Axial Spondyloarthritis in Athletes: A Narrative Review of Diagnostic Challenges and Quality of Medical Management

Authors

DOI:

https://doi.org/10.12775/QS.2026.55.71213

Keywords

axial spondyloarthritis, sports medicine, diagnostic delay, bone marrow edema, quality of medical management, magnetic resonance imaging, therapeutic use exemptions

Abstract

Background. Axial spondyloarthritis (axSpA) is a chronic inflammatory disease affecting the spine and sacroiliac joints. In athletes, clinical identification is difficult due to symptomatic overlap with mechanical overuse and specific behavioral patterns of professional competitors.

Aim. This review evaluates diagnostic hurdles of axSpA in athletes and analyzes medical management quality based on evidence from 2021–2026. 

Material and methods. Following SANRA guidelines, a systematic search of PubMed and Google Scholar was performed, focusing on peer-reviewed literature at the intersection of inflammatory diseases and sports medicine. Results. The athletic culture of enduring pain contributes to a diagnostic delay often exceeding seven years. Professional athletes frequently present with exercise-induced bone marrow edema on MRI, which can mimic active sacroiliitis. Effective management requires a multidisciplinary approach integrating modern pharmacotherapy with specialized physiotherapy, adhering to 2022 ASAS-EULAR recommendations and WADA regulations.  Conclusions. A research gap exists regarding prospective studies in elite athletes. Improving care quality necessitates specialized screening protocols to differentiate physiological adaptations from systemic inflammation, ensuring career longevity and high quality of life. 

References

[1] Navarro-Compán V, Sepriano A, El-Zorkany B, van der Heijde D. Axial spondyloarthritis. Ann Rheum Dis. 2021;80(12):1511-1521.

https://doi.org/10.1136/annrheumdis-2021-221035

[2] Bittar M, Khan MA, Magrey M. Axial Spondyloarthritis and Diagnostic Challenges: Over-diagnosis, Misdiagnosis, and Under-diagnosis. Curr Rheumatol Rep. 2023;25(3):47-55. https://doi.org/10.1007/s11926-022-01096-0

[3] Zimba O, Kocyigit BF, Korkosz M. Diagnosis, monitoring, and management of axial spondyloarthritis. Rheumatol Int. 2024;44(8):1395-1407.

https://doi.org/10.1007/s00296-024-05615-3

[4] Zhao SS, Pittam B, Harrison NL, Ahmed AE, Goodson NJ, Hughes DM. Diagnostic delay in axial spondyloarthritis: a systematic review and meta-analysis. Rheumatology (Oxford). 2021;60(4):1620-1628.

https://doi.org/10.1093/rheumatology/keaa807

[5] Garrido-Cumbrera M, Navarro-Compán V, Bundy C, et al. Identifying parameters associated with delayed diagnosis in axial spondyloarthritis: data from the European map of axial spondyloarthritis. Rheumatology (Oxford). 2022;61(2):705-712.

https://doi.org/10.1093/rheumatology/keab369

[6] Bandinelli F, Martinelli-Consumi B, Manetti M, Vallecoccia MS. Sex Bias in Diagnostic Delay: Are Axial Spondyloarthritis and Ankylosing Spondylitis Still Phantom Diseases in Women? A Systematic Review and Meta-Analysis. J Pers Med. 2024;14(1):91. Published 2024 Jan 13.

https://doi.org/10.3390/jpm14010091

[7] Hay CA, Packham J, Ryan S, Mallen CD, Chatzixenitidis A, Prior JA. Diagnostic delay in axial spondyloarthritis: a systematic review. Clin Rheumatol. 2022;41(7):1939-1950.

https://doi.org/10.1007/s10067-022-06100-7

[8] Danve A, Magrey M, Deodhar A. An update on the management of axial spondyloarthritis for sports medicine professionals. BMC Sports Sci Med Rehabil. 2024;16(1):211. Published 2024 Oct 7.

https://doi.org/10.1186/s13102-024-00998-z

[9] Poddubnyy D. Challenges in non-radiographic axial spondyloarthritis. Joint Bone Spine. 2023;90(1):105468.

https://doi.org/10.1016/j.jbspin.2022.105468

[10] Hay CA, Packham J, Prior JA, Mallen CD, Ryan S. Barriers and facilitators in diagnosing axial spondyloarthritis: a qualitative study. Rheumatol Int. 2024;44(5):863-884.

https://doi.org/10.1007/s00296-024-05554-Z

[11] Mease P, Deodhar A. Differentiating nonradiographic axial spondyloarthritis from its mimics: a narrative review. BMC Musculoskelet Disord. 2022;23(1):240. Published 2022 Mar 12.

https://doi.org/10.1186/s12891-022-05073-7

[12] Expert Panel on Musculoskeletal Imaging, Czuczman GJ, Mandell JC, et al. ACR Appropriateness Criteria® Inflammatory Back Pain: Known or Suspected Axial Spondyloarthritis: 2021 Update. J Am Coll Radiol. 2021;18(11S):S340-S360.

https://doi.org/10.1016/j.jacr.2021.08.003

[13] Diekhoff T, Lambert R, Hermann KG. MRI in axial spondyloarthritis: understanding an 'ASAS-positive MRI' and the ASAS classification criteria. Skeletal Radiol. 2022;51(9):1721-1730.

https://doi.org/10.1007/s00256-022-04018-4

[14] Ward MM, Yao L. Sacroiliac Bone Marrow Edema: Innocent Until Proven Guilty?. Arthritis Rheumatol. 2022;74(9):1474-1476.

https://doi.org/10.1002/art.42143

[15] Kiil RM, Mistegaard CE, Loft AG, Zejden A, Hendricks O, Jurik AG. Differences in topographical location of sacroiliac joint MRI lesions in patients with early axial spondyloarthritis and mechanical back pain. Arthritis Res Ther. 2022;24(1):75. Published 2022 Mar 24.

https://doi.org/10.1186/s13075-022-02760-7

[16] Besutti G, Marvisi C, Muratore F, Spaggiari L. The role of sacro-iliac joint magnetic resonance imaging in the diagnosis of axial spondyloarthritis: focus on differential diagnosis in women. Reumatismo. 2024;76(3). Published 2024 Sep 11.

https://doi.org/10.4081/reumatismo.2024.1768

[17] Badr S, Jacques T, Lefebvre G, Boulil Y, Abou Diwan R, Cotten A. Main Diagnostic Pitfalls in Reading the Sacroiliac Joints on MRI. Diagnostics (Basel). 2021;11(11):2001. Published 2021 Oct 28.

https://doi.org/10.3390/diagnostics11112001

[18] Al-Mnayyis A, Obeidat S, Badr A, et al. Radiological Insights into Sacroiliitis: A Narrative Review. Clin Pract. 2024;14(1):106-121. Published 2024 Jan 3.

https://doi.org/10.3390/clinpract14010009

[19] Khan MA. HLA-B*27 and Ankylosing Spondylitis: 50 Years of Insights and Discoveries. Curr Rheumatol Rep. 2023;25(12):327-340.

https://doi.org/10.1007/s11926-023-01118-5

[20] Deodhar A, Gill T, Magrey M. Human Leukocyte Antigen B27-Negative Axial Spondyloarthritis: What Do We Know?. ACR Open Rheumatol. 2023;5(7):333-344.

https://doi.org/10.1002/acr2.11555

[21] Ciurea A, Götschi A, Bräm R, et al. Early axial spondyloarthritis according to the ASAS consensus definition: characterisation of patients and effectiveness of a first TNF inhibitor in a large observational registry. RMD Open. 2023;9(4):e003455. Published 2023 Dec 1.

https://doi.org/10.1136/rmdopen-2023-003455

[22] Fröhlich F, Micheroli R, Hebeisen M, et al. HLA-B27 as a predictor of effectiveness of treatment with TNF inhibitors in axial spondyloarthritis: data from the Swiss Clinical Quality Management Registry. Clin Rheumatol. 2023;42(5):1267-1274.

https://doi.org/10.1007/s10067-022-06490-8

[23] Ramiro S, Nikiphorou E, Sepriano A, et al. ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Ann Rheum Dis. 2023;82(1):19-34.

https://doi.org/10.1136/ard-2022-223296

[24] Bittar M, Deodhar A. Axial Spondyloarthritis: A Review. JAMA. 2025;333(5):408-420.

https://doi.org/10.1001/jama.2024.20917

[25] George N, Liew JW, Dubreuil M. The role of upadacitinib for the treatment of axial spondyloarthritis. Immunotherapy. 2023;15(15):1227-1237.

https://doi.org/10.2217/imt-2023-0032

[26] Deodhar A, Van den Bosch F, Poddubnyy D, et al. Upadacitinib for the treatment of active non-radiographic axial spondyloarthritis (SELECT-AXIS 2): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. 2022;400(10349):369-379.

https://doi.org/10.1016/S0140-6736(22)01212-0

[27] Ahmed S, Yesudian R, Ubaide H, Coates LC. Rationale and concerns for using JAK inhibitors in axial spondyloarthritis. Rheumatol Adv Pract. 2024;8(4):rkae141. Published 2024 Nov 7.

https://doi.org/10.1093/rap/rkae141

[28] Keeling S, Maksymowych WP. JAK inhibitors, psoriatic arthritis, and axial spondyloarthritis: a critical review of clinical trials. Expert Rev Clin Immunol. 2021;17(7):701-715.

https://doi.org/10.1080/1744666X.2021.1925541

[29] Schwartzman S, Ruderman EM. A Road Map of the Axial Spondyloarthritis Continuum. Mayo Clin Proc. 2022;97(1):134-145.

https://doi.org/10.1016/j.mayocp.2021.08.007

[30] Zhang M, Liang Z, Tian L, et al. Effects of Exercise Therapy in Axial Spondyloarthritis: A Systematic Review, Meta-analysis, and Meta-regression of Randomized Trials. Arch Phys Med Rehabil. 2025;106(1):113-123.

https://doi.org/10.1016/j.apmr.2024.06.005

[31] Boudjani R, Challal S, Semerano L, Sigaux J. Impact of different types of exercise programs on ankylosing spondylitis: a systematic review and meta-analysis. Disabil Rehabil. 2023;45(24):3989-4000.

https://doi.org/10.1080/09638288.2022.2140842

[32] Gravaldi LP, Bonetti F, Lezzerini S, De Maio F. Effectiveness of Physiotherapy in Patients with Ankylosing Spondylitis: A Systematic Review and Meta-Analysis. Healthcare (Basel). 2022;10(1):132. Published 2022 Jan 10.

https://doi.org/10.3390/healthcare10010132

[33] Carbo M, Hilberdink B, Paap D, et al. Physical activity in relation to health status, quality of life and compliance with World Health Organization recommendations in patients with axial spondyloarthritis. Arthritis Res Ther. 2025;27(1):112. Published 2025 May 21.

https://doi.org/10.1186/s13075-025-03575-y

[34] Kiefer D, Braun J, Kiltz U, et al. Patients' awareness towards physical activity in the treatment of axial spondyloarthritis. Joint Bone Spine. 2023;90(5):105585.

https://doi.org/10.1016/j.jbspin.2023.105585

[35] Luo Y, Chen Y, Yan X, Zhang L, Shang Y, Seo JC. Effectiveness of exercise intervention in relieving symptoms of ankylosing spondylitis: A network meta-analysis. PLoS One. 2024;19(6):e0302965. Published 2024 Jun 14.

https://doi.org/10.1371/journal.pone.0302965

[36] Chwaliszewski K, Fikas K, Waz D, et al. Chronic Low Back Pain: Investigating the Influence of Lifestyle and Physical Activity on Factors that Exacerbate or Enhance Patient Outcomes. Quality in Sport. 2025;39:58915.

https://doi.org/10.12775/QS.2025.39.58915

[37] WADA. International Standard for Therapeutic Use Exemptions (ISTUE). World Anti-Doping Agency. 2023.

https://www.wada-ama.org/en/what-we-do/science-medicine/therapeutic-use-exemptions

[38] Vernec A, Pipe A, Slack A, et al. Low prevalence of Therapeutic Use Exemptions among Olympic and Paralympic athletes (2016–2022). Br J Sports Med. 2024. Published online 2024.

https://www.wada-ama.org/en/news/wada-study-confirms-low-prevalence-therapeutic-use-exemptions-among-olympic-and-paralympic

[39] Webers C, Grimm S, van Tubergen A, et al. The value of correctly diagnosing axial spondyloarthritis for patients and society. Semin Arthritis Rheum. 2023;62:152242.

https://doi.org/10.1016/j.semarthrit.2023.152242

[40] Poddubnyy D, Garrido-Cumbrera M, Sommerfleck F, et al. Diagnostic delay in patients from the International Map of Axial Spondyloarthritis: geographic, sociodemographic and disease-related factors. Rheumatology (Oxford). 2025;64(4):1873-1879.

https://doi.org/10.1093/rheumatology/keae521

[41] Katsifis-Nezis D, Fanouriakis A. Year in Review: Axial Spondyloarthritis. Mediterr J Rheumatol. 2026;37(Suppl 1):1-11. Published 2026 Jan 8.

https://doi.org/10.31138/mjr.300925.era

Quality in Sport

Downloads

Published

2026-05-13

How to Cite

1.
KRUCZEK, Zuzanna, KUDŁA, Martyna, KOCIUBA, Julia, KRAWCZYK, Agata, KOŁKOWICZ, Dorota, ŁOBAZA, Paulina, PAWEŁCZAK, Natalia, KURCIŃSKA, Julia, KURCIŃSKI, Szymon, ZAJĄC, Gabriela, CZECHOWICZ, Paweł, CZECHOWICZ, Justyna, ANTKIEWICZ, Mikołaj, ARCZYŃSKA-ANTKIEWICZ, Aleksandra and DROZD, Maria. Axial Spondyloarthritis in Athletes: A Narrative Review of Diagnostic Challenges and Quality of Medical Management. Quality in Sport. Online. 13 May 2026. Vol. 55, p. 71213. [Accessed 13 May 2026]. DOI 10.12775/QS.2026.55.71213.

Issue

Vol. 55 (2026)

Section

Medical Sciences

License

Copyright (c) 2026 Zuzanna Kruczek, Martyna Kudła, Julia Kociuba, Agata Krawczyk, Dorota Kołkowicz, Paulina Łobaza, Natalia Pawełczak, Julia Kurcińska, Szymon Kurciński, Gabriela Zając, Paweł Czechowicz, Justyna Czechowicz, Mikołaj Antkiewicz, Aleksandra Arczyńska-Antkiewicz, Maria Drozd

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Stats

Number of views and downloads: 3
Number of citations: 0