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Diffuse idiopathic skeletal hyperostosis (DISH)By Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/diffuse-idiopathic-skeletal-hyperostosis/DS00740
Diffuse idiopathic skeletal hyperostosis (DISH) is calcification or a bony hardening of ligaments in areas where they attach to your spine.
Also known as Forestier's disease, diffuse idiopathic skeletal hyperostosis may cause no symptoms and require no treatment. The most common symptoms are mild to moderate pain and stiffness in your upper back. DISH may also affect your neck and lower back. Some people experience DISH in other areas, such as shoulders, elbows, knees and heels.
DISH can be progressive. As it worsens, DISH can cause serious complications.
You may have no signs or symptoms with DISH. For those who have signs and symptoms, the upper portion of the back (thoracic spine) is most commonly affected. Signs and symptoms may include:
- Stiffness. Stiffness may be most noticeable in the morning.
- Pain. You may feel pain in your back or in other affected areas, such as your shoulder, elbow, knee or heel.
- Loss of range of motion. You may notice this most when stretching side to side.
- Difficulty swallowing or a hoarse voice. You may experience 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.
It isn't clear what causes diffuse idiopathic skeletal hyperostosis, but 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 may be more likely to develop DISH than are those who don't have diabetes. Other conditions that may 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 similar to vitamin A, can increase your risk of diffuse idiopathic skeletal hyperostosis. It isn't clear whether high intake of vitamin A increases your risk, however.
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 and painful to use your arm.
- Difficulty swallowing. Bone spurs in the neck can put pressure on your esophagus, making it difficult to swallow. The pressure from bone spurs can also cause a hoarse voice or sleep apnea, a sleep disorder in which you stop breathing repeatedly. Rarely, this can become serious and may 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 may require surgery to repair.
Preparing for your appointment
If you have signs and symptoms common to DISH, make an appointment with your family doctor or a general practitioner. After an initial evaluation, your doctor may 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 and know what to expect from your doctor.
What you can do
- Write down any symptoms you've been experiencing, and for how long.
- Write down your key medical information, including any other conditions with which you've been diagnosed as well as the names of all medications, vitamins or supplements that you're taking.
- Write down any possible causes of injury to the affected area.
- Write down questions to ask your doctor.
Preparing a list of questions will help you make the most of your time with your doctor. For DISH, some basic questions to ask include:
- What's the most likely cause of my symptoms?
- Are there other possible causes for my symptoms?
- 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?
- If the first treatment approach doesn't work, what will you recommend next?
- I have these other health conditions. How can I best manage them together?
- Are there brochures or other materials I can take with me? What websites do you recommend?
Don't hesitate to ask any other relevant questions you have.
What to expect from your doctor
Your doctor is likely to ask you a number of questions, including:
- What are your symptoms, and when did you first notice them?
- Have your symptoms gotten worse over time?
- Are your symptoms worse in the morning?
- Do you have any difficulty moving the affected joint?
- Are you having difficulty swallowing?
- What, if anything, seems to improve your symptoms?
- Have you been diagnosed with other medical conditions?
- What medications do you take or have you taken recently, including prescription and over-the-counter drugs, vitamins and supplements?
- Have you previously taken any long-term, prescribed medications, such as for acne or other skin conditions?
- Have you ever had an accident or injury that might have caused trauma to the affected area?
What you can do in the meantime
If you're in pain, try applying heat to the affected area. Over-the-counter pain relievers also may help. Acetaminophen (Tylenol, others) or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve, others), may work well. But avoid NSAIDs if you have a history of allergy to these medications or a history of gastrointestinal bleeding.
Tests and diagnosis
To determine whether you have DISH, your doctor may 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. Any pain you experience from the pressure on your spine may be a clue to the diagnosis. DISH may cause pain at the point where the affected tendon or ligament attaches to a bone. Your doctor may be able to detect bone spurs.
Your doctor also will order imaging tests to help with the diagnosis. Tests that may be used include:
X-rays. Your doctor will order X-rays to confirm a diagnosis of diffuse idiopathic skeletal hyperostosis.
X-rays may show calcification along the bones that make up your spine. The calcification has a distinct appearance that doctors sometimes refer to as cascading or flowing. Some compare the appearance to that of candle wax dripping and oozing down your spine.
- Computerized tomography (CT) and magnetic resonance imaging (MRI). These tests can rule out conditions that may cause similar signs and symptoms, such as ankylosing spondylitis.
Treatments and drugs
While there's no cure for diffuse idiopathic skeletal hyperostosis, there are steps you can take to reduce pain and stiffness. Treatment is also aimed at keeping the condition from getting worse and preventing complications.
Because of the relationship between DISH and conditions such as obesity, insulin resistance and type 2 diabetes, treating those conditions may slow or halt the progression of DISH.
Treatment for pain
Treatment for pain caused by DISH is similar to that of other joint ailments. Your doctor may recommend acetaminophen (Tylenol, others) or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, others). More severe pain can be treated with corticosteroid injections.
Treatment for stiffness
Physical therapy can reduce the stiffness associated with DISH. Exercises may also increase your range of motion in your joints. Ask your doctor about specific exercises you can do. He or she may refer you to a physical therapist for further guidance.
Surgery may be required in rare cases when diffuse idiopathic skeletal hyperostosis causes severe complications. People who experience difficulty swallowing due to large bone spurs in the neck may need surgery to remove the bone spurs. Surgery may also relieve pressure on the spinal cord caused by diffuse idiopathic skeletal hyperostosis.
Lifestyle and home remedies
To help you manage any pain and stiffness you experience 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 you start an exercise program.
- Achieve and maintain a desirable weight. Since obesity is associated with DISH, losing weight may help keep the disease from progressing and lower your risk of complications.
- Apply heat. Use a heating pad on areas of your body that are affected by diffuse idiopathic skeletal hyperostosis to reduce pain. Set the heating pad at a low setting so that it's warm, not hot, to reduce the risk of burns.
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