History and exam

Key diagnostic factors

common

asymptomatic

Osteoporosis is asymptomatic until fracture occurs. Most vertebral fractures are subclinical or asymptomatic.[62]​​

Other diagnostic factors

common

back pain

May be due to vertebral fracture.

kyphosis

May be evidence of vertebral fractures.[2]​​[31]

height loss

May indicate asymptomatic vertebral fracture.[31]​

uncommon

vertebral tenderness

In patients with back pain, vertebral tenderness may indicate vertebral fracture.

Risk factors

strong

prior fragility fracture

Incidence of new fracture has been found to be greater in people with prior fragility fracture.​[21][22]​ In one meta-analysis, the cumulative incidence of a subsequent fracture was 11.6% (95% CI 8.9% to 14.2%) in the 2 years after the first fragility fracture.​​​[23]

Moderate or severe vertebral fractures, even when asymptomatic, are strong risk factors for subsequent vertebral and nonvertebral fractures.[24]

female sex

Women reach lower peak bone mass than men and have greater declines in bone mass over time.[3][25]

white ancestry

In the US and UK, white people have an increased risk of fragility fractures compared with people of other races.[26][27]​ In the US, studies suggest that white people are at greater risk for low bone mineral density (BMD) compared with black people, but data on Hispanic and Asian populations is limited and less consistent.[28]​​

older age (>50 years for women and >65 years for men)

Increasing age is associated with decreases in bone mineral density (BMD), especially in men.[29][30][31]​​​

Rate of reduction of bone mass accelerates at age 50 for women and age 65 for men.[3]

low BMI

Loss of bone mass is accelerated in men and women with lower body mass index (BMI). BMI <20 kg/m² has been associated with increased loss of bone mineral density (BMD).[31]​​

loss of height

May be evidence of vertebral fractures.[2]​​

family history of maternal hip fracture

Maternal history of condition or hip fracture predicts low bone mineral density (BMD).[2]​​

postmenopause

Estrogen decline at menopause is strongly associated with decreases in bone mineral density (BMD).[2]​​[3]

secondary amenorrhea

Has been associated with low estrogen before menopause and can lead to decreased bone mineral density (BMD). Can be a consequence of anorexia nervosa or exercise-induced amenorrhea.[3]

primary hypogonadism

Has been associated with increased risk of condition.[2]​​

tobacco use

Bone mass declines more rapidly in men and postmenopausal women who smoke tobacco than in those who do not.[29][31]​​[32]​​

excessive alcohol use

Excessive alcohol use (more than 3 drinks per day) has been associated with increased risk of the condition, but moderate alcohol intake has been associated with decreased rate of decline in bone mineral density (BMD) and a reduced risk of osteoporotic fractures.[3]​​[31][33][34]

prolonged immobilization

Bone mineral density (BMD) declines as a result of immobilization regardless of the cause (e.g., bed rest or paralysis).[3]

low calcium intake

In a study of 36,282 women, women assigned to placebo had a greater loss of bone mineral density (BMD) than those given calcium and vitamin D supplementation.[35] However, there was no significant difference between the groups in the incidence of hip fractures.

vitamin D deficiency

Has been associated with increased parathyroid hormone production and consequent increased bone resorption.[3]

diabetes

Type 1 and type 2 diabetes are associated with an increased risk of osteoporosis and fractures.[31][36]​ The mechanisms are not entirely clear, but may be related to changes in bone quality and an increased risk of falls due to diabetes-related comorbidities such as diabetic retinopathy or peripheral neuropathy.[37][38]

rheumatoid arthritis

People with rheumatoid arthritis have an increased risk of osteoporosis.[31] In one meta-analysis, the estimated point prevalence of osteoporosis in people with rheumatoid arthritis was 27.6%.[39]

sarcopenia

People with sarcopenia have an increased risk of osteoporosis and vice versa.[40]​ In one meta-analysis, patients with coexisting osteoporosis and sarcopenia (osteosarcopenia) had a higher risk of fracture than patients with either sarcopenia or osteoporosis/osteopenia alone.[41]

glucocorticoid excess

Approximately 50% of people with Cushing syndrome experience fractures, especially vertebral fractures.[42]

corticosteroid use

The mechanisms of corticosteroid-induced osteoporosis are multifactorial and include osteoclast activation, osteoblast inhibition, decreased gastrointestinal and renal calcium absorption, and decreased gonadotropin secretion.[42]

weak

proton-pump inhibitor use

Evidence suggests that there is an increased risk of fractures, osteoporosis, and changes in bone mineral density (BMD) for people taking proton-pump inhibitors, but the certainty of evidence is very low.[43][44]

hyperthyroidism

Hyperthyroidism increases osteoclast activity.[45]

Risk of fracture is greater with clinically evident hyperthyroidism than with subclinical hyperthyroidism.

heparin use

Unfractionated heparin is associated with osteoporotic fractures.

The mechanism of heparin-induced osteoporosis is uncertain, but may be related to osteoclast activation or parathyroid hormone-like effects.[46]

anticonvulsant use

Has been associated with an increased risk of fracture.

Mechanism of fracture has not been related to a specific class of anticonvulsant.[47]

A combination of factors may contribute to increased risk, including reduced bone mineral density (BMD), trauma during seizure, and increased risk of falls due to neurotoxic adverse effects of drugs.

androgen deprivation treatment (men)

There is evidence of decreased bone mineral density (BMD) with all types of androgen deprivation therapy, presumably due to its antitestosterone effect.[48][49]

aromatase inhibitor treatment (women)

Oncologic female patients on aromatase inhibitor treatment will develop estrogen deficiency with subsequent bone loss.[50]

use of drugs associated with an increased risk of falls

Multiple drugs have been associated with an increased risk of falls and fractures in older adults, including benzodiazepines, antipsychotics, nonbenzodiazepine benzodiazepine receptor agonists (also known as z-drugs; e.g., zolpidem), and antidepressants.[51][52][53]​ In one case-control study, the absolute increased risk of fractures was highest for people age ≥75 years using selective serotonin-reuptake inhibitors (SSRIs), tricyclic antidepressants, antipsychotics, or ≥3 fall-risk increasing drugs concurrently.[54]​​​

Use of this content is subject to our disclaimer