Exercise is strongly recommended in ankylosing spondylitis (AS), and the key principle is that very few exercises are absolutely contraindicated — rather, certain activities require modification or avoidance depending on disease stage and spinal involvement. The ACR/SPARTAN/SAA 2019 guidelines strongly recommend physical therapy for all AS patients and conditionally recommend active (supervised) exercise over passive interventions.
Exercises and Activities to Avoid or Modify
• Spinal manipulation: The ACR strongly recommends against spinal manipulation in patients with spinal fusion or advanced spinal osteoporosis, due to the high risk of fracture. AS patients have a vertebral fracture prevalence of ~14% and a significantly elevated fracture risk (OR 2.26 for vertebral fractures).
• High-impact contact sports (e.g., rugby, football, hockey, wrestling): These should generally be avoided, particularly in patients with spinal ankylosis, because the fused spine behaves as a long bone and is highly susceptible to fracture from even minor trauma.
• Heavy axial loading exercises (e.g., heavy overhead press, heavy barbell squats with poor form): These may place excessive stress on a rigid, fused spine and should be approached with caution or avoided in advanced disease.
• Exercises promoting excessive spinal flexion in patients with significant kyphosis: Movements that reinforce a flexed posture (e.g., sit-ups/crunches) are generally discouraged, as they may worsen the characteristic thoracic kyphosis. Extension-based exercises are preferred.
• Forceful or ballistic stretching of the spine: Aggressive passive stretching or high-velocity movements can risk fracture in a stiffened or fused spine.
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