive consideration of symptoms and examination results, which can present issues of diagnostic sensitivity and specificity.
Therefore, in my previous response, I used the term "should." However, based on the evidence you have provided, I believe it is indeed the case.

Best regards from the Allergy, Immunology, and Rheumatology Department of Changhua Hospital, Ministry of Health and Welfare.

Reply Date: 2022/05/31

More Info

Ankylosing Spondylitis (AS) is a chronic inflammatory disease primarily affecting the spine and the sacroiliac joints, leading to pain and stiffness. One of the hallmark symptoms of AS is morning stiffness, which is often worse after periods of inactivity, such as sleeping. However, not all patients with AS experience morning stiffness, and the absence of this symptom can lead to questions about the diagnosis.

1. Do All Ankylosing Spondylitis Patients Experience Morning Stiffness?
While morning stiffness is a common symptom of AS, it is not universally experienced by all patients. The presence and severity of morning stiffness can vary significantly among individuals. Factors such as the stage of the disease, the specific joints affected, and individual pain thresholds can influence whether a patient experiences this symptom. In your case, the MRI findings indicate inflammation in the sacroiliac joints but not in the lumbar spine (L4/L5). This could explain the absence of morning stiffness, as stiffness is often associated with spinal involvement. However, it is important to note that AS can progress, and symptoms may develop over time.

2. Could the Absence of Morning Stiffness Indicate a Different Condition?
The absence of morning stiffness does not necessarily rule out AS, especially since you have other indicators, such as positive HLA-B27 and MRI findings suggestive of sacroiliitis. However, if AS is ruled out, other conditions could be considered, such as non-radiographic axial spondyloarthritis or other forms of inflammatory arthritis. It is essential to continue monitoring your symptoms and discuss any changes with your rheumatologist.

3. Is It Possible for AS to Progress Without Morning Stiffness?
Yes, AS can progress without the presence of morning stiffness. Some patients may experience pain and inflammation localized to the sacroiliac joints without significant spinal involvement initially. Over time, the disease may progress to involve the spine, at which point morning stiffness may become more pronounced.

4. What Should You Do Next?
Given your current symptoms and MRI findings, it is advisable to follow up with your rheumatologist for a comprehensive evaluation. They may recommend treatment options, including anti-inflammatory medications or disease-modifying antirheumatic drugs (DMARDs), to manage inflammation and pain. Regular physical therapy and exercise can also be beneficial in maintaining mobility and reducing stiffness.

In conclusion, while morning stiffness is a common symptom of ankylosing spondylitis, its absence does not exclude the diagnosis. The presence of sacroiliitis and other inflammatory markers suggests that you may still have AS or a related condition. Continuous monitoring and communication with your healthcare provider are crucial in managing your symptoms and adjusting your treatment plan as necessary.

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