DISH: A Culprit in Back Pain

By Linda Rath

Doctors once thought diffuse idiopathic skeletal hyperostosis (DISH), also known as “Forestier’s Disease”, didn’t cause symptoms for most people, so it wasn’t discussed much. But Simon Helfgott, MD, a rheumatologist at Brigham and Women’s Hospital and associate professor at Harvard Medical School, says that’s slowly changing.

DISH may be present in an estimated 10% of Americans over the age of 50 — nearly 11 million people, according to AARP. An arthritis outlier, it doesn’t cause much inflammation or attack joint cartilage. Instead, it hardens tendons and ligaments, mainly around the spine. These hard bands of tissue can form growths called bone spurs where they connect to bones. Less often, DISH can cause bone spurs in the hips, knees, feet and shoulders.

Why It’s Under the Radar
“In the past, it was felt that DISH was an asymptomatic finding, meaning it didn’t explain a person’s back or spine pain. Nowadays our thinking is beginning to change, and the structural changes affecting the spine in people with DISH may account for some of their pain,” Dr. Helfgott says.

Other symptoms may include stiffness and limited range of motion in the upper back or neck. It can even lead to trouble swallowing if a bone spur compresses the esophagus.

Who Gets It
DISH probably results from a combination of factors. Your risk is greater if you:

• Are male.

• Are over age 50.

• Have diabetes or are obese.

• Have taken the acne medication isotretinoin (brand names Accutane, Absorica, Amnesteem, Claravis and others), a synthetic derivative of vitamin A. There’s not enough research to show if natural vitamin A from food or supplements might also be a factor.

• Are a member of the Native American Pima tribe.

• Have unusual spine anatomy.

Why It’s Treated Like OA
There’s no treatment specifically for DISH, so doctors treat it as they do osteoarthritis (OA) or degenerative disk disease. That means regular exercise and over-the-counter pain relievers to get pain under control and stretching to improve stiffness and range of motion.

“There’s no role for surgery in people with DISH except [in] rare situations,” Dr. Helfgott says.

On X-ray, DISH can mimic another form of arthritis that often affects the spine, called ankylosing spondylitis (AS). However, Dr. Helfgott says, DISH “doesn’t respond to treatment with biological drugs, such as tumor necrosis factor [TNF] inhibitors,” which are used in AS.

DISH is closely associated with diabetes and obesity, so keeping blood sugar and weight in a healthy range may slow or stop its progression.

Originally appeared in Arthritis Today, Winter 2018-’19. Posted 4/21/2021