Forestier's disease

Forestier's Disease: What You Need to Know About This Bone and Ligament Disorder

Forestier’s disease causes excessive bone formation along certain ligaments, especially in the spine. Ligaments are strong bands that connect bones. The English name for the disease is diffuse idiopathic skeletal hyperostosis, often abbreviated as DISH. This bone formation, called ossification, primarily affects the ligaments in front of the vertebrae—the stacked bones that form the spine. It develops gradually, especially in the middle of the back. ^{1, 2} The condition may seem alarming, but it does not always cause symptoms. When pain or stiffness occurs, treatment can help manage it and maintain mobility.

What exactly is Forestier's disease?

La Forestier's disease forme de l’os sur des ligaments devant les vertèbres, surtout dans la région thoracique, soit le milieu du dos. Ces dépôts osseux peuvent progressivement s'étendre et, dans certains cas, relier plusieurs vertèbres entre elles.³ À la radiographie, une image obtenue avec des rayons X, cet os peut former une bande continue devant plusieurs vertèbres. Il suit notamment le ligament longitudinal antérieur, qui longe l’avant de la colonne.⁴ Cette apparence est parfois comparée à une coulée de cire de chandelle, comme dans une étude d’imagerie de 2023⁵. Cette comparaison existe aussi pour la mélorhéostose, une autre maladie osseuse. Elle ne suffit donc pas, à elle seule, à distinguer ces maladies.⁶

Forestier’s disease differs from ankylosing spondylitis, a condition in which inflammation—a defensive reaction of the body—plays a central role. Forestier’s disease is usually classified as non-inflammatory and can affect several regions of the skeleton. Researchers are, however, investigating the possible role of low-grade local inflammation. It is also associated with abnormalities in the way the body uses sugars and fats. ⁷

What are the risk factors for developing Forestier's disease?

Forestier's disease is more common in men, older adults, and people who are obese or have diabetes. It is also associated with abnormal blood lipid levels, known as dyslipidemia, and high uric acid levels, known as hyperuricemia. These associations do not prove that each of these factors causes the disease. The observed links with weight and cholesterol do not yet explain how bone forms. ^{8, 9}

These health problems can occur in the same person. A common cause remains a hypothesis. Uric acid is a waste product naturally present in the blood. High levels can contribute to gout, a condition in which crystals cause painful joint attacks. High levels of uric acid have been reported more frequently in patients with Forestier’s syndrome. ⁹ This does not prove that gout causes this disease.

The prevalence of the disease increases with age. This observation does not allow us to precisely distinguish the role of aging from that of other associated factors.

What are the symptoms of Forestier's disease?

Symptoms of Forestier's disease, when present, may include pain, stiffness of the spine, and reduced trunk mobility. The presence of an extra bone does not automatically mean that it is painful. Many people can live with this condition without ever experiencing pain or discomfort. This ossification may be discovered by chance on images taken for another reason. ^{11, 10}

La douleur peut toucher le milieu du dos, le bas du dos ou le cou. Son intensité varie; elle peut rester légère même lorsque plusieurs vertèbres sont reliées par de l’os. Une revue des manifestations de la maladie¹¹ décrit notamment cette situation. La raideur peut limiter les mouvements du tronc et être plus marquée le matin, comme l’explique la fiche de la Cleveland Clinic¹².

La maladie peut aussi toucher les attaches des tendons sur l’os. Les tendons relient les muscles aux os. Une étude comparant des personnes avec et sans Forestier rapporte plus souvent une atteinte au talon ou à la rotule.¹³ La revue d’imagerie de 2023⁷ décrit aussi la formation d’os à l’attache des tendons d'Achille, derrière le talon. La douleur peut parfois affecter le cou (notre guide sur la Neck pain) plutôt que le milieu du dos. Lorsque la colonne cervicale est touchée, les ossifications peuvent aussi être associées à des difficultés à avaler.¹ Ces différents symptômes peuvent apparaître séparément.

What are the serious symptoms to watch out for?

Forestier’s warning signs include new or worsening weakness in the legs, loss of sensation or balance, and new bladder or bowel problems. These signs may indicate nerve damage and require urgent evaluation. Pain following a fall or impact—even a minor one—also requires urgent medical attention due to the risk of a fracture.

Severe weakness or paralysis in one or both legs constitutes a medical emergency. Similarly, a significant or even complete loss of sensation in one or both legs must be evaluated immediately. A recent loss of balance while walking or a significant, new difficulty coordinating movements are also concerning signs that require prompt medical attention.

Une difficulté nouvelle à commencer à uriner, à vider la vessie ou à retenir l’urine ou les selles demande une consultation immédiate à l’urgence. Une perte nouvelle de sensation autour des organes génitaux, entre les jambes ou au passage du papier de toilette demande la même attention, même sans les autres signes. Ces symptômes peuvent indiquer un syndrome de la queue de cheval, une compression des nerfs au bas de la colonne. La fiche du NHS sur ces symptômes¹⁴ recommande de se présenter immédiatement à l’urgence si un de ces signes apparaît soudainement.

Ces complications sont rares dans l’ensemble des cas de douleur lombaire. Cependant, une colonne rigidifiée par Forestier peut se fracturer après un choc léger. Après une chute ou un accident, faites évaluer une douleur nouvelle au dos ou au cou sans attendre une paralysie. Une radiographie ordinaire peut manquer certaines fractures; le médecin choisira les examens appropriés. La revue d’imagerie de Forestier⁷ explique ce risque. Une difficulté nouvelle à avaler demande aussi un avis médical. Si vous avez de la difficulté à respirer, appelez les Services d’urgence.

What are the causes of Forestier's disease?

The exact cause of Forestier's disease remains unknown, although several hypotheses have been put forward by scientific researchers. Familial forms and genetic variations have been described. Genes carry the instructions that guide the body’s functioning. The family study involved 12 families from the Azores who also had calcium deposits in the cartilage, the lining of the joints. This finding does not necessarily describe all forms of Forestier’s disease. Researchers are studying how genes might influence bone formation. ^{815, 16}

The condition is often associated with obesity, diabetes, and certain difficulties the body has in managing blood sugar. Glucose intolerance means that blood sugar levels rise more than expected. Hyperinsulinemia refers to high levels of insulin, the hormone that helps regulate blood sugar. ¹⁷ Researchers are therefore investigating the possible role of sugars, fats, and uric acid in bone formation. The observed associations do not prove that any of these factors triggers the disease. ⁸

IGF-1 is a protein involved in tissue growth. Its role in bone formation is being studied. One study found higher levels of IGF-1 in people with Forestier’s disease who were experiencing symptoms. ¹⁸ Another study, however, found normal levels of IGF-1, despite a higher prevalence of abnormal levels of other hormones—the substances that transmit messages throughout the body. ¹⁹ The results vary depending on the groups studied. They are not sufficient to prove that IGF-1 causes bone formation in Forestier syndrome. The links to diabetes and obesity also remain to be clarified.

How is Forestier's disease diagnosed?

The diagnosis of Forestier's disease is based on spinal imaging, interpreted in conjunction with your symptoms and a physical examination. In particular, the doctor looks for bony bridges spanning several vertebrae. The classic criteria look for bone formation connecting at least four consecutive vertebrae, with relatively preserved disc height. Discs are cushions between the vertebrae. The doctor also examines the joints of the spine and pelvis to rule out other conditions. These criteria primarily identify a disease that is already advanced. Other criteria have been proposed for early-stage forms, but they are less widely adopted. The history of symptoms—that is, how the pain began and has progressed—provides important clues. The physical examination assesses spinal movement, painful areas, strength, and sensitivity. These tests look specifically for nerve involvement. ^{20, 7}

Medical imaging tests confirm the bone changes characteristic of Forestier's disease. Standard X-rays generally reveal the characteristic ossification of the anterior vertebral ligaments. ²¹ In some cases, blood tests may be performed to rule out other inflammatory conditions and to measure, in particular, blood sugar and certain blood lipids.

Among workers with recent lower back pain that prevented them from working, an early MRI performed without a recognized medical indication was associated with longer periods of disability and higher costs. MRI, or magnetic resonance imaging, uses a magnetic field to produce detailed images. ²² This study on back pain does not prove that MRI causes a poor outcome. It involved individuals without a recognized indication for this test. It does not call into question imaging that is necessary to identify a herniated disc or to look for a fracture or nerve compression.

Images of the spine often show age-related changes—particularly in the discs—in people who are pain-free. These changes are largely part of normal aging and are not necessarily the cause of pain. ²³

When to consult a physiotherapist for Forestier's disease?

A physical therapy consultation is recommended when back pain or stiffness limits your activities, provided there are no urgent symptoms as described above. Physical therapy for lower back pain typically includes mobility, stretching, and strengthening exercises. In a small study by Forestier, 15 of the 17 participants completed a 24-week program. Eight of these 15 people reported feeling better. The most marked improvement was in a measure of forward movement of the lower back. The other physical changes were minor and inconclusive. ²⁴ This trial, which lacked a comparison group, yielded encouraging results, though it did not allow for distinguishing the effect of the exercises from natural progression or other influences.

In Quebec, you can see a physical therapist without a doctor’s prescription. However, this option does not replace seeking urgent medical attention if you experience the symptoms described above. Physical therapists are primary-care professionals who can assess your condition and refer you to other health care professionals if necessary. If your condition requires you to see a doctor, your physical therapist will be able to tell you so and refer you to the appropriate care.

What are the physiotherapy treatments for Forestier's disease?

La physiothérapie pour Forestier propose des exercices adaptés, des conseils pour ajuster les activités et, selon l’évaluation, des soins manuels pour le confort. Le physiothérapeute évalue d’abord les mouvements difficiles et les activités limitées. Il examine la mobilité de votre colonne et recherche des signes d’atteinte des nerfs (notre page Comprendre les nerfs), notamment avec des tests de force, de sensibilité et de réaction aux mouvements.

Your posture and movements will be observed to identify the positions and actions that are currently triggering your pain. An uncomfortable position can be adjusted based on your tolerance and the limitations caused by stiffness in your spine. The goal is to make your daily activities easier. Your strength and endurance will also be assessed.

Les mobilisations et manipulations articulaires ne conviennent pas toutes à une colonne rigidifiée par Forestier. Les mobilisations sont des mouvements appliqués par le thérapeute; les manipulations comportent une impulsion rapide. Une fracture du cou a été rapportée après une manœuvre manuelle chez une personne atteinte de Forestier. Le geste exact n’a pas pu être établi dans ce rapport de cas²⁵. Informez votre physiothérapeute du diagnostic et de toute chute récente. Les zones reliées par de l’os ne doivent pas être forcées. L’évaluation guide le choix de soins doux pour le confort et de mouvements adaptés, y compris pour des symptômes nerveux lorsque ces mouvements sont appropriés.

You may be given specific exercises to do at home to maintain or improve your range of motion. The small study on Forestier examined daily mobility, stretching, and strengthening exercises, with 14 supervised sessions during the first eight weeks. ²⁴ These exercises target symptoms and functional abilities. No available treatment can cure the disease itself. ¹⁶ Depending on the results of your evaluation, the program may include exercises for the stabilizing muscles, which focus on control and endurance of the muscles surrounding your spine. The choice depends on your abilities, symptoms, and goals. Your physical therapist will also teach you how to adjust the duration, intensity, and breaks in your daily activities and leisure pursuits, and will provide personalized advice on your posture and movement habits.

Treatment aims to reduce pain and stiffness and make it easier to perform daily activities. It does not eliminate bone bridges. In the small exercise trial, eight out of 15 participants reported an improvement after 24 weeks; three saw no change, and four were unsure. ²⁴ The physical therapist will therefore monitor your actual response and adjust the program in consultation with you.

What to do at home for Forestier's disease?

Home care for Forestier includes walking and adapted mobility exercises, provided the assessment indicates that these activities are appropriate for your condition. A recent fall or any urgent symptoms require a medical evaluation first. Next, avoid long periods of inactivity if they increase your stiffness. For recent lower back pain, staying active offers slight benefits over bed rest. For sciatica—pain that radiates down the leg and is related to a nerve in the lower back—this review finds little or no difference between these two approaches. ²⁶

Si vous bougez peu et que votre état le permet, commencez par des marches courtes et régulières. Faites les exercices de mobilité pour le dos recommandés selon votre tolérance, sans forcer les zones rigides. Si vous êtes déjà actif, continuez vos activités qui ne provoquent pas trop de douleur. Les exercices de renforcement et d'endurance musculaire peuvent faire partie du programme pour entretenir votre force et votre capacité à bouger.

For persistent lower back pain with no specific identified cause, exercise provides modest benefits in terms of pain relief and functional ability compared to standard care. The review does not identify any one type of exercise as clearly superior to the others. These findings pertain to persistent lower back pain; their application to Forestier requires adaptation. Work with your physical therapist to choose activities that you can tolerate. ²⁷

A professional evaluation helps you understand what is limiting your activities and adjust your treatment plan.

What conditions are associated with Forestier's disease?

Forestier’s disease has been linked to lumbar osteoarthritis and lumbar stenosis in some studies. Lumbar osteoarthritis refers to changes in the joints of the lower back; stenosis is a narrowing of the space through which the nerves pass. A population-based study found an association with lumbar osteoarthritis, referred to as spondylosis in that study. ²⁸ The presence of both conditions in the same person does not prove that one causes the other. See our guide on lumbar osteoarthritis to learn more.

Lumbar spinal stenosis is associated with Forestier's disease. ²⁹ The authors suggest that the parts of the spine connected by bone place a greater load on the parts that remain mobile. This explanation remains a hypothesis. The formation of bone in front of the vertebrae does not, in and of itself, mean that the neural canal is narrowed. Stenosis can cause pain, numbness, or weakness in the legs.

Lumbar facet syndrome involves the joints at the back of the vertebrae and may contribute to pain in people with Forestier's disease. Pain originating from these joints may coexist with Forestier's disease, but it must be evaluated separately. The mere presence of calcium deposits does not confirm this as the source of the pain.

Can Forestier's disease be prevented?

There is currently no proven method for preventing Forestier’s disease. Regular exercise, managing your diabetes and cholesterol, and discussing your weight with a healthcare professional are still beneficial for your health. Obesity is associated with Forestier’s disease, but this does not prove that weight loss prevents its development.

A balanced diet and regular physical activity also support muscle and joint health. Their effect on bone growth in Forestier has yet to be determined.

How can I get help for Forestier's disease?

A consultation with our physical therapists will help you understand Forestier’s disease and choose a treatment plan tailored to your specific challenges. The evaluation focuses on your movements, activities, and goals. The urgent symptoms described above require immediate medical attention.

Schedule an appointment to have your symptoms evaluated and discuss a treatment plan.

Sources

1. Mader R, Verlaan JJ, Buskila D. Diffuse idiopathic skeletal hyperostosis: clinical features and pathogenic mechanisms. Nat Rev Rheumatol. 2013;9(12):741-50.↩ Back to text: 1st, 2nd, 3rd, 4th mentions
2. Resnick D, Niwayama G. Radiographic and pathologic features of spinal involvement in diffuse idiopathic skeletal hyperostosis (DISH). Radiology. 1976;119(3):559-68.↩ Back to text
3. Kuperus JS, Buckens CF, Šprem J, Oner FC, de Jong PA, Verlaan JJ. The Natural Course of Diffuse Idiopathic Skeletal Hyperostosis in the Thoracic Spine of Adult Males. J Rheumatol. 2018;45(8):1116-1123.↩ Back to text
4. Gazel U, Ayan G, Hryciw N, Delorme JP, Hepworth E, Sampaio M, et al. Disease-specific definitions of new bone formation on spine radiographs: a systematic literature review. Rheumatol Adv Pract. 2024;8(2):rkae061.↩ Back to text
5. Takahashi T, Yoshii T, Mori K, Kobayashi S, Inoue H, Tada K, et al. Comparison of radiological characteristics between diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis: a multicenter study. Sci Rep. 2023;13(1):1849.↩ Back to text
6. Jha S, Fratzl-Zelman N, Roschger P, Papadakis GZ, Cowen EW, Kang H, et al. Distinct Clinical and Pathological Features of Melorheostosis Associated With Somatic MAP2K1 Mutations. J Bone Miner Res. 2019;34(1):145-156.↩ Back to text
7. Eshed I. Imaging Characteristics of Diffuse Idiopathic Skeletal Hyperostosis: More Than Just Spinal Bony Bridges. Diagnostics (Basel). 2023;13(3).↩ Back to text: 1st, 2nd, 3rd, 4th mentions
8. Kuperus JS, Mohamed Hoesein FAA, de Jong PA, Verlaan JJ. Diffuse idiopathic skeletal hyperostosis: Etiology and clinical relevance. Best Pract Res Clin Rheumatol. 2020;34(3):101527.↩ Back to text: 1st, 2nd, 3rd mentions
9. Nascimento FA, Gatto LA, Lages RO, Neto HM, Demartini Z, Koppe GL. Diffuse idiopathic skeletal hyperostosis: A review. Surg Neurol Int. 2014;5(Suppl 3):S122-5.↩ Back to text: 1st, 2nd mentions
10. Herrán de la Gala D, Barba Arce AB, Lamagrande Obregón A, Landeras Álvaro RM, Cobo Ruiz T, Gallardo Agromayor EC. Diffuse idiopathic skeletal hyperostosis: Imaging findings with special focus on extraspinal involvement. Radiologia (Engl Ed). 2024;66(5):447-458.↩ Back to text
11. Belanger TA, Rowe DE. Diffuse idiopathic skeletal hyperostosis: musculoskeletal manifestations. J Am Acad Orthop Surg. 2001;9(4):258-67.↩ Back to text
12. Cleveland Clinic. Diffuse Idiopathic Skeletal Hyperostosis (DISH Disease).↩ Back to text
13. Mata S, Fortin PR, Fitzcharles MA, Starr MR, Joseph L, Watts CS, et al. A controlled study of diffuse idiopathic skeletal hyperostosis. Clinical features and functional status. Medicine (Baltimore). 1997;76(2):104-17.↩ Back to text
14. Worcestershire Acute Hospitals NHS Trust. Cauda Equina Syndrome (feuillet pour les patients).↩ Back to text
15. Bruges-Armas J, Couto AR, Timms A, Santos MR, Bettencourt BF, Peixoto MJ, et al. Ectopic calcification among families in the Azores: clinical and radiologic manifestations in families with diffuse idiopathic skeletal hyperostosis and chondrocalcinosis. Arthritis Rheum. 2006;54(4):1340-9.↩ Back to text
16. Ji W, Yang W, Su S, Sun S, Cai H, Wang K, et al. Genetics and pathophysiology of diffuse idiopathic skeletal hyperostosis. Front Endocrinol (Lausanne). 2026;17:1745930.↩ Back to text: 1st, 2nd mentions
17. Pillai S, Littlejohn G. Metabolic factors in diffuse idiopathic skeletal hyperostosis - a review of clinical data. Open Rheumatol J. 2014;8:116-28.↩ Back to text
18. Denko CW, Boja B, Malemud CJ. Growth hormone and insulin-like growth factor-I in symptomatic and asymptomatic patients with diffuse idiopathic skeletal hyperostosis (DISH). Front Biosci. 2002;7:a37-43.↩ Back to text
19. Denko CW, Boja B, Moskowitz RW. Growth promoting peptides in osteoarthritis and diffuse idiopathic skeletal hyperostosis--insulin, insulin-like growth factor-I, growth hormone. J Rheumatol. 1994;21(9):1725-30.↩ Back to text
20. Kuperus JS, de Gendt EEA, Oner FC, de Jong PA, Buckens SCFM, van der Merwe AE, et al. Classification criteria for diffuse idiopathic skeletal hyperostosis: a lack of consensus. Rheumatology (Oxford). 2017;56(7):1123-1134.↩ Back to text
21. Cammisa M, De Serio A, Guglielmi G. Diffuse idiopathic skeletal hyperostosis. Eur J Radiol. 1998;27 Suppl 1:S7-11.↩ Back to text
22. Webster BS, Bauer AZ, Choi Y, Cifuentes M, Pransky GS. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine (Phila Pa 1976). 2013;38(22):1939-46.↩ Back to text
23. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-6.↩ Back to text
24. Al-Herz A, Snip JP, Clark B, Esdaile JM. Exercise therapy for patients with diffuse idiopathic skeletal hyperostosis. Clin Rheumatol. 2008;27(2):207-10.↩ Back to text: 1st, 2nd, 3rd mentions
25. Hartel MJ, Seidel U, Iselin L, Exadaktylos AK, Benneker LM. Partial tetraplegic syndrome as a complication of a mobilizing/manipulating procedure of the cervical spine in a man with Forestier's disease: a case report. J Med Case Rep. 2011;5:529.↩ Back to text
26. Hagen KB, Jamtvedt G, Hilde G, Winnem MF. The updated cochrane review of bed rest for low back pain and sciatica. Spine (Phila Pa 1976). 2005;30(5):542-6.↩ Back to text
27. van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol. 2010;24(2):193-204.↩ Back to text
28. Kagotani R, Yoshida M, Muraki S, Oka H, Hashizume H, Yamada H, et al. Prevalence of diffuse idiopathic skeletal hyperostosis (DISH) of the whole spine and its association with lumbar spondylosis and knee osteoarthritis: the ROAD study. J Bone Miner Metab. 2015;33(2):221-9.↩ Back to text
29. Yamada K, Satoh S, Hashizume H, Yoshimura N, Kagotani R, Ishimoto Y, et al. Diffuse idiopathic skeletal hyperostosis is associated with lumbar spinal stenosis requiring surgery. J Bone Miner Metab. 2019;37(1):118-124.↩ Back to text

Nos physiothérapeutes ont défini la stratégie de recherche, le plan et le contenu clinique de cet article. Un outil d’IA a soutenu la recherche documentaire et la révision du texte pour assurer une cohérence du contenu et du style d’écriture.