What is the best treatment approach for an elderly patient with a history of falls, mild bilateral crest enthesopathy on pelvic x-ray, and potential underlying health conditions, including possible osteoporosis?

Treatment of Elderly Patient with Fall and Mild Bilateral Iliac Crest Enthesopathy

This elderly patient with a fall history and pelvic imaging findings requires a comprehensive fall prevention program including balance and strength training, vitamin D 800 IU daily, medication review, home safety assessment, and osteoporosis evaluation—the enthesopathy itself is an incidental finding that does not require specific treatment. 1

Understanding the Imaging Finding

• Mild bilateral iliac crest enthesopathy represents degenerative changes at tendon/ligament insertion sites on the pelvis and is a common age-related finding that does not cause falls or require specific treatment 2
• The critical issue is not the enthesopathy but rather the fall itself and the need to identify occult posterior pelvic ring injuries, as 70% of elderly patients with pelvic imaging after falls have undetected posterior segment fractures on plain radiographs 3
• If only plain X-ray was performed, strongly consider CT scan of the pelvis to exclude sacral or sacroiliac fractures, which are frequently missed and cause persistent pain limiting mobilization 3, 4

Immediate Fall Risk Assessment

All elderly patients presenting after a fall require systematic evaluation using the following key elements: 1, 5

• History of circumstances: Was this a mechanical trip or did the patient feel dizzy, weak, or lose consciousness? 1
• Medication review focusing on high-risk drugs: vasodilators, diuretics, antipsychotics, sedative/hypnotics—these significantly increase fall risk and should be discontinued or reduced when possible 1, 5
• Orthostatic vital signs: Measure blood pressure and heart rate supine and after 1-3 minutes standing to identify orthostatic hypotension 1
• Vision assessment: Formal visual acuity testing, as visual impairment is a modifiable fall risk factor 5
• Cognitive screening: Use Mini-Cog or Memory Impairment Screen, as cognitive impairment significantly increases fall risk 5
• "Get Up and Go Test": Time the patient rising from a chair without using arms, walking several paces, and returning—if >12 seconds or unsteady, further intervention is mandatory 1, 5

Multifactorial Fall Prevention Intervention Plan

The American Geriatrics Society mandates multifactorial intervention for any elderly patient who has fallen, which must include: 1

Exercise Prescription (Non-Negotiable)

• Balance training 3 or more days per week 1, 5
• Strength training twice weekly focusing on lower extremity muscle groups 1, 5
• Immediate physical therapy referral for gait training and assessment for assistive devices (cane or walker if Get Up and Go test >12 seconds) 1, 5
• Consider tai chi or similar balance-focused programs as these reduce fall risk 5

Medication Management

• Comprehensive medication review with focus on deprescribing: Discontinue or minimize psychotropic medications, sedatives, and medications causing orthostatic hypotension 1, 5
• Avoid vestibular suppressants which impair balance 5
• Review polypharmacy burden—each additional medication increases fall risk 5

Home Safety Modifications

• Occupational therapy home assessment with direct intervention to remove loose rugs, ensure adequate lighting throughout the home, install grab bars in bathroom, and recommend properly fitting non-skid footwear 1, 5
• These modifications are Grade C evidence but essential for comprehensive fall prevention 1

Osteoporosis Evaluation and Treatment

Given the fall history, this patient requires osteoporosis screening and treatment to prevent future fractures: 1, 6

• Order DXA scan of spine and hip to assess bone mineral density 1, 6, 7
• Initiate vitamin D 800 IU daily immediately—this reduces non-vertebral fractures by 15-20% and falls by 20% 1
• Ensure calcium intake of 1000-1200 mg daily through diet and supplementation if needed 1, 6, 7
• Avoid high pulse doses of vitamin D as these paradoxically increase fall risk 1

Pharmacologic Osteoporosis Treatment

• If DXA confirms osteoporosis (T-score ≤-2.5) or patient has fragility fracture, initiate oral bisphosphonate (alendronate 70 mg weekly or risedronate 35 mg weekly) as first-line therapy 1, 6, 7
• For patients with oral intolerance, dementia, malabsorption, or non-compliance, use zoledronic acid (IV annually) or denosumab 60 mg subcutaneously every 6 months 1, 8
• Treatment duration is typically 3-5 years, longer if high fracture risk persists 1

Follow-Up and Monitoring

• Reassess at 2-4 weeks: Confirm physical therapy and occupational therapy appointments completed, review medication changes, repeat Get Up and Go test 5
• Monitor for recurrent falls: This patient is at very high risk—any additional fall warrants hospitalization consideration if safety cannot be ensured 1, 5
• Repeat DXA in 1-2 years if osteoporosis treatment initiated to assess response 6, 7
• Annual fall risk reassessment with established screening questions 1, 5

Critical Pitfalls to Avoid

• Do not dismiss the fall as "accidental"—elderly falls are rarely purely mechanical and require systematic evaluation for underlying causes including cardiac arrhythmias, orthostatic hypotension, and medication effects 9
• Do not rely solely on plain X-ray findings—if the patient has persistent pain limiting mobilization, obtain CT scan to exclude occult sacral or posterior pelvic fractures 3, 4
• Do not prescribe assistive devices without proper fitting and training—improperly fitted walkers themselves become fall hazards 5
• Do not treat osteoporosis without concurrent calcium and vitamin D—all bisphosphonate trials included these supplements and they are mandatory for efficacy 1, 8