Last reviewed: 17 May 2021
Last updated: 29 Jul 2020



History and exam

Other diagnostic factors

  • back pain
  • kyphosis
  • impaired vision
  • impaired gait, imbalance, and lower-extremity weakness
  • vertebral tenderness

Risk factors

  • prior fragility fracture
  • female sex
  • white ancestry
  • older age (>50 years for women and >65 years for men)
  • low BMI
  • family history of maternal hip fracture
  • loss of height
  • postmenopause
  • secondary amenorrhoea
  • primary hypogonadism
  • smoking
  • excessive alcohol use
  • prolonged immobilisation
  • low calcium intake
  • vitamin D deficiency
  • glucocorticoid excess
  • corticosteroid use
  • proton-pump inhibitors
  • hyperthyroidism
  • heparin use
  • anticonvulsant use
  • weight loss >10% body weight
  • androgen deprivation treatment (men)
  • aromatase inhibitor treatment (women)

Diagnostic investigations

Investigations to consider

  • Fracture Risk Assessment Tool (FRAX)
  • quantitative ultrasound (QUS) of the heel
  • x-ray (wrist, heel, spine, and hip)
  • quantitative CT
  • biochemical markers of bone resorption and bone formation
  • serum alkaline phosphatase
  • serum calcium
  • serum albumin
  • serum creatinine
  • serum phosphate
  • serum 25-hydroxy vitamin D
  • serum parathyroid hormone
  • thyroid function tests
  • urinary free cortisol
  • serum testosterone (men)
  • urine protein electrophoresis
  • serum protein electrophoresis

Treatment algorithm


Professor in Internal Medicine

Division Chief of Mineral Metabolism

Center for Mineral Metabolism and Clinical Research

UT Southwestern Medical Center at Dallas




KS declares that he has no competing interests.

Assistant Professor

Internal Medicine

University of Texas Southwestern




AVCC declares that he has no competing interests.

Dr Khashayar Sakhaee and Dr Alberto V Cabo Chan Jr. would like to gratefully acknowledge Dr Lisa Leinau, a previous contributor to this topic.


LL declares that she has no competing interests.

Peer reviewersVIEW ALL


Veterans Administration Hospital




KO declares that she has no competing interests.

Head of Division of Applied Medicine & Professor of Rheumatology

School of Medicine & Dentistry

University of Aberdeen




DMR has attended meetings sponsored by or been paid speaker fees by Amgen, Merck, Novartis, Procter & Gamble, Roche, and Servier. He has been a paid advisor to Amgen, Merck, Novartis, Procter & Gamble, Roche, Servier, and Shire Pharmaceuticals. He has undertaken research studies funded by Amgen, Merck, Novartis, Procter & Gamble, and Roche.

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