21.6 — Bone, Joint and Muscle Problems

A hip fracture in an older person carries a mortality of around 20 to 30 percent within a year.

That number is worth sitting with, because hip fractures are usually thought of as an injury rather than as a life-threatening event. And the fracture itself is rarely what kills — it is the immobility, the pneumonia, the clots, and the loss of independence that follows.

Most of these fractures happen because of two things that are both treatable: weak bone and falling over.

Osteoporosis

Bone loses density and its internal structure thins, so it breaks under forces that would not normally break it.

Around 1 in 3 women and 1 in 5 men over 50 will have a fracture caused by it.

And it is completely silent until the first fracture, which is the whole problem.

How bone works

Bone is living tissue, constantly rebuilt (Chapter 5.1). Osteoclasts break old bone down; osteoblasts build new bone.

Peak bone mass is reached in the late twenties. After that there is slow net loss, and in women a rapid phase for around 5 to 10 years after menopause, because oestrogen restrains the osteoclasts.

Which is why menopause is the single biggest event in most women's bone history, and why the years immediately after it matter so much.

Risk factors

Age, female sex, and previous fracture — and a previous fragility fracture is the strongest single predictor, which makes it the moment to investigate rather than just to treat the break.

Family history, particularly a parental hip fracture.

Steroids — long-term oral steroids cause rapid bone loss, most of it in the first months, which is why bone protection is started at the same time as the steroid rather than later.

Smoking, heavy alcohol, low body weight.

Early menopause, and low testosterone in men.

Medical conditions — coeliac disease, inflammatory bowel disease, rheumatoid arthritis, hyperthyroidism, hyperparathyroidism, and chronic kidney disease.

And immobility, because bone responds to load — which is why bed rest and weightlessness both cause rapid loss.

Finding it

DXA scan — measuring bone density, reported as a T-score comparing to a young adult average. Osteoporosis is a T-score of −2.5 or below.

Fracture risk calculators combine density with clinical factors to estimate ten-year risk, which is more useful than density alone.

And vertebral fractures are frequently silent — found incidentally on chest X-rays, and showing up in life as height loss and a rounded upper back. Losing more than 4 centimetres of height is a reason to investigate.

Treatment

Bisphosphonates — alendronate, risedronate, zoledronate. They stick to bone and shut down the osteoclasts, reducing fracture risk by around 40 to 70 percent depending on the site.

Taken correctly they work well, and the instructions are strict for a reason: on an empty stomach, with plain water, sitting or standing upright for 30 minutes afterwards, because the tablet can cause severe oesophageal irritation if it lingers. Zoledronate is given as a yearly infusion, which avoids all of that.

On the rare side effects, honestly: osteonecrosis of the jaw and atypical femoral fractures both occur and are genuinely rare — in the range of a few per ten thousand patient-years, and lower still at the doses used for osteoporosis rather than for cancer. The fractures they prevent are far commoner than the harms they cause, and fear of these two complications has led to substantial under-treatment. Drug holidays after several years are used to reduce the atypical fracture risk further.

Denosumab — a six-monthly injection blocking the signal that activates osteoclasts. Effective, and with one critical caveat: stopping it causes rapid rebound bone loss and a risk of multiple vertebral fractures. It must not simply be discontinued; another drug is started when it is stopped.

Anabolic drugs — teriparatide, abaloparatide, romosozumab — which build new bone rather than only preventing loss. For severe osteoporosis, and followed by a bisphosphonate to lock the gains in.

Hormone replacement therapy — effective for prevention in women around the time of menopause (Chapter 15.10).

Calcium and vitamin D — supporting treatment rather than treatment. Around 700 to 1200 mg of calcium daily, preferably from diet, and vitamin D where deficient. They are not sufficient on their own for someone with osteoporosis, and supplementing them alone was a common mistake.

And exercise: weight-bearing and resistance exercise, plus balance training, which helps bone modestly and prevents falls substantially.

Falls

And this is where most of the benefit actually is, because a strong bone still breaks if you hit the floor hard enough, and a weak bone does not break if you stay upright.

What causes falls: muscle weakness, poor balance, poor vision, medications — particularly sedatives, sleeping tablets and blood pressure drugs causing dizziness on standing — foot problems, cognitive impairment, and hazards at home.

What prevents them, with real evidence:

Strength and balance exercise, which is the single most effective intervention. Tai chi has particularly good trial evidence.

Medication review, and stopping the ones that contribute.

Vision correction — and a specific point: bifocals and varifocals increase falls outdoors, because the lower part of the lens blurs the ground. Single-vision distance glasses for walking outside are safer.

Home assessment — lighting, rails, removing loose rugs, and non-slip mats.

Vitamin D where deficient.

And checking blood pressure lying and standing, because a drop on standing is a very common and very treatable cause.

Back pain

Around 80 percent of people experience it, and it is the leading cause of disability worldwide.

And the most useful thing to know is that the imaging usually does not explain it. Scans of people with no pain at all show disc bulges, degeneration and other findings at high rates that rise with age. Which means finding those on a scan in someone with pain does not establish that they are the cause, and being told you have a "crumbling spine" measurably worsens outcomes by producing fear and avoidance.

Non-specific low back pain — the great majority.

Management, and it is not what most people expect:

Stay active. Bed rest makes it worse and prolongs it.

Continue normal activity as far as pain allows, and return to work early, which improves outcomes rather than delaying recovery.

Exercise and physiotherapy, and the type matters less than doing it consistently.

Analgesia used briefly — NSAIDs, and paracetamol has little evidence in back pain specifically. Opioids are not recommended, because they perform poorly and carry substantial risk.

Reassurance grounded in fact: most acute episodes improve substantially within weeks.

And for persistent pain, addressing fear of movement, low mood and sleep matters as much as anything physical, because chronic pain involves changes in how the nervous system processes signals rather than continuing tissue damage.

Sciatica — pain radiating down the leg from nerve root compression, usually by a disc. Most improve without surgery over weeks to months. Surgery speeds recovery and gives similar results by a year, so it is offered for severe or persistent symptoms rather than automatically.

And the red flags requiring urgent assessment:

Cauda equina syndrome — this is the emergency. Numbness in the saddle area — the inner thighs, buttocks and genitals; difficulty passing urine or loss of the sensation of needing to; loss of bowel control; and weakness in both legs. Delay causes permanent loss of bladder, bowel and sexual function, and it is measured in hours, not days. Go to an emergency department immediately.

Also: new severe back pain over 50 or under 20; a history of cancer; unexplained weight loss; fever; night pain that does not ease with position; recent significant trauma; and progressive neurological weakness.

Common soft tissue problems

Tendinopathy — and the name changed from tendinitis for a reason: the tissue shows disorganised collagen and failed repair rather than inflammation, which is why anti-inflammatories help pain briefly and do not fix it.

What does work is loading the tendon progressively — controlled strengthening exercise, particularly slow eccentric loading, over months. It is slow and it is the treatment.

Common sites: Achilles, rotator cuff at the shoulder, tennis and golfer's elbow, and the patellar tendon.

Steroid injections give short-term relief and can be worse in the longer term for some tendons, which is why they are used selectively.

Frozen shoulder — progressive stiffness and pain, with genuine loss of movement in all directions including when someone else moves the arm.

Three phases over 1 to 3 years: freezing, frozen and thawing. It usually resolves eventually, and commoner in diabetes. Physiotherapy, steroid injection, and hydrodilatation.

Rotator cuff problems — pain on lifting the arm, worse at night when lying on that side. Exercise-based rehabilitation is first line and works for most people.

Plantar fasciitis — heel pain, classically worst on the first steps in the morning and after sitting, easing then returning with prolonged standing. Calf and plantar fascia stretching, supportive footwear, and load management. It resolves for most people, and it takes months.

Sprains and strains — a sprain is a ligament, a strain is a muscle or tendon.

And the advice has changed: the old RICE protocol has been replaced, because prolonged rest and ice delay healing. Current guidance: protect briefly, then progressive loading, with early gentle movement. Ice for pain relief in the first day or two is reasonable and it is not a treatment.

Muscle problems

Cramps — very common, usually benign. Associated with dehydration, electrolyte changes and unaccustomed exercise, and often with nothing identifiable. Stretching during the cramp works; the evidence for supplements is weak.

Statin-associated muscle symptoms — aching, usually in the large muscles. Genuinely reported by many people, and blinded trials find that most of these symptoms occur equally on placebo, which is a real and uncomfortable finding. The practical approach is to re-challenge, switch statin, or reduce the dose rather than abandoning treatment, since the cardiovascular benefit is substantial.

Rhabdomyolysis — muscle breaking down and releasing myoglobin, which damages the kidneys. After crush injury, extreme exertion, prolonged immobility, some drugs, or severe infection. Dark cola-coloured urine with severe muscle pain and weakness is the picture. A medical emergency requiring aggressive fluids.

Fibromyalgia — widespread pain, fatigue, unrefreshing sleep and cognitive difficulty.

And it is a real condition with a physical basis: central sensitisation, where the nervous system amplifies pain signals (Chapter 11.13). It is not imagined, and it is not inflammation.

What works: graded exercise, which has the best evidence and must be started gently because too much too soon causes flares; sleep improvement; CBT; and low-dose amitriptyline, duloxetine or pregabalin. Ordinary painkillers and opioids do not work, which follows from the mechanism.

Inflammatory myopathies — polymyositis and dermatomyositis, causing progressive weakness of the muscles closest to the trunk, with difficulty rising from a chair or lifting the arms. Raised muscle enzymes, and treated with immunosuppression.

What to actually do

Build bone before 30 and maintain it after 50 — weight-bearing exercise, adequate calcium and vitamin D, no smoking, moderate alcohol.

If you break a bone from a minor fall after 50, ask about a bone density scan. That fracture is the warning, and acting on it prevents the next one.

Strength and balance training after 60 is the highest-value exercise there is, because it prevents the fall that starts everything else.

For back pain: keep moving, avoid unnecessary scans, and know the cauda equina red flags.

For tendon pain: load it progressively, and expect months rather than weeks.

What the next page fixes

Chapter 21.7 covers the skin, eyes and ears — the conditions you can see, the ones that threaten sight and hearing, and how to tell the urgent from the ordinary.