Diffuse idiopathic skeletal hyperostosis (DISH)

Overview

Diffuse idiopathic skeletal hyperostosis (DISH) is a bony hardening of ligaments in areas where they attach to your spine.

Also known as Forestier's disease, this condition might not cause symptoms or require treatment. If it does cause symptoms, the most common are mild to moderate pain and stiffness in your upper back. DISH can also affect your neck and lower back, and some people have DISH in other areas, such as shoulders, elbows, knees and heels.

DISH can be progressive. As it worsens, it can cause serious complications.

Symptoms

You might have no signs or symptoms with DISH. For those who have signs and symptoms, the upper portion of the back is most commonly affected. Signs and symptoms might include:

  • Stiffness. Stiffness may be most noticeable in the morning.
  • Pain. You might feel pain in your back or in other affected areas, such as your shoulder, elbow, knee or heel.
  • Loss of range of motion. You might notice this most when stretching side to side.
  • Difficulty swallowing or a hoarse voice. You might have these if you have DISH in your neck.

When to see a doctor

Make an appointment with your doctor if you have persistent pain or stiffness in any joint or in your back.

Causes

DISH is caused by the buildup of calcium salts in the ligaments and tendons and a hardening and overgrowth of bone. But what causes these to occur is unknown.

Risk factors

Doctors have some idea of what can increase your risk of the condition. Risk factors include:

  • Sex. Men are more likely to develop DISH.
  • Older age. DISH is most common in older adults, especially in people older than 50.
  • Diabetes and other conditions. People with type 2 diabetes might be more likely to develop DISH than are those who don't have diabetes. Other conditions that can raise insulin levels in your body may also increase your risk, including hyperinsulinemia, prediabetes and obesity.
  • Certain medications. Long-term use of medications called retinoids, such as isotretinoin (Amnesteem, Claravis, others), which are used to treat skin conditions such as acne, can increase your risk.

Complications

People with DISH are at risk of certain complications, such as:

  • Disability. Loss of range of motion in the affected joint can make it difficult to use that joint. For instance, DISH in your shoulder can make it difficult to use your arm.
  • Difficulty swallowing. Bone spurs in the neck can put pressure on your esophagus. The pressure from bone spurs can also cause a hoarse voice or sleep apnea, a sleep disorder in which you stop breathing repeatedly during sleep. Rarely, this can become serious and might require surgery to remove the bone spurs.
  • Spinal fracture. DISH can increase your risk of breaking bones in your spine, especially if you have moderate to severe disease. Even minor injuries can cause fractures. Breaks might require surgery to repair.

Diagnosis

To determine whether you have DISH, your doctor might begin with a physical examination of your spine and joints. He or she will press lightly on your spine and joints to feel for abnormalities and check your range of motion.

Your doctor will also order imaging tests, such as X-rays, CT scans or MRIs, to look for changes in your spine.

Treatment

While there's no cure for diffuse idiopathic skeletal hyperostosis, you can take steps to reduce pain and stiffness. Treatment is also aimed at keeping the condition from worsening and at preventing complications.

Because of the relationship between DISH and conditions such as obesity, insulin resistance and type 2 diabetes, treating those conditions might slow or halt the progression of DISH.

Medications

Your doctor might recommend over-the-counter pain relievers, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others). More-severe pain can be treated with corticosteroid injections.

Therapy

Physical therapy can reduce the stiffness associated with DISH. Exercises might also increase the range of motion in your joints. Ask your doctor about specific exercises you can do. He or she might refer you to a physical therapist for further guidance.

Symptoms

Surgery

Surgery might be needed in rare cases when diffuse idiopathic skeletal hyperostosis causes severe complications. People who have difficulty swallowing due to large bone spurs in the neck might need surgery to remove the bone spurs. Surgery might also relieve pressure on the spinal cord caused by DISH.

Lifestyle and home remedies

To help you manage pain and stiffness and to halt progression of the disease, try these self-care measures:

  • Exercise regularly. Regular aerobic exercise, such as walking or swimming, can increase your endurance, keep your body more nimble and help you cope with DISH. Talk with your doctor before starting an exercise program.
  • Achieve and maintain a desirable weight. Since obesity is associated with DISH, losing weight might help keep the disease from progressing and lower your risk of complications.
  • Apply heat. Use a heating pad on affected areas of your body to reduce pain. Set the heating pad to low to reduce the risk of burns.

Preparing for an appointment

You're likely to start by seeing your family doctor or a general practitioner. After an initial evaluation, your doctor might refer you to a specialist such as a rheumatologist, physiatrist, orthopedic surgeon or neurologist.

Here's some information to help you get ready for your appointment.

What you can do

Make a list of:

  • Your symptoms and when they began
  • Key medical information, including other conditions you have as well as the names and doses of all medications, vitamins or supplements you take
  • Possible causes of injury to the affected area
  • Questions to ask your doctor

For DISH, some basic questions to ask include:

  • What's the most likely cause of my symptoms?
  • What are other possible causes?
  • What tests do I need?
  • Which treatment do you recommend?
  • What self-care steps can help me manage this condition?
  • Do I need to restrict my activities?
  • How often will you see me for follow-up visits?
  • I have other health conditions. How can I best manage them together?
  • Are there brochures or other materials I can have? What websites do you recommend?

Don't hesitate to ask other questions.

What to expect from your doctor

Your doctor is likely to ask you questions, including:

  • Have your symptoms gotten worse over time?
  • Are your symptoms worse in the morning?
  • Do you have difficulty moving the affected joint?
  • Are you having difficulty swallowing?
  • What, if anything, seems to improve your symptoms?
  • Have you previously taken long-term, prescribed medications, such as for acne or other skin conditions?

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