Avin Patel

Ankylosing Spondylitis and AxSpA

Ankylosing Spondylitis is a rheumatological condition related to rheumatoid arthritis and inflammatory bowel disease. Like these conditions, it is autoimmune: meaning the body is attacking its own cells.

Ankylosing Spondylitis

Symptoms and Disease Process

Initially, AS may seem like basic lower back pain. You may be inclined to ignore it and wait for it to go away. Symptoms may come and go in the early stages, but they will slowly progress. This is because after periods of inflammation, the body heals incorrectly, growing new bone over the joints in the lower back and pelvis. This is what the “ankylosing” refers to: it means fused or anchored. Along with the lower back pain and stiffness, symptoms can be quite wide reaching:

  • Uveitis: inflammation within the eye causing redness
  • Ethesitis: inflammation at the point where tendon meets bone, for example at the base of the achilles tendon
  • Inflammatory pattern of pain: morning stiffness, improvement with NSAIDs such as ibuprofen
  • Arthritis of any kind in hands, feet, or limbs

We might suspect AS or another rheumatoid condition if you have inflammatory back pain and:

  • Psoriasis
  • IBD (Crohn’s Disease or Ulcerative Colitis)

Misconceptions about AxSpA and Ankylosing Spondylitis

Recently a lot of information about AS has arisen. Previously we thought that AS affected men more than women, but we know now that it just affects them differently. It seems to affect both sexes equally. We also thought that the “question mark posture” with the flattened lower back was a good diagnostic point. Now we know that it is a sign of extensive fusion. These important points make spotting AS earlier possible.

We also have new ideas for treating patients with AS. Whereas with other patients we may see stiffness or over-compensation in the upper back and manipulate it, this is inappropriate in AS patients. The upper back is not unaffected by the process of AS, and these bones are more prone to injury from strong techniques than in the general population.

Medical Referral and Treatment

Early stage AS is technically called AxSpA (Axial Spondyloarthritis). This is when we want a diagnosis because intervention here is most effective. Diagnosis needs to be made by a rheumatologist, although we can refer back to the GP if we suspect AxSpA/AS. Investigation may include blood tests and MRI. For best results in managing the condition, medication may be appropriate. Some stronger medications also have to be prescribed by the rheumatologist, so early referral to the specialist is ideal.

Osteopaths cannot cure AS, but we may be able to help you manage symptoms. Inflammatory conditions like this are aggravated by rest or excessive activity, so treatment and advice are about striking a balance. On a bad day with AxSpA, you may find relief in a few minutes of gentle treatment. With later stage AS, you may benefit from work to the muscles around affected joints, and mobilisation of joints that are compensating for the fusions.

Book now if you suspect your back pain might be Ankylosing Spondylitis/AxSpA


A scoliosis is a lateral curve of the spine: a curve visible from behind. No one is perfectly straight, but sometimes this curve can present problems. If it is only present in certain positions such as sitting, it is called a functional scoliosis. When the curve is there all the time it is called a structural scoliosis.

Signs and Symptoms

Initially, this may present with or without pain. In children, parents may be the first to notice things like:

  • One raised shoulder
  • Lateral curves
  • Clothing sitting unevenly
  • Ribs raised on one side when bending forwards

Functional Scoliosis

Functional scolioses are generally not problematic and can be managed with lifestyle changes. For example if someone only has a scoliosis when sitting with their wallet in the back pocket they can be advised that this is the cause.

Functional Scoliosis

There may also be habitual factors at play. If you tend to stand with one leg bent, the body will aim to correct this imbalance before it reaches your head. If you wear a heavy shoulder bag, you may develop a temporary concavity on that side.

These are not problems in themselves unless they cause discomfort, or stop resolving when the position is corrected.

Structural Scoliosis

Structural scolioses tend to form during childhood or adolescence. Often the cause is unknown, so it is referred to as an idiopathic scoliosis. If this is picked up before a person finishes growing they may be referred for treatment.

Structural Scoliosis

Ageing spines also develop these curves- most elderly people have some sort of curve.

If not Idiopathic

In contrast to functional curves, this type of scoliosis can come down to the structure of the bones. In other cases, neurology plays a role. Scoliosis can follow trauma or be caused by conditions such as cerebral palsy. Neuromuscular scoliosis requires medical intervention.

Treatment and Management

In mild cases osteopathic management may help. However for more severe cases the patient may be referred for a brace or surgery. Severity of the angle can be measured using an X-ray of the spine.

Although osteopaths cannot change the curve in adults with a structural scoliosis, we can work to relieve symptoms. The muscles on the concave side of the curve will be shortened and tighter and the opposite will be true on the convex side. The body is generally good at adapting to these changes but if they are uncomfortable we can work to balance.

In reality, the curve is unlikely to be purely lateral. Rotation through the mid and upper back is common, and can cause compression through the ribs on one side. Osteopathy can help work on the muscles between the ribs, as well as general breathing mechanics. We can also suggest exercises to continue at home.

If you suffer the effects of scoliosis, book in today and see what we can do.

Clicky Jaw: The TMJ

When you find yourself with a clicky jaw, it can be hard to know how to address it. Is it a job for your dentist? Will the GP be interested? Or could you start with your osteopath?

The role of posture in a clicky jaw

Often patients mention their clicky jaw during treatment for something else. Sometimes this is because they didn’t think it warranted its own appointment, other times it’s just that they didn’t know where to start.

What Causes a Clicky Jaw?

The jaw joint is basically a hinge joint with a disc of cartilage in the middle. Some muscles in the cheek attach to this disc, and if they get tight, they can pull the disc in a way that allows it to fold.

Clicky jaw anatomy

This folding is not permanent, and will likely only happen at a certain point in the movement. This might mean restriction in opening your mouth all the way, or a click when it’s open very wide.

When a clicky jaw is caused by this muscle pull, it can be really easy to manage. Sometimes just a few minutes of work will temporarily resolve it completely, although typically it will return if just treated once.


As mentioned above, jaw symptoms might resolve quickly but temporarily after the first treatment. For this reason, your osteopath will devise a plan for a longer term benefit. This might include daily exercises to keep the muscles relaxed. There may be secondary effects into the neck and shoulders, or as far away as the diaphragm, so breathing exercises might be helpful too.

If the muscles are getting tight because of teeth grinding, we might need help from a third party. Your dentist may be able to provide you with a “splint” to limit night-time teeth grinding. If you grind your teeth because of anxiety, you might like a referral to a counsellor. We will not refer you onto anyone without your consent.

As always, osteopathy is holistic, and the jaw is no exception. The first diagram shows how holding your head forwards can cause tightening in the muscles that pull on the disc. In order to get to the root of the problem, your osteopath needs to help you fix this. Treatment around the neck and shoulders could be enough, or there might be room for improvement into your lower back too.

If you’re irritated by a clicky jaw, make an appointment today.

Thoracic Outlet Syndrome

The thoracic outlet is the area between the arm and ribs where nerves and blood vessels leave the thorax (rib cage). There is not a lot of space here, so sometimes those nerves and vessels can be compressed. This causes symptoms into the arm, and is known as Thoracic Outlet Syndrome (TOS).

Thoracic Outlet Syndrome

The Thoracic Outlet

There are a few small spaces in the outlet where nerves and vessels pass through. They become even smaller in certain movements, such as taking your arm out to the side or rotating out. As a result, people who do these movements in daily life may be more prone to developing TOS. They may also notice that their symptoms are worse when moving through these positions.

However, the two most common causes of TOS are traumatic or anatomical. It may be the case that you were already predisposed to TOS because of your anatomy, but it took an injury on top of that to initiate it.

Symptoms of TOS

With both kinds of TOS, symptoms affect the arm. Symptoms may be mild a lot of the time with an increase during activity. There may also be a pattern associated with things like desk work. Tight pectoral muscles can play a role in TOS, and modern life encourages this tightness.

Neurological TOS

The symptoms of TOS caused by nerve compression are similar to those of compressed nerves elsewhere. They can include:

  • Weakness
  • Wasting of hand muscles
  • Numbness
  • Pins and needles

When a nerve is repeatedly irritated, it can become hyper sensitive. This means that longer-standing problems typically take longer to resolve.

Vascular TOS

If a blood vessel is compressed, this is more urgent. This form of TOS is usually related to a cervical rib: where the lowest vertebra in the neck has ribs. This in itself is not too rare or significant, but when it compresses a blood vessel it can have major complications. Treatment may be surgical to remove or reduce the side of the rib.

There are tests we can use to determine whether your TOS is caused by a trapped nerve or vessel. It may also be evident which type you have from the case history. Vascular TOS can cause:

  • Arm swelling
  • Pain in the arm or hand in a less defined area
  • Changes to skin colour in the arm (looking more red or blue)
  • Pain when using the affected arm

Managing Thoracic Outlet Syndrome

In cases where conservative treatment is appropriate, your osteopath will devise a plan for you. Treatment might involve relaxing of the muscles around the thoracic outlet. As mentioned above, modern life can easily lead to tight pectoral muscles. This is further exacerbated by weakness in the upper back, allowing shoulders to round further and compress the outlet more.

In response to this, your osteopath might give you exercises to do between sessions. A stretch for the chest and strengthening for the upper back complement each other well.

As with any presentation, your osteopath will also look further afield to identify other predisposing factors. Treatment to the neck, upper back, or around the shoulder blade could be appropriate depending on your case.

If these sound like your symptoms, you can make an appointment online.