Osteoporosis Clinical Presentation
- Author: Monique Bethel, MD; Chief Editor: Herbert S Diamond, MD more...
Keep in mind that osteoporosis occurs in many people who have few or no risk factors for this condition. Often, patients who have not sustained a fracture do not report symptoms that would alert the clinician to suspect a diagnosis of osteoporosis; thus, this disease is a "silent thief" that generally does not become clinically apparent until a fracture occurs.
Screening at-risk populations is, therefore, essential; unfortunately, many women are not receiving proper screening or treatment for osteoporosis, which, in turn, may result in improper management of this disease and its related complications. For example, the existence of a disorder in a patient known to cause secondary osteoporosis—such as rheumatoid arthritis, celiac disease, or Crohn disease—should increase a clinician’s suspicion that osteoporosis may be present and that screening may be indicated.
Multiple risk factors exist for osteoporosis. The National Osteoporosis Foundation (NOF) has categorized these risk factors into two categories: nonmodifiable and modifiable. Nonmodifiable risk factors include the following:
Personal history of fracture as an adult
History of fracture in a first-degree relative
Poor health or fragility
Potentially modifiable risk factors include the following:
Current cigarette smoking
Low body weight (< 127 lb)
Estrogen deficiency such as that caused by early menopause (age < 45 years) or bilateral ovariectomy and prolonged premenopausal amenorrhea (>1 year)
Low lifelong calcium intake
Impaired eyesight despite adequate correction
Inadequate physical activity
Poor health or frailty
Assessment of fracture risk
A thorough history should be obtained to screen for and identify the presence of known risk factors for osteoporosis and osteoporotic fracture. Specifically, the history should focus on the following[90, 91] :
Age (>50 years), sex (female), and race (white or Asian)  ; the US Preventive Services Task Force (USPSTF) recommendations include screening for osteoporosis in women aged 65 years or older and in younger women with a fracture risk that is the same or greater than that of a 65-year-old white woman who has no additional risk factors 
Family history of osteoporosis, particularly maternal history of fractures
Reproductive factors, especially regarding early menopause and estrogen replacement therapy: postmenopausal women are at high risk, as are women who have undergone hysterectomy and oophorectomy
Smoking: smokers are at higher risk
Low levels of physical activity: immobility increases the risk  ; spinal cord injury and stroke cause physical impairment and are common causes of immobility
Strenuous exercise that results in amenorrhea (such as that which occurs in marathon runners)
Calcium and vitamin D intake
History of low-trauma "fragility" fracture in patients aged 40 years or older: a fragility fracture is defined as a fracture due to trauma that would not normally cause fracture (a force equal to or less than that resulting from a fall from standing height)
Signs of vertebral fracture (see below)
Coexisting medical conditions associated with bone loss
Medications associated with bone loss
Risk factors for falls in older patients: these include poor balance, orthostatic hypotension, weakness of the lower extremity muscles and deconditioning, use of medications with sedative effects, poor vision or hearing, and cognitive impairment
Although the USPSTF did not find any studies that assessed effects of the use of risk prediction instruments on patient outcomes, either alone or in combination with bone measurement tests, there are many validated instruments for predicting the risk for low bone mineral density (BMD) in postmenopausal women; few of these, however, have been validated for use in men.
The Fracture Risk Assessment (FRAX) tool, accessible to healthcare providers and patients, is a validated instrument used to estimate 10-year risks for fractures, including those for black, Asian, and Hispanic women. A 65-year-old white woman with no other risk factors has a 9.3% 10-year risk for any osteoporotic fracture. Generally, estimated fracture risks in nonwhite women are lower than those for white women of the same age.
White women between the ages of 50 and 64 years with ≥10-year fracture risks based on specific risk factors include the following persons :
A 50-year-old current smoker with a body mass index (BMI) less than 21 kg/m 2, daily alcohol use, and parental fracture history
A 55-year-old woman with a parental fracture history
A 60-year-old woman with a BMI less than 21 kg/m 2 and daily alcohol use
A 60-year-old current smoker with daily alcohol use
Differentiating fracture types by history
Patients with acute insufficiency fractures may report a history of minimal or no trauma resulting in pain. They may report a fall from a standing or sitting position. Patients with compression fractures resulting in thoracic kyphosis may report iliocostal friction with associated abdominal protrusion, decreased tolerance for oral intake, and breathing difficulties. Patients with hip, pelvic, or sacral fractures may report pain that is worsened with weight-bearing.
Patients who have sustained a vertebral compression fracture may note progressive kyphosis with loss of height. They may also present with an episode of acute back pain after bending, lifting, or coughing. It should be noted, however, that two thirds of vertebral fractures are asymptomatic.
With respect to those vertebral fractures that are painful, typical subjective information may include the following:
The episode of acute pain may follow a fall or minor trauma
Pain is localized to a specific, identifiable, vertebral level in the midthoracic to lower thoracic or upper lumbar spine
The pain is described variably as sharp, nagging, or dull; movement may exacerbate pain; in some cases, pain radiates to the abdomen
Pain is often accompanied by paravertebral muscle spasms exacerbated by activity and decreased by lying supine
Patients often remain motionless in bed because of fear of causing an exacerbation of pain
Acute pain usually resolves after 4-6 weeks; in the setting of multiple fractures with severe kyphosis, the pain may become chronic
Patients who have sustained a hip fracture may experience the following:
Pain in the groin, posterior buttock, anterior thigh, medial thigh, and/or medial knee during weight-bearing or attempted weight-bearing of the involved extremity
Diminished hip range of motion (ROM), particularly internal rotation and flexion
External rotation of the involved hip while in the resting position
Patients with osteoporosis may report lactose intolerance and celiac sprue. Celiac sprue has been shown to be associated with osteoporosis in approximately 5% of cases.
Patients with suspected osteoporosis should undergo a comprehensive physical examination. The physical examination should begin with an inspection of the patient. Height measurement with a stadiometer at each visit may be useful. Examination of active and passive range of motion (ROM) assists in determining whether spine, hip, wrist, or other osseous pathology may be present. A thorough neurologic examination is essential to rule out spinal cord and/or peripheral nerve compromise.
The examination may elicit pain, or the patient may be pain free. Thoracic kyphosis may be present secondary to vertebral compression fractures, a dowager hump, and a history of loss of height. Patients may have an associated scoliosis.
Areas of concern include the following:
A history of loss of height
Low body weight (body mass index < 19 kg/m 2)
Signs that might indicate existing osteoporosis (eg, kyphosis or dowager hump; point tenderness over a vertebra or other suspected fracture site)
Signs suggestive of secondary osteoporosis
Signs in older patients that may indicate increased fall risk (eg, difficulty with balance or gait, orthostatic hypotension, lower-extremity weakness, poor vision or hearing, cognitive impairment)
A 10-year longitudinal study assessed the Timed Up and Go (TUG) test performance (a validated predictor of falling) and hip area BMD (bone mineral density calculated using bone area as opposed to bone volume). Using data from 1126 women (mean age, 75 years), the study noted that risks of nonvertebral fracture and hip fracture were significantly higher among those who had slow TUG test performance and normal hip BMD or both slow TUG test performance and low hip BMD. These results suggest that the TUG test is an independent risk factor for incident nonvertebral fracture; this inexpensive physical assessment may be beneficial in screening patients with increased risk of fracture.
Signs of fracture
Patients with vertebral compression fractures may demonstrate a thoracic kyphosis with an exaggerated cervical lordosis (dowager hump). This is followed by a loss of lumbar lordosis. After each episode of vertebral compression fracture and progressive kyphosis, the patient's height may decrease by 2-3 cm.
Patients with acute vertebral fractures may have point tenderness over the involved vertebrae. Palpation of the spinous processes often does not aid the examiner in localizing point tenderness, but percussion may be helpful in acute or subacute vertebral compression fractures.
Patients with hip fractures may have severe pain with ambulation. A FABER (ie, flexion in abduction and external rotation) hip joint test may reveal limited ROM with end-range pain. Patients with hip fractures may show decreased weight-bearing on the fractured side or an antalgic gait pattern.
Patients with pubic and sacral fractures may report marked pain with ambulation and tenderness to palpation, percussion, or both. Furthermore, patients with sacral fractures may have pain with physical examination techniques used to assess the sacroiliac joint, such as the FABER, Gaenslen, or squish test.
Signs of collagen defects
Patients with osteoporosis may have physical findings consistent with subtle collagen defects. These include a short fifth digit, dentinogenesis imperfecta, hyperlaxity, hearing loss, pes planus, bunions, and blue sclerae.
Patients with osteoporosis are known to have decreased balance, possibly secondary to differences in balance control strategies and sway amplitude. Patients may have difficulty performing tandem gait and performing single limb stance. Poor balance may be noted particularly in patients with severe kyphosis resulting from vertebral compression fractures because their altered center of gravity makes ambulation with a stable base of support difficult for them.
Fractures are the most common and serious complication of osteoporosis. Patients with osteoporosis are at high risk for recurrent fractures of the hips, vertebrae, ribs, and wrists.
Screening in Men
Although routinely screening men for osteoporosis is not as widespread a practice as that of screening in women, the US Preventive Services Task Force (USPSTF) indicates that using bone measurement tests in men may not only help to detect this disease but also prevent its associated burden of fractures and fracture-related illness.
In weighing the risk versus benefit of screening men, clinicians should consider that osteoporosis is a preventable condition and that the potential harm in screening is likely to be small and mostly due to cost, such as that required to increase the number of dual-energy x-ray absorptiometry (DXA) scanners available for screening. In addition, assuming that the risk versus benefit of therapy for osteoporosis is similar for men and women, the men who are most likely to benefit from screening would be those with a 10-year risk for osteoporotic fracture that is equal to or greater than that for 65-year-old white women who have no additional risk factors. It is important to note, however, that there is insufficient current evidence for assessing the risk versus benefit of screening for osteoporosis in men.
The American College of Physicians (ACP) has similar recommendations for screening of osteoporosis in men, including periodic evaluation of risk factors in older men before age 65 years (particularly men who do not choose to be screened) and obtaining DXA for men at increased risk for the disease who are candidates for drug therapy. Risk factors for osteoporosis in men include the following :
Age older than 70 years
Low body weight (body mass index [BMI] < 20 to 25 kg/m 2)
Greater than 10% weight loss (relative to the usual young or adult weight or weight loss in recent years)
Androgen deprivation therapy
Previous fragility fracture
Like the USPSTF, the ACP recommends further research to assess osteoporosis screening tests in men, to determine whether risk factors for osteoporosis in women also apply to men.
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- Table 1. WHO Definition of Osteoporosis Based on BMD Measurements by DXA
- Table 2. Types of Primary Osteoporosis
- Table 3. Causes of Secondary Osteoporosis in Adults
- Table 4. Prevalence of Osteoporosis Among Racial and Ethnic Groups
- Table 5. Baseline Studies for Baseline Conditions in Osteoporosis
- Table 6. Tests for Secondary Causes of Osteoporosis
|Definition||Bone Mass Density Measurement||T-Score|
|Normal||BMD within 1 SD of the mean bone density for young adult women||T-score ≥ –1|
|Low bone mass (osteopenia)||BMD 1–2.5 SD below the mean for young-adult women||T-score between –1 and –2.5|
|Osteoporosis||BMD ≥2.5 SD below the normal mean for young-adult women||T-score ≤ –2.5|
|Severe or “established” osteoporosis||BMD ≥2.5 SD below the normal mean for young-adult women in a patient who has already experienced ≥1 fractures||T-score ≤ –2.5 (with fragility fracture[s])|
(1) World Health Organization (WHO). WHO scientific group on the assessment of osteoporosis at primary health care level: summary meeting report. Available at: http://www.who.int/chp/topics/Osteoporosis.pdf. Accessed February 23, 2015.
(2) Kanis JA. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. WHO Study Group. Osteoporos Int. Nov 1994;4(6):368-81.
(3) Czerwinski E, Badurski JE, Marcinowska-Suchowierska E, Osieleniec J. Current understanding of osteoporosis according to the position of the World Health Organization (WHO) and International Osteoporosis Foundation. Ortop Traumatol Rehabil. Jul-Aug 2007;9(4):337-56.
BMD = bone mass density; DXA = dual x-ray absorptiometry; SD = standard deviation; T-score = a measurement expressed in SD units from a given mean that is equal to a patient's BMD measured by DXA minus the value in a young healthy person, divided by the SD measurement in the population.
|Type of Primary Osteoporosis||Characteristics|
|Hematologic and neoplastic disorders||
(1) American Association of Clinical Endocrinologists medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates for 2003. Endocr Pract. Nov-Dec 2003;9(6):544-64.
(2) Kelman A, Lane NE. The management of secondary osteoporosis. Best Pract Res Clin Rheumatol. Dec 2005;19(6):1021-37.
|Race/Ethnicity||Sex (age ≥50 y)||% Estimated to have osteoporosis||% Estimated to have low bone mass|
|Non-Hispanic white; Asian||Women||15.8||52.6|
|Source: Wright NC, Looker AC, Saag KG, Curtis JR, Delzell ES, Randall S, et al. The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res. Nov 2014;29(11):2520-6. [Medline].|
|Complete blood count (CBC)||CBC results may reveal anemia, as in sickle cell disease (patients with anemia, particularly those older than 60 years, should also be evaluated for multiple myeloma), and may raise the suspicion for alcohol abuse (in conjunction with results from serum chemistry tests and liver function tests)|
|Serum chemistry levels||Calcium levels can reflect underlying disease states (eg, severe hypercalcemia may reflect underlying malignancy or hyperparathyroidism; hypocalcemia can contribute to osteoporosis)
levels of serum calcium, phosphate, and alkaline phosphatase are usually normal in persons with primary osteoporosis, although alkaline phosphatase levels may be elevated for several months after a fracture
levels of serum calcium, phosphate, alkaline phosphatase, and 25(OH) vitamin D may be obtained to assess osteomalacia
Creatinine levels may decrease with increasing parathyroid hormone (PTH) levels or may be elevated in patients with multiple myeloma
Creatinine levels are also used to estimate creatinine clearance, which may indicate reduced renal function in elderly patients
Magnesium is very important in calcium homeostasis ; decreased levels of magnesium may affect calcium absorption and metabolism
|Liver function tests||Increased levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), bilirubin, and alkaline phosphatase may indicate alcohol abuse|
|Thyroid-stimulating hormone (TSH) level||Thyroid dysfunction has been associated with osteoporosis and should therefore be ruled out|
|25-Hydroxyvitamin D level||This test assesses for vitamin D insufficiency; inadequate vitamin D levels can predispose persons to osteoporosis|
|Tests for Secondary Causes of Osteoporosis||Disorder|
|24-Hour urine calcium level||This study assesses for hypercalciuria and hypocalciuria|
|Parathyroid hormone (PTH) level||An intact PTH result is essential in ruling out hyperparathyroidism; an elevated PTH level may be present in benign familial hypocalciuric hypercalcemia|
|Thyrotropin level (if on thyroid replacement)||Experts are divided on whether to include thyrotropin testing, regardless of a history of thyroid disease or replacement; however, one study showed reduced femoral neck bone mineral density (BMD) in women with subclinical hypothyroidism and hyperthyroidism|
|Testosterone and gonadotropin levels in younger men with low bone densities||These tests may help evaluate a sex hormone deficiency as a secondary cause of osteoporosis|
|Urinary free cortisol level and tests for adrenal hypersecretion||These tests are used to exclude Cushing syndrome, which, although uncommon, can lead to rapidly progressive osteoporosis when the condition is present; a urine free cortisol value or overnight dexamethasone suppression test should be ordered in suspected cases|
|Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP)||These are used to identify multiple myeloma|
|Antigliadin and antiendomysial antibodies||These tests can help identify celiac disease|
|Serum tryptase and urine N-methylhistamine||These tests help identify mastocytosis|
|Bone marrow biopsy||This study is obtained when a hematologic disorder is suspected|