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Purpose: To compare tomosynthesis performance to radiography for the differentiation of sacroiliitis versus normal or degenerative changes in sacroiliac joints in patients with suspected axial spondyloarthritis (SpA). Materials and methods: Radiography, tomosynthesis and CT of sacroiliac joints (29 patients) were performed on the same day in consecutive patients with suspected SpA. The examinations were retrospectively read independently, blinded by two radiologists (one junior and one senior, and twice by one junior). Interobserver and intraobserver agreement was evaluated using the kappa coefficient. Effective doses for each imaging sensitivity, specificity and accuracy were assessed and compared with CT as gold standard. Results: CT detected 15/58 joints with sacroiliitis. The imaging sensitivity, specificity and accuracy were 60%, 84% and 44%, respectively, for radiography and 87%, 91% and 77% for tomosynthesis. The mean effective dose for tomosynthesis was significantly lower than that of CT (5-fold less) and significantly higher than that of radiography (8-fold more). Conclusion: Tomosynthesis is superior to radiography for sacroiliitis detection in patients with suspected SpA, with 5-fold less radiation exposure than CT.