Ankylosing spondylitis presents significant challenges in diagnosis due to its non-specific onset in some instances, and its symptoms overlap with other conditions. Mechanical back pain or poor posture are two of the most misinterpreted symptoms that clinicians attribute to other reasons than inflammatory back pain, leading to irreversible spinal damage, reduced treatment response and diminished quality of life. Misdiagnosis with conditions such as degenerative arthritis or trauma or even fibromyalgia further delays effective treatment, resulting in disease progression. Ankylosing spondylitis management also faces pitfalls such as underappreciation of extra-spinal manifestations, suboptimal treatment strategies and medication-related side effects. Additionally, physical therapy, regular exercise and the psychological component of the disease are frequently overlooked. A key strategy to overcome these pitfalls is early referral, suitable imaging tools, a treat-to-target approach using newer disease-modifying anti-rheumatic drugs and physical therapy. This strategy will improve long-term outcomes, prevent complications and enhance the quality of life of patients with ankylosing spondylitis.