Does osteoporosis cause pain?

Does Osteoporosis Cause Pain?

Osteoporosis itself is asymptomatic and does not cause pain—it is a "silent disease" until a fracture occurs. 1, 2 Pain in osteoporosis is exclusively the result of fractures or their complications, not the low bone density itself.

Understanding the Pain-Fracture Relationship

Osteoporosis Without Fracture

• Osteoporosis is characterized by low bone mineral density and compromised bone strength affecting the entire skeleton, but this skeletal fragility produces no symptoms until structural failure (fracture) occurs 1, 2
• Patients can have severe osteoporosis with T-scores ≤ -2.5 and remain completely pain-free for years if no fractures develop 1

Pain Only Occurs With Fractures

• Pain in osteoporosis is caused by fractures, not by the disease itself 3, 4
• Fractures induce both acute nociceptive pain (from tissue damage) and can progress to chronic neuropathic pain (from nerve involvement and central sensitization) 3
• The most common fracture sites that cause pain are vertebral compression fractures, hip fractures, wrist fractures, and proximal humerus fractures 1, 2

Vertebral Fractures: The Most Common Pain Source

Clinical Presentation

• Vertebral compression fractures are the earliest and most frequent osteoporotic fracture, affecting over 700,000 Americans annually 2
• Critically, two-thirds of vertebral fractures are asymptomatic or minimally symptomatic—only one-third result in medical attention 1, 2
• When symptomatic, vertebral fractures cause acute back pain that typically subsides over 6-8 weeks as the fracture heals 1
• Severe pain from vertebral fractures can limit ambulation and prevent physical therapy 5

Chronic Pain Development

• Some patients develop chronic back pain after vertebral fractures, particularly with multiple fractures or progressive vertebral collapse 3, 4
• Height loss (particularly >4 cm) from vertebral collapse can occur and may be associated with chronic discomfort 2
• Central sensitization plays a pivotal role in developing and maintaining chronicity of post-fracture pain 3

Critical Clinical Pitfalls

The Silent Nature Creates Diagnostic Challenges

• Most patients with osteoporosis have no symptoms and are unaware of their condition until a fracture occurs 1, 2
• Many vertebral fractures are detected only incidentally on imaging performed for other reasons 2
• The absence of pain does not exclude significant osteoporosis or even the presence of vertebral fractures 1, 2

Distinguishing Pain Sources

• In patients with known osteoporosis and back pain, the fracture on imaging may not always correlate with the source of pain—comprehensive assessment is needed 6
• Radiographic fracture assessment is not a reliable surrogate measure of symptomatic fracture 1
• Chronic fractures (>1 year old) may or may not be responsible for current pain symptoms 1

Pain Management Implications

When Fractures Cause Pain

• Conservative treatment with analgesics, bed rest, orthotic devices, and physical therapy is appropriate for most vertebral compression fractures with mild pain 1
• Prolonged bed rest causes bone loss at 1% per week (50 times faster than normal age-related loss) and should be minimized 5
• After just 10 days of bed rest, healthy older adults lose 15% of lower extremity strength and 10-15% of aerobic capacity 1

Severe or Refractory Pain

• Vertebral augmentation (vertebroplasty or kyphoplasty) should be considered when pain remains severe despite appropriate analgesic therapy, preventing ambulation or physical therapy 5
• Significant analgesic side effects (confusion, sedation, severe constipation) may necessitate procedural intervention 5
• Conservative management failure after a minimum of 6 weeks (or 3 weeks for severe cases) warrants consideration of vertebral augmentation 5

The Bottom Line for Clinical Practice

If a patient with osteoporosis has pain, look for a fracture—the osteoporosis itself is not the pain source. 1, 2, 3 The disease creates fracture risk, but pain only manifests when structural failure occurs. This distinction is critical because it means:

• Pain-free patients with osteoporosis still require treatment to prevent future fractures 1
• Patients presenting with new pain need imaging to identify fractures, not just bone density testing 1, 2
• Dedicated vertebral imaging should be performed in high-risk patients even without pain symptoms, as most vertebral fractures are clinically silent 2