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Though the progression of ankylosing spondylitis may be mild in some patients, others may experience progressive structural deterioration, pain, and functional disability. Patients may experience periods of painful, active inflammation called "flares", and periods during which the disease is inactive known as "remissions". Typically, for patients whose AS is progressive, symptoms become chronic and pain becomes more persistent during flares and remissions are not very long. Within a few months of onset, pain in the back becomes bilateral (felt on both sides). Over time (months or years) the pain and stiffness may spread up the spine and into the neck. Often, pain and tenderness also affect the ribs, shoulder blades, hips, thighs, and heels. Progression and severity are not related to age or gender.

Some patients may develop bone tenderness together with the back pain or stiffness. Others may develop arthritis of the hips or shoulders early in the course of ankylosing spondylitis. Neck pain and stiffness are usually indicators of advanced disease. Disease activity usually persists for decades and patients seldom experience a long period of remission.

If ankylosing spondylitis is not treated in a timely fashion, it continues to deteriorate and can cause significant health problems, including:

• Postural changes
• Destruction of normal lumbar lordosis (exaggeration of the forward curve of the lower part of the back, sometimes called "sway-back")
• Atrophy of the buttocks
• Exaggerated thoracic spine kyphosis (outward curvature of the upper back giving a "hunchback" appearance)
• Forward positioning of the neck over the chest

Complications that the patient with progressive AS may encounter include:

• Spinal Ankylosis
• Hip involvement
• Joint involvement
• Chest involvement
• Jaw involvement

Spinal Ankylosis

As ankylosing spondylitis progresses, chronic inflammation of the spine can cause the vertebrae of the spinal column to fuse together, a condition known as ankylosis. Ankylosis causes stiffness/rigidity of the spinal column leading to loss of normal spinal flexibility and deformity of the spine as well as loss of function/mobility.

The most serious complication for patients with ankylosing spondylitis is spinal fracture. Since the bone that forms is inherently weak, the spine becomes very rigid and fragile, and even mild trauma can result in fracture. The cervical spine is at greatest risk and fractures at this level may result in quadriplegia.

Hip Involvement

Hip and/or shoulder involvement affects approximately one-third of patients with ankylosing spondylitis. Hip symptoms (inflammation and pain) typically develop slowly. Sometimes the patient may feel referred pain from the hip in the back of their knees or the front of their thigh which can confuse the diagnostic workup. Hip involvement is more common when onset takes place in younger patients and is thought to carry high risk for severe progression of AS. Shoulder involvement is usually mild in part because the shoulder is not a weight bearing joint.

Joint Involvement

As ankylosing spondylitis progresses, the chronic inflammation can spread to joints and cause joint pain and joint stiffness. Joints that may be affected include:

• Hips
• Knees
• Shoulders
• Ankles
• Wrists
• Occasionally, chronic inflammation of the small joints of the toes can produce "sausage" shape toes

Chest Involvement