What is Diffuse Idiopathic Skeletal Hyperostosis (DISH)?

What is Diffuse Idiopathic Skeletal Hyperostosis (DISH). Diffuse Idiopathic Skeletal Hyperostosis or DISH, also known as Forestier’s disease, is a condition characterised by the gradual stiffening and hardening of ligaments and tendons in the spine and other areas of the body. The process of ligament hardening is called calcification and ossification, which is literally what it sounds like, the deposition of calcium in the spinal ligaments, leading to them turning to bone (ossification).

Diffuse Idiopathic Skeletal Hyperostosis (DISH) was first described by Forestier and Rotes-Querol in 1950 and was originally known as “senile ankylosing hyperostosis of the spine” 1. The exact cause remains unclear2,3,4,5, which is why it still has the word “idiopathic” in its name, as this is the medical term for cause unknown. DISH primarily affects biological males over the age of 405,6 and is associated with various metabolic and lifestyle factors, such as obesity, insulin resistance syndrome, type II diabetes, high blood pressure (hypertension), and an imbalance of cholesterol (dyslipidemia) 6,7. Believe it or not, DISH has been described in ancient Egyptian Pharaoh Ramses II and in Neanderthals8,9. We have spoken before about the human link to Neanderthals in our blog how the shape of the spine can cause back pain.

So why am I writing this blog? Why DISH? Well, there are several reasons for this blog. Reason the first is that I have seen DISH a lot in my clinical career and patients rarely get an opportunity to learn about their condition. Reason the second is that for me, DISH is the keystone condition that epitomises why X-rays are so important in chiropractic clinical practice.  Reason the third is we have a patient case study coming soon of a patient with DISH and this blog will help put context to the case study. In this blog, we will explore the symptoms, diagnosis, treatment options, and lifestyle management strategies for individuals living with DISH.

What is DISH? In a nutshell, DISH is a non-inflammatory condition that primarily affects the spine, although it can also involve other areas such as the shoulders, hips, knees, heels, and elbows. The hallmark feature of DISH is the formation of new bone along the ligaments of the spine, which can lead to stiffness, reduced mobility, and pain.

Symptoms of DISH

The symptoms of DISH can vary widely among individuals. Some common signs and symptoms include:

  • Progress stiffness and limited range of motion in the spine and affected joints.
  • Pain, especially in the back and shoulders.
  • Difficulty swallowing or breathing in severe cases where the spinal bones impinge on the oesophagus or windpipe (trachea).
  • Formation of bony outgrowths (osteophytes) visible on X-rays.
  • Occasionally, DISH can lead to complications such as spinal fractures or neurological issues if the bony growths compress nerves.

Diagnosis of DISH

Diagnosing DISH typically involves a combination of medical history, physical examination, and ultimately, the diagnosis can only be confirmed with imaging studies. X-rays are commonly used to visualise the characteristic bony growths along the spine and affected joints. In some cases, additional imaging tests such as CT scans or MRI scans may be ordered to assess the extent of the condition and rule out other potential causes of the patients’ symptoms. The hallmark of DISH on x-ray is a large amount of excessive bone bridging across at least four consecutive spinal levels as shown in figure 1 below.

Physical Therapy Management and DISH

Currently, there is no cure for DISH, and treatment primarily focuses on managing symptoms. Some intervention options from chiropractors and other manual therapists, particularly spinal manipulative therapy are contraindicated for DISH patients due to an increased risk of fracture of the affected bones and joints. Whilst the joint may have ossified, the bone quality is poor and can fracture easily4. Other complications of DISH can include:

  • Difficulty swallowing (dysphagia).
  • Narrowing of the spinal canal (spinal stenosis).
  • Progressive neurological compression (myelopathy)10.

Due to these complications, manual therapies focus on increasing the patients’ mobility, such as stretches, mobilisations and mobility exercises. Spinal traction has also been applied in one published case report and showed an improvement in the patient’s pain and increased flexibility10. Hoffman et al (1995) discussed the use of “chiropractic manipulation” on four DISH patients11. Three of them found improvement in their symptoms, however the fourth was referred for surgical management.

Lifestyle Management

Living with DISH can present challenges, but there are steps individuals can take to manage their condition and improve their quality of life:

  • Maintain a healthy lifestyle: Eating a balanced diet, staying physically active, and avoiding tobacco and excessive alcohol consumption.
  • Practice good posture: Maintaining proper posture can help alleviate pressure on the spine and reduce discomfort.
  • Use ergonomic tools: Using ergonomic chairs, pillows, and other supportive devices can help alleviate strain on the spine and joints during daily activities.

In conclusion, while living with DISH can be challenging, proper management and lifestyle adjustments can help individuals maintain mobility, manage pain, and improve overall quality of life. It is essential for individuals with DISH to work closely with healthcare professionals to develop a comprehensive treatment plan tailored to their specific needs and symptoms. Manual interventions can be used to help improve symptoms and quality of life, however, if is vitally important that a thorough assessment of the patient, including x-rays has been performed prior to commencing treatment. Understanding the severity of the condition is vital to apply the most appropriate management strategy and reduce the risk of complications.


  1. Forestier J, Rotes-Querol J. Senile ankylosing hyperostosis of the spine. Ann Rheum Dis. 1950;9(4):321-330. doi:10.1136/ard.9.4.321
  2. Cammisa M, De Serio A, Guglielmi G. Diffuse idiopathic skeletal hyperostosis. Eur J Radiol. 1998;27 Suppl 1(SUPPL. 1). doi:10.1016/S0720-048X(98)00036-9
  3. Kiss C, O’Neill TW, Mituszova M, Szilágyi M, Poór G. The prevalence of diffuse idiopathic skeletal hyperostosis in a population-based study in Hungary. Scand J Rheumatol. 2002;31(4):226-229. doi:10.1080/030097402320318422
  4. Harlianto NI, Ezzafzafi S, Foppen W, et al. The prevalence of vertebral fractures in diffuse idiopathic skeletal hyperostosis and ankylosing spondylitis: A systematic review and meta-analysis. North Am Spine Soc J. 2024;17(November 2023):100312. doi:10.1016/j.xnsj.2024.100312
  5. Mader R, Verlaan JJ, Buskila D. Diffuse idiopathic skeletal hyperostosis: Clinical features and pathogenic mechanisms. Nat Rev Rheumatol. 2013;9(12):741-750. doi:10.1038/nrrheum.2013.165
  6. Van der Merwe AE, Maat GJR, Watt I. Diffuse idiopathic skeletal hyperostosis: Diagnosis in a palaeopathological context. HOMO- J Comp Hum Biol. 2012;63(3):202-215. doi:10.1016/j.jchb.2012.03.005
  7. Mader R, Lavi I. Diabetes mellitus and hypertension as risk factors for early diffuse idiopathic skeletal hyperostosis (DISH). Osteoarthr Cartil. 2009;17(6):825-828. doi:10.1016/J.JOCA.2008.12.004
  8. Chhem RK, Schmit P, Faure C. Did Ramesses II really have ankylosing spondylitis? A reappraisal. Can Asssoc Radiol J. 2004;55(4):211-217.
  9. Crubézy E, Trinkaus E. Shanidar 1: a case of hyperostotic disease (DISH) in the middle Paleolithic. Am J Phys Anthropol. 1992;89(4):411-420. doi:10.1002/AJPA.1330890402
  10. Troyanovich SJ, Buettner M. A structural chiropractic approach to the management of diffuse idiopathic skeletal hyperostosis. J Manipulative Physiol Ther. 2003;26(3):202-206. doi:10.1016/S0161-4754(02)54132-4
  11. Hoffman LE, Taylor JA, Price D, Gertz G. Diffuse idiopathic skeletal hyperostosis (DISH): a review of radiographic features and report of four cases. J Manip Physiol Ther. 1995;18(8):547-553.


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