Osteoporosis - OrthoInfo - AAOS (2023)

Osteoporosis is a condition in which the bones become thinner, weaker, and more likely to break.

According to the National Center for Health Statistics (part of the Centers for Disease Control and Prevention), in 2017-2018, the prevalence of osteoporosis and low bone mass in adults 50 and older was 55.7%*. That means more than half of all adults 50 and older in the U.S. are either living with or have an increased risk of developing osteoporosis.

People with osteoporosis are more vulnerable to fractures (broken bones) than those without this disorder. The National Osteoporosis Foundation reported that in the U.S. in 2015, as many as 2 million Medicare recipients (adults 65 and older) sustained roughly 2.3 million fractures related to osteoporosis.

Why Osteoporosis Occurs

Your bone changes over time, just like the other tissues in your body. In fact, your body naturally removes old, damaged bone and replaces it with new bone every 7 to 10 years after you become an adult. This process is called bone remodeling.

  • Balanced bone remodeling. Before age 30, especially around the time of puberty and early adulthood, people can make bigger, thicker bones with weight-bearing exercise and good nutrition. Until about age 30, your body makes new bone at about the same rate as the old bone tissue is removed; in other words, bone remodeling is balanced.
  • Unbalanced bone remodeling. After age 30-40, bone remodeling may gradually become unbalanced. You start to remove old bone more quickly than your body can replace it — leading to a loss of both bone density and architecture, which decreases the strength and quality of your bones as you age.

Osteoporosis - OrthoInfo - AAOS (1)

Vertebrae showing signs of osteoporosis. Normal vertebrae (left), vertebrae with mild osteoporosis (center), and vertebrae with severe osteoporosis (right).

Osteoporosis is more common in women than in men. This is because the loss of estrogen in women at menopause causes rapid bone loss, and because women often have smaller, thinner bones than men to begin with. Bone weakness develops later in life in men because their hormone loss occurs gradually with age.

Weakened bone can also occur in both men and women at younger ages due to various causes, including poor nutrition and a sedentary lifestyle.

(Video) What is Osteoporosis?

Osteopenia, or Low Bone Mass

Osteopenia is a condition in which you have low bone mass that is not severe enough to be called osteoporosis by bone density measurements. Osteopenia is now called low bone mass, which occurs because of low peak bone mass and/or bone loss after age 30.

It might be helpful to think of osteopenia as “pre-osteoporosis.” If unbalanced bone remodeling continues with aging, it will eventually lead to osteoporosis. Your risk of a fracture is higher than normal with low bone mass, but not as high as with osteoporosis.

The loss of bone tends to occur most in the spine, lower forearm above the wrist, and upper femur or thigh — the site of hip fractures. Spine fractures, wrist fractures, and hip fractures are common injuries in older adults.

The first sign that low bone mass has progressed to osteoporosis can be suffering a broken bone from a minor injury that probably would not have caused a fracture in a healthy person. For example, if you trip over a rug at home and break your wrist or your hip, this is most likely because of underlying bone weakness. A person with normal bone strength is not likely to break a wrist or hip from this small amount of trauma. Similarly, if you lift bags of groceries or push up a heavy window and sustain a spinal fracture, it’s also likely to be due to osteoporosis.

Recent studies have shown that even fractures caused by greater degrees of injury than simple falls, such as car crashes, can be associated with bone weakness.

Main causes of Osteoporosis


Most people with osteoporosis are over 50; at this age, bone formation is not keeping up with bone removal.

Osteoporosis - OrthoInfo - AAOS (2)

With aging, the thick outer shell of the bone (cortex) becomes thinner, and the architecture in the spongy bone also becomes thinner and less connected. This causes structural weakness in the bone that leads to fractures.

People who have smaller bones at the end of growth are at more risk of fractures with aging than those who have larger bones. After age 30, weight-bearing exercise can help decrease bone loss and maintain bone mass and strength, but it cannot make bigger, thicker bones. That is why it’s so important to build a maximum peak skeletal size and strength during your growth years.

(Video) Understanding Bone Health and Osteoporosis

Hormonal Changes

The levels of certain sex hormones — estrogen in both sexes and testosterone in men — are involved in the process of building and remodeling bones:

  • Estrogen levels in women drop quickly at menopause.
  • In men, loss of sex hormones occurs more slowly with age, though some men experience testosterone deficiency (hypogonadism) at a younger age.

Sex hormone loss and other aging factors increase the rate of bone turnover, causing more bone to be removed than replaced and leading to progressive bone loss.

Genetic Predisposition

Your risk increases if you have:

  • A family history of osteoporosis
  • A history of fractures on your mother’s side of the family

Additional Risk Factors for Osteoporosis

Certain other factors can increase your risk of osteoporosis independent of your bone density, age, or gender.


  • Corticosteroids, such as prednisone
  • Heparin, if taken chronically
  • Anti-seizure (epilepsy) drugs
  • Thyroid medications, if taken in larger doses than necessary
  • Drugs used to treat breast and prostate cancers
  • Methotrexate, given for inflammatory arthritis
  • Diuretics
  • Lithium
  • Depo-progesterone, used for birth control
  • Antacids that contain aluminum

Health Conditions and Procedures

  • Gastrointestinal and digestive disorders, including inflammatory bowel disease and celiac disease
  • Prostate or breast cancer
  • Chronic kidney disease or liver disease (including biliary cirrhosis)
  • Autoimmune disorders, including lupus, rheumatoid arthritis, multiple sclerosis, and ankylosing spondylitis
  • Hematologic disorders, including leukemia, lymphoma, multiple myeloma, and sickle cell disease
  • Neurological disorders, including stroke, spinal cord injury, and Parkinson’s disease
  • Endocrine disorders, such as hyperparathyroidism or hyperthyroidism, diabetes, Cushing’s syndrome, or premature menopause
  • Certain surgical procedures, including gastrointestinal bypass, gastrectomy, and organ transplantation

Poor Nutrition

  • Low intake of calcium
  • Vitamin D deficiency
  • Low intake of dietary protein
  • Significant weight loss or an eating disorder

Lifestyle Choices

  • Excessive use of alcohol. Women should consume no more than 1 daily alcoholic beverage; men should have no more than 2 drinks per day.
  • Smoking. Nicotine acts directly on bone-forming cells to decrease the amount of bone formed. It also causes your body to lose bone even more quickly than normal by affecting hormone metabolism. Learn more about smoking and bone health.
  • Lack of physical activity, both in childhood and adulthood. You should aim for at least 150 minutes per week of moderate physical activity, including weight-bearing exercises that help build or maintain bone.

Doctor Examination

At a routine health checkup, your doctor might look for signs of osteoporosis, such as significant height loss with age. This is especially important if you have a family history of osteoporosis, have any medical diagnoses that increase fracture risk, or are taking medications that can lead to bone loss.

Osteoporosis - OrthoInfo - AAOS (3)

Loss of height and a stooped appearance of a person with osteoporosis results from partial collapse of weakened vertebrae.

At your appointment, your doctor will examine you and take a complete medical history. This means reviewing:

  • Your past health
  • Your family members’ health
  • All of your medications and supplements
  • Recent falls
  • Any problems or concerns you have now, including balance issues or a history of fractures

If you sustain a fracture after age 40, not only should you receive treatment for the fracture itself, you should also notify your family physician so you can be seen and evaluated for future fracture risk.


If your doctor believes you might have low bone mass/osteoporosis, you will probably have further testing. The doctor wants to learn if you do have low bone mass and how severe the problem is. Testing, which may also detect treatable cause of excessive bone loss, typically includes:

  • Blood and urine tests
  • Specialized X-ray testing called bone densitometry testing, or DXA. A DXA scan is the main way doctors look for low bone mass because this test can find low bone mass before a fracture occurs. The test is safe (with less radiation than you get from a regular chest X-ray), accurate, and painless. If you have low bone mass or osteoporosis, your doctor will usually follow DXA scans every 2 or 3 years to recheck your bones as you age.

T score

Your DXA scan gives your doctor a result called a T score. Your T score is the main measurement of your bone density, indicating how your bone density compares to that of a healthy 30-year-old.

This is what different T scores mean:

  • If your T score is -1 to +1, you have normal bone density
  • If your T score is -1 to -2.4, you have osteopenia, now called low bone mass
  • If your T score is -2.5 or lower, you have osteoporosis
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Prevention and Treatment

Bone loss and fractures don’t have to be an inevitable part of aging. Based on your test results and medical history, your doctor will work with you to develop a treatment plan to protect and improve your bone and prevent falls that may lead to fractures.

Prevention and treatment for osteoporosis will probably include one or more of the following:

  • Changing your diet
  • Taking supplements — especially calcium and vitamin D
  • Making lifestyle modifications, such as developing a sustainable exercise plan, quitting smoking if you smoke, and limiting alcohol consumption
  • Taking medications to lower your risk of fractures by increasing bone density, preventing bone loss, or building new bone
  • Preventing falls, including addressing fall risks in your home, and doing exercises to improve your balance. Learn more about how to prevent falls.
  • Preventing or controlling diabetes
  • Preventing or controlling high blood pressure
  • Lowering disease risk, including the risk of breast and prostate cancer, multiple sclerosis, rheumatoid arthritis, and osteoarthritis
  • Starting estrogen replacement therapy if you are postmenopausal

To learn more, see: Osteoporosis Prevention and Treatment

*NCHS Data Brief No. 405, March 2021; PDF Versionpdf iconpdf icon

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What is T-score and Z-score in osteoporosis? ›

A bone density scan gives a person a Z-score and a T-score. T-scores compare bone density with that of a healthy person, whereas Z-scores use the average bone density of people of the same age, sex, and size as a comparator.

What is the gold standard for diagnosing osteoporosis? ›

In the absence of a fragility fracture, BMD assessment by dual-energy x-ray absorptiometry (DXA) is the gold standard to diagnose osteoporosis, according to the classification of World Health Organization (WHO) [3].

What is the WHO criteria for osteoporosis? ›

As defined by the World Health Organization (WHO), osteoporosis is present when BMD is 2.5 SD or more below the average value for young healthy women (a T-score of <−2.5 SD). A second, higher threshold describes “low bone mass” or osteopenia as a T-score that lies between −1 and −2.5 SD.

What 3 bones are most affected by osteoporosis? ›

Osteoporotic bone breaks are most likely to occur in the hip, spine or wrist, but other bones can break too. In addition to causing permanent pain, osteoporosis causes some patients to lose height. When osteoporosis affects vertebrae, or the bones of the spine, it often leads to a stooped or hunched posture.

What is a normal T-score for a 70 year old woman? ›

For postmenopausal women and men age 50 years and older, the T-score is the number that is used for diagnostic classification, as follows: A T-score of -1.0 or above is normal bone density.

Which is better Z-score or T-score? ›

Key Differences between Z score vs T score

Z score is the standardization from the population raw data or more than 30 sample data to standard score while T score is standardization from the sample data of less than 30 data to a standard score. Z score ranges from -3 to 3, while the T score ranges from 20 to 80.

Should I use T-score or Z-score? ›

When you know the population standard deviation you should use the z-test, when you estimate the sample standard deviation you should use the t-test. Usually, we don't have the population standard deviation, so we use the t-test.

Which diagnostic test is the most accurate when diagnosing osteoporosis? ›

Bone density measurement by DXA at the hip and spine is generally considered the most reliable way to diagnose osteoporosis and predict fracture risk.

What is the best screening test for osteoporosis? ›

Osteoporosis is diagnosed with a bone density scan (also referred to as bone density test or bone mineral density test or by the medical name DXA test). It is a simple scan that measures the density of your bones at the hip and spine.

Why is DEXA the gold standard for osteoporosis? ›

It uses very low levels of x-rays to measure how dense your bones are. DEXA stands for “dual-energy X-ray absorptiometry.” Medical experts consider DEXA scans to be the most useful, easy, and inexpensive test for helping to diagnose osteoporosis. The test is quick and painless.

What is the normal range for osteoporosis? ›

A T score of -1 to +1 is considered normal bone density. A T score of -1 to -2.5 indicates osteopenia (low bone density). A T score of -2.5 or lower is bone density low enough to be categorized as osteoporosis.

What are 7 risk factors for osteoporosis? ›

​Risk factors you can change:
  • Sex hormones. Abnormal absence of menstrual periods (amenorrhea), low estrogen level (menopause), and low testosterone level in men can bring on osteoporosis.
  • Anorexia nervosa. ...
  • Calcium and vitamin D intake. ...
  • Medication use. ...
  • Lifestyle. ...
  • Cigarette smoking. ...
  • Alcohol intake.

What is a severe osteoporosis T-score? ›

A T-score of −2.5 or lower indicates that you have osteoporosis. The greater the negative number, the more severe the osteoporosis. Bone density is within 1 SD (+1 or −1) of the young adult mean. Bone density is between 1 and 2.5 SD below the young adult mean (−1 to −2.5 SD).

What foods destroy bone density? ›

What foods destroy bone density?
  • Excess salt.
  • Hydrogenated oil.
  • Alcohol.
  • Food rich in vitamin A.
  • Soft drinks.
29 Aug 2022

What are the 3 warning signs of osteoporosis? ›

Once osteoporosis has set in and your bones have weakened, watch for these three warning signs: A stooped posture and even a loss of height over time. Back pain that could be caused by a collapsed or fractured vertebra in your back. A bone that breaks more easily than expected.

What are 5 symptoms of osteoporosis? ›

Kuchynski says, include:
  • Fragility-related fractures. These occur when even mild impact causes a fracture of the wrist, back, hip or other bones.
  • Height loss. More than two inches in height can be lost over time.
  • Receding gums. ...
  • A curved, stooped shape to the spine. ...
  • Lower back pain.
13 Dec 2017

What is the fastest way to increase bone density? ›

Weight-bearing exercises, such as walking, jogging, and climbing stairs, can help you build strong bones and slow bone loss.

What is the best and safest treatment for osteoporosis 2022? ›

Bisphosphonates are usually the first choice for osteoporosis treatment. These include: Alendronate (Fosamax), a weekly pill. Risedronate (Actonel), a weekly or monthly pill.

What is the newest treatment for osteoporosis? ›

Romosozumab (Evenity).

This is the newest bone-building medication to treat osteoporosis. It is given as an injection every month at your doctor's office and is limited to one year of treatment.

What is the average T-score for a 65 year old woman? ›

In females 65 years of age and older at baseline screening, with normal or slightly low bone mass (T-score -1.01 to -1.49), and with no risk factors for accelerated bone loss, we will typically perform a follow-up DXA in 10 to 15 years.

Can you improve your bone density T-score? ›

Can I improve my T-score? In some cases, a T-score can be improved. However, it depends on where your score falls within the risk range and your lifestyle. Building up your bone density may involve taking medications as prescribed, eating plenty of foods that contain calcium and vitamin D, and exercising regularly.

Can walking reverse osteoporosis? ›

A person with osteoporosis has weakened bones that are more likely to break. Although the condition is not reversible, people can prevent further bone loss and rebuild bones with medication, a nutrient-dense diet, and weight bearing exercise.

How do you interpret a bone density Z-score? ›

A Z-score compares your bone density to the average values for a person of your same age and gender. A low Z-score (below -2.0) is a warning sign that you have less bone mass (and/or may be losing bone more rapidly) than expected for someone your age.

Why do we use T-scores instead of z-scores? ›

Like z-scores, t-scores are also a conversion of individual scores into a standard form. However, t-scores are used when you don't know the population standard deviation; You make an estimate by using your sample.

What does Z-score tell you? ›

Z-score indicates how much a given value differs from the standard deviation. The Z-score, or standard score, is the number of standard deviations a given data point lies above or below mean. Standard deviation is essentially a reflection of the amount of variability within a given data set.

Why do we use t-test instead of z-test? ›

As mentioned, a t-test is primarily used for research with limited sample sizes whereas a z-test is deployed for hypothesis testing that requires researchers to look at a population size that's larger than 30.

Is it better if the z score is higher or lower? ›

In general, a Z-score below 1.8 suggests a company might be headed for bankruptcy, while a score closer to 3 suggests a company is in solid financial positioning.

Why is z-test more powerful than t-test? ›

For each significance level in the confidence interval, the Z-test has a single critical value (for example, 1.96 for 5% two tailed) which makes it more convenient than the Student's t-test whose critical values are defined by the sample size (through the corresponding degrees of freedom).

What is the best test for bone density? ›

Dual-energy x-ray absorptiometry — Experts agree that the most useful and reliable bone density test is a specialized kind of x-ray called dual-energy x-ray absorptiometry, or DXA. DXA provides precise measurements of bone density at important bone sites (such as the spine, hip, and forearm) with minimal radiation.

Can vitamin D reverse osteoporosis? ›

Vitamin D supplementation may decrease bone turnover and increase bone mineral density. Several randomized placebo-controlled trials with vitamin D and calcium showed a significant decrease in fracture incidence. However, very high doses of vitamin D once per year may have adverse effects.

What is the safest osteoporosis drug? ›

Raloxifene. Raloxifene is the only SERM approved for the prevention and treatment of postmenopausal osteoporosis and the recommended daily dose is 60 mg daily.

How can I increase my bone density after 60? ›

5 Ways to Strengthen Older Bones
  1. Exercise. Just 30 minutes of exercise each day can help strengthen bones and prevent osteoporosis. ...
  2. Eat a balanced diet. ...
  3. Take supplements. ...
  4. Make sure your body absorbs the calcium and vitamin D it needs. ...
  5. Avoid salty foods and caffeinated beverages. ...
  6. Get a bone density scan.
6 Mar 2020

What is the difference between a DEXA scan and a bone density test? ›

A bone density test, also referred to as a DEXA scan, is a noninvasive test that measures calcium and other minerals in your bones. It measures the strength and thickness, or mass, of your bones. As we age, bones naturally become thinner. Osteopenia occurs when bones are thinner than normal.

Who should not take Fosamax? ›

People with the following condition should not use Fosamax:

People with abnormalities or problems related to the esophagus. People who cannot sit upright or stand for at least 30 minutes. People with hypocalcemia (low calcium in the blood) People allergic to ingredients in Fosamax or Fosamax Plus D.

Why is DEXA the most accurate? ›

Where a regular X-ray can show changes in bone density after 40 percent bone loss, the DEXA detects changes as small as 1 percent – making it more sensitive and accurate. These statistics give you an idea of the precision with which body composition and fat content are measured with a DEXA scan.

What are the disadvantages of DEXA? ›

A major disadvantage of DXA is that currently there is a lack of standardization in bone and soft tissue measurements. There are large discrepancies in measurements obtained on instruments from the three major manufacturers of DXA machines.

How often do you need BMD for osteoporosis? ›

How Often Should I Get Tested? If you are taking medication for osteoporosis, expect to have a bone density test every 1 to 2 years. Even if you don't have osteoporosis, your doctor may suggest that you get a bone density test every 2 years, especially for women during or after menopause.

Are there stages of osteoporosis? ›

There are several stages of osteoporosis. The first two are more like precursors to the actual disease. In the latter two stages, you may have frequent fractures or breaks, experience pain, or even have deformities from bone loss.

How is osteoporosis severity measured? ›

To diagnose osteoporosis and assess your risk of fracture and determine your need for treatment, your doctor will most likely order a bone density scan. This exam is used to measure bone mineral density (BMD). It is most commonly performed using dual-energy x-ray absorptiometry (DXA or DEXA) or bone densitometry.

What is the beginning stage of osteoporosis? ›

The first stage in osteoporosis occurs when your bone loss and bone formation occur at the same rate, meaning you no longer make more bone than you're losing. At this stage, there are no symptoms, and your bone density scores are above -1.

What foods to avoid if you have osteoporosis? ›

Eating foods that have a lot of salt (sodium) causes your body to lose calcium and can lead to bone loss. Try to limit the amount of processed foods, canned foods and salt added to the foods you eat each day. To learn if a food is high in sodium, look at the Nutrition Facts label.

What exercises should be avoided with osteoporosis? ›

If you have osteoporosis, don't do the following types of exercises: High-impact exercises. Activities such as jumping, running or jogging can lead to fractures in weakened bones. Avoid jerky, rapid movements in general.

What is a good T-score for a 70 year old woman? ›

For postmenopausal women and men age 50 years and older, the T-score is the number that is used for diagnostic classification, as follows: A T-score of -1.0 or above is normal bone density.

What is a serious T-score? ›

A T-score within 1 SD (+1 or -1) of the young adult mean indicates normal bone density. A T-score of 1 to 2.5 SD below the young adult mean (-1 to -2.5 SD) indicates low bone mass. A T-score of 2.5 SD or more below the young adult mean (more than -2.5 SD) indicates the presence of osteoporosis.

What is considered moderate osteoporosis? ›

A T-score of -1.0 or higher is normal. A T-score between -1 and -2.49 indicates osteopenia (early thinning of bones) and is graded as mild, moderate, and advanced. T-scores of -2.5 or more indicate osteoporosis.

What should you not do if you have osteoporosis? ›

If you have osteoporosis, avoid activities that involve twisting your spine or bending forward from the waist, such as conventional sit-ups, toe touches, or swinging a golf club. Those are the best ways to keep your bones strong and healthy. Learn more about keeping your bones strong to prevent falls.

What is the most common type of osteoporosis? ›

Primary osteoporosis is the most common form of the disease and includes postmenopausal osteoporosis (type I), and senile osteoporosis (type II). Secondary osteoporosis is characterized as having a clearly definable etiologic mechanism.

What is the first line of treatment for osteoporosis? ›

Bisphosphonates are usually the first choice for osteoporosis treatment. These include: Alendronate (Fosamax), a weekly pill. Risedronate (Actonel), a weekly or monthly pill.

What is the best drink for bone density? ›

Milk. Calcium is the bone-building darling in a glass of milk, but the beverage also naturally contains other nutrients that benefit bone health, including vitamin D, magnesium, and phosphorus.

Are bananas good for bone density? ›

Foods that are high in potassium can also build bone health. Tomatoes, potatoes, papayas, oranges, and bananas are all excellent sources of this nutrient. Raisins and orange juice are also good options, but be aware of the possible added sugars in these foods.

Can you rebuild bone if you have osteoporosis? ›

The short answer is no, osteoporosis cannot be completely reversed and is not considered curable, but there are a number of health and lifestyle adjustments you can make to improve bone loss. Your provider may also prescribe you medications to help rebuild and slow down bone loss.

What are the two medications that may cause osteoporosis after long term use? ›

Several medicines can cause bone loss if used over the long term (several years). Some common ones include: Glucocorticoids, also called steroids, such as cortisone and prednisone.

What is a normal T score for a 70 year old woman? ›

For postmenopausal women and men age 50 years and older, the T-score is the number that is used for diagnostic classification, as follows: A T-score of -1.0 or above is normal bone density.

What is the best management of osteoporosis? ›

Treatments for established osteoporosis may include exercise, vitamin and mineral supplements, and medications. Exercise and supplementation are often suggested to help you prevent osteoporosis. Weight-bearing, resistance and balance exercises are all important.


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