Osteoporosis: Diagnosis and Treatment

Bone is living tissue that renews throughout life, not an inert structure. Old bone is continually broken down and replaced. Formation exceeds breakdown in youth, with peak bone mass reached at approximately 25–30 years. The balance then gradually shifts towards breakdown. Osteoporosis occurs when this loss progresses enough to make bones prone to fracture.

The problem is more than "less bone". The honeycomb-like internal network thins and loses connections, making bone both less dense and less resistant to impact. A fall that would not harm a healthy bone may therefore break an osteoporotic one. This is called a fragility fracture: a fracture caused by low-energy trauma, such as a fall from standing height.

The intermediate stage of bone loss that has not reached the osteoporosis threshold is called osteopenia (low bone mass). Osteopenia alone is not considered a disease, but it informs treatment decisions when other fracture risk factors are present. Bone loss accelerates in the first years after menopause, but osteoporosis also affects men and is often overlooked in them.

The difficult aspect of osteoporosis is that it may cause no symptoms for a long time, hence the name "silent disease". Bone loss itself does not cause pain. Widespread body pain is usually due to another condition, while someone with no pain may have substantial bone loss. The condition is often discovered after a fracture or during routine screening.

• A fracture after a minor fall, sneeze or heavy lifting, most commonly affecting the wrist, hip or spine
• Loss of height over the years by more than a few centimetres
• Forward bending of the back and a markedly hunched posture
• Sudden severe back or lower back pain that increases with movement may indicate a vertebral compression fracture
• Ribs moving closer to the pelvis, the abdomen protruding forwards and a feeling of breathlessness

Some risks cannot be changed, while others relate to daily habits. Both groups are reviewed because treatment decisions depend on overall fracture risk, not the measurement alone.

• Increasing age; menopause in women, particularly early menopause before age 45
• A parental history of hip fracture, a thin build and low body weight
• A previous fracture following minor trauma (one of the strongest warning signs)
• Long-term cortisone (corticosteroid) use and certain medicines
• Smoking, excessive alcohol, inactivity and being bedbound
• Vitamin D deficiency, a diet low in calcium and limited sun exposure
• Thyroid and parathyroid disease, rheumatoid arthritis, malabsorption such as coeliac disease, and chronic kidney or liver disease

Assessment starts with history and examination: previous fractures, height loss, medicines, falls and diet are discussed. The main diagnostic tool is bone density measurement (DEXA / DXA). This painless scan uses low-dose X-rays, takes approximately 10–15 minutes and usually measures the lumbar spine and hip.

The result is reported as a T-score. The generally accepted classification is: −1 or above is normal, between −1 and −2,5 is low bone mass (osteopenia), and −2,5 or below is osteoporosis. In someone who has sustained a fragility fracture, osteoporosis may be diagnosed even when the measurement is borderline. Tools estimating fracture risk using age, sex, fracture history and other factors also inform the decision.

X-rays are not sensitive enough to show early bone loss, but they can identify vertebral compression fractures. Blood and urine tests, including calcium, phosphate, vitamin D, thyroid and parathyroid hormones, and kidney and liver function, investigate other diseases causing bone loss. This distinction matters because an underlying cause becomes the first treatment target.

The goal is preventing fractures, not merely changing a bone density number. The plan has three parts: diet and supplements, exercise and fall prevention, and medication where needed.

Fracture treatment itself, whether casting, fixation or replacement, depends on its location and type and is described on the relevant pages. This section addresses the step often missed after fracture treatment: investigating and treating why the bone broke so easily.

A fragility fracture is a strong indication of osteoporosis. Someone who has had one has a markedly higher risk of another fracture than a person of the same age without a previous fracture, particularly during the first year. A fracture is therefore now viewed not as an isolated event but as a point at which bone health needs reassessment.

In practice, this means arranging a bone density scan while the fracture heals or soon afterwards, checking vitamin D and calcium levels and screening for other conditions that can cause bone loss, starting medication in suitable patients and reviewing the causes of falls. A history of fracture may alter the treatment decision even if the scan result is borderline. Because immobility after a fracture accelerates bone loss, early movement and rehabilitation within the limits permitted by the doctor are also part of this plan.

This assessment should not be delayed even if the fracture was treated elsewhere; bring X-rays and discharge summaries from that period to help planning.

• Hip Fractures in Older People
• Fracture Treatment (General)
• Bone and Joint Health in Older Age

Daily habits are part of osteoporosis treatment. The points below directly concern bone and spinal health. Since most fractures follow a simple fall at home, home safety and fall prevention are equally important; a detailed list is in the walking difficulties and falls in older adults section.

• Obtain calcium primarily from food: milk and dairy products, leafy greens, pulses, sesame and molasses
• Have vitamin D measured and take the dose prescribed if deficient; do not take high doses indiscriminately
• Eat enough protein at every meal; preserving muscle mass goes hand in hand with preserving bone
• Stop smoking and limit alcohol; both accelerate bone loss
• Do not lift heavy loads by bending at the waist; bend the knees, keep the load close to your body and avoid twisting your trunk
• Avoid sit-up-type exercises that bend the spine forwards and sudden trunk rotation; ask your doctor about your programme, particularly after a vertebral fracture
• Make regular weight-bearing walking and strengthening and balance exercises two to three days a week a habit