Last reviewed: 1 Sep 2023
Last updated: 14 Mar 2023



History and exam

Key diagnostic factors

  • asymptomatic
More key diagnostic factors

Other diagnostic factors

  • back pain
  • kyphosis
  • vertebral tenderness
Other diagnostic factors

Risk factors

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

Diagnostic investigations

1st investigations to order

  • dual-energy x-ray absorptiometry (DXA)
More 1st investigations to order

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
More investigations to consider

Treatment algorithm


not glucocorticoid-induced: women

not glucocorticoid-induced: men




Khashayar Sakhaee, MD

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.

Alberto V Cabo Chan Jr., MD

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 reviewers

Kimberly Olson, MD


Veterans Administration Hospital




KO declares that she has no competing interests.

David Reid, MBBS

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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