When psoriatic arthritis affects the spine, it may cause pain and stiffness in the back and pelvic area.

Psoriatic arthritis (PsA) is most common in people with psoriasis or a family history of psoriatic disease. Research from 2021 suggests that 30% of people with psoriasis develop this type of arthritis.

According to that research, the likelihood that PsA will affect the spine, known as axial involvement, may range from 25–70%, depending on how the axial involvement is defined. In one study from 2017, imaging tests suggested that axial involvement occurred in around 43% of people with PsA.

When PsA affects the spine, doctors may refer to it as axial psoriatic arthritis, or axial PsA.

Axial PsA can affect the spine, shoulders, or hips but commonly affects the cervical spine, which refers to the vertebrae in the upper part of the back. If PsA affects the spine, it often affects the joints in the arms, legs, hands, and feet as well.

Doctors may also refer to axial PsA as spondylitis. Spondylitis affects the spine and sacroiliac joints, where the spine attaches to the pelvis.

Learn more about how PsA affects the spine and the treatment options available.

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PsA can cause pain and inflammation in any part of the spine.

Psoriatic disease is a systemic inflammatory disease, which means it can cause inflammation throughout the body. Many people with PsA report back pain. They may receive a diagnosis of axial PsA or sacroiliitis.

Axial PsA involves inflammation in the joints between the vertebrae, the small bones that form the spine. Sacroiliitis refers to inflammation in the joints between the spine and the pelvis.

The joints between the vertebrae in the spinal column are essential for mobility and movement. PsA can cause inflammation in any or all of these joints. A person will feel pain and stiffness where the inflammation occurs.

Back involvement is often a later stage of PsA, but not always.

PsA is not the only cause of back pain, so axial PsA can be hard to diagnose. A person with PsA and back pain may not receive a diagnosis of axial PsA for 10 years, according to the Arthritis Foundation.

How does PsA affect the body?

It may be difficult for a doctor to determine whether a person has PsA in the spine or ankylosing spondylitis. Both conditions cause pain and stiffness in the spinal joints.

Ankylosing spondylitis is a form of arthritis that mainly affects the spine but can develop in other joints. It causes inflammation and severe discomfort. In serious cases, new bone matter forms, fusing the bones in the spine and significantly limiting mobility.

Anyone who has concerns about back pain should see a doctor or a rheumatologist who will identify the cause of the pain. Imaging tests can offer clues about to whether a person has axial PsA, ankylosing spondylitis, or another condition.

What causes back pain?

PsA in the spine can also develop in other areas, such as the hands and feet. Symptoms can range from mild to severe.

A person with axial PsA may experience inflammation, pain, and stiffness in the:

  • neck
  • lower back
  • sacroiliac joints

Joint motion in these areas may be painful and difficult.

Most people with axial PsA will already have symptoms of PsA in other joints. In some people, however, symptoms primarily affect the spine.

Other features of axial back pain are:

  • pain that disturbs sleep
  • pain that improves with exercise and worsens when sitting down
  • pain in the hips and buttocks
  • back stiffness lasting 30 minutes or more in the morning

Other symptoms a person may have include:

  • joint pain and stiffness in the feet, hands, and limbs
  • enthesitis, an inflammation in the place where the tendons meet the joints
  • skin symptoms of psoriasis, such as areas of flaky, scaly skin
  • nail psoriasis, where the nails may be pitted, ridged, crumbling, or thickened
  • uveitis, which causes eye inflammation
  • dactylitis, or swollen fingers or toes, sometimes described as “sausage-shaped”

Symptoms of PsA can grow worse, then lessen or disappear for a time. Many people refer to a period of worsened symptoms as a flare.

What are the symptoms of PsA?

A doctor will likely:

  • ask about symptoms
  • ask about personal and family medical history
  • carry out a physical examination
  • do some tests

Blood tests may show the person has HLA-B27 blood protein and a high erythrocyte sedimentation rate.

PsA is more likely to be present in people with several damaged joints and longer history of PsA.

People with axial PsA may have a higher risk of moderate to severe symptoms of psoriasis and higher levels of disease activity, with a greater effect on a person’s quality of life.

There is currently no standard protocol or criteria for diagnosing axial involvement in PsA, but research is underway to develop one.

What is the difference between PsA and RA?

According to 2018 guidelines, a treatment plan for PsA may include a combination of:

Additional strategies for spinal involvement include:

  • changing to a different type of biologic drug
  • stopping the use of DMARDs
  • receiving corticosteroid injections into the sacroiliac joint
  • using bisphosphonates to strengthen the bones and treat and prevent osteoporosis
  • doing physical therapy to maintain flexibility in the spine

What medications can treat PsA?

Physical therapy and exercise can help a person with PsA maintain or regain mobility and flexibility.

The Canadian Spondylitis Association recommends doing at least 150 minutes of moderate intensity aerobic physical activity every week. This should include:

  • muscle-strengthening exercise
  • stretching exercise
  • range of motion exercises

They also recommend applying heat and cold, for example with warm and cool packs. Always wrap a cool pack in a cloth to prevent skin damage, and ensure heat packs are not too hot.

Low impact exercise

Guidelines from 2018 recommend low impact exercise for people with PsA, such as:

A physical therapist can advise people on the best exercises.

Regular exercise

People with PsA can also benefit from regular exercise when symptoms allow.

Experts say that regular exercise can:

  • reduce joint stiffness and pain
  • increase chest expansion
  • improve mobility of the spine
  • improve heart and lung capacity

Cardiovascular exercise, in particular, can help with weight management. Maintaining a moderate weight can help with arthritic symptoms.

Some good options for a person with PsA include:

  • walking
  • swimming
  • cycling

A person can do any sport or exercise they are comfortable with, but should consult with a doctor before taking part in contact sports or heavy exercise.

Which exercises can help with PsA?

Without appropriate treatment, PsA can cause permanent joint damage. This may lead to changes in the shapes of the joints. Treatment can prevent or slow down the progression of the condition.

People with PsA are also more likely to have:

Here are some questions people often ask about back pain with PsA.

Why does back pain happen with psoriatic arthritis?

PsA is an immune-mediated psoriatic disease linked to skin and nail psoriasis. It causes inflammation, pain, and swelling in the joints. In some people, it can affect the spine, including the vertebrae and sacroiliac joints, where the spine joins the pelvis. Inflammation in the joints between vertebrae can lead to pain, swelling, and stiffness.

How common is back pain with psoriatic arthritis?

Estimates vary. Research from 2021 notes that spinal involvement with PsA could range from 25–70%. Experts are currently working on standardizing guidelines for defining spinal, or axial, involvement.

How long can back pain last with psoriatic arthritis?

Like other aspects of psoriatic disease, PsA symptoms tend to worsen during flares and improve during remission, but the length, frequency, and severity of flares will vary between individuals. Treatment with biologic drugs can help reduce the severity of symptoms and may lower the chance of a flare. One sign of PsA-related back pain is stiffness that lasts 30 minutes or longer in the morning.

PsA is a lifelong disease that can worsen with time, but the outlook will vary between people.

There is currently no cure for PsA, but effective treatment can help manage symptoms and may prevent flares or slow the progression of the condition.

Prompt diagnosis and treatment can prevent joint damage in the spine and other parts of the body.

Some people with PsA develop back pain. This can happen if inflammation occurs in the joints between the vertebrae or the sacroiliac joint, where the spine joins the pelvis.

Most people with back involvement have other PsA-related joint concerns first. For some, however, back pain and stiffness may be the only sign of PsA.

Treatment — including medications and low impact exercise — can help address symptoms and may reduce the frequency and severity of flares.