Question

A 20 year old patient presenting with chronic low backache and early morning stiffness since last 2 years. Since 6 months there are bilateral heel pain also. Most likely diagnosis for this patient is

• A. TB spine
• B. Ankylosing spondylitis
• C. Mechanical pain
• D. Disc prolapsed

Hint:

Bilateral heel pain (enthesitis) with inflammatory back pain in a young male strongly suggests a seronegative spondyloarthropathy.

Answer 1

The Correct Option is B

Step 1: Identify key clinical features. The patient is a 20-year-old with:
- Chronic low backache for 2 years (long-standing inflammatory pattern)
- Early morning stiffness (improves with activity -- characteristic of inflammatory arthritis)
- Bilateral heel pain for 6 months (enthesitis at Achilles tendon or plantar fascia insertion)

Step 2: Recognise the pattern of inflammatory back pain. Ankylosing spondylitis (AS) presents with inflammatory back pain: insidious onset before age 40, early morning stiffness lasting >1 hour, improving with exercise and worsening with rest. Bilateral enthesitis (heel pain) is a hallmark extra-articular feature of seronegative spondyloarthropathies, especially AS.

Step 3: Enthesitis in AS. Enthesitis is inflammation at the site where tendons/ligaments insert into bone. Common sites in AS include the Achilles tendon insertion (causing heel pain), plantar fascia, and iliac crest. Bilateral heel pain in a young male with inflammatory back pain is highly suggestive of AS.

Step 4: Eliminate other diagnoses.
- TB spine: causes mechanical, localised back pain with constitutional symptoms (fever, weight loss, night sweats); not bilateral heel pain or morning stiffness pattern.
- Mechanical pain: worsens with activity, improves with rest (opposite of AS); no enthesitis.
- Disc prolapse: acute or subacute onset, radicular pain, exacerbated by Valsalva manoeuvre; no enthesitis.

Conclusion: Young male, 2 years of inflammatory back pain with morning stiffness + bilateral enthesitis (heel pain) = Ankylosing spondylitis. HLA-B27 testing and sacroiliac joint X-ray/MRI would confirm the diagnosis.