BONE HEALTH & FRACTURES
Your bone density number is only half the story
In rheumatic disease, inflammation and steroids raise fracture risk before a scan changes, and loading plus falls prevention do more than most patients are told.
Week of August 28, 2026. Angelo Papachristos PT, ACPAC. RheumAcademy | Arthros Inc.
She came in with the printout of her bone scan, the word osteopenia circled in blue pen, and a question she'd clearly been sitting with for a while. She was 58, had rheumatoid arthritis, and had been on 5 mg of prednisone most days for a couple of years to keep her hands working. Her mother had broken a hip. She wanted to know two things: did the scan mean she was about to break something, and could she just walk more instead of taking another pill.
What the scan measures, and what it quietly misses
A DXA scan gives you a T-score, a comparison of your bone density to a healthy young adult. A T-score of -2.5 or lower is called osteoporosis, and between -1 and -2.5 is osteopenia. Useful numbers. But density is only one ingredient in whether a bone breaks, and it is not the biggest one for many people.
Here is the part that surprises patients. In the National Osteoporosis Risk Assessment cohort, reported by Siris and colleagues in Archives of Internal Medicine in 2004, about four in five of the women who fractured in the following year had T-scores better than the osteoporosis cutoff. They were not, on paper, osteoporotic. They broke anyway. Density predicts fractures across a population, but it is a weak crystal ball for any single person, because it says nothing about bone quality, how hard you fall, or how often.
So when your scan says osteopenia, the honest answer is that it moved the needle a little, not that it decided your future. The rest of the picture is what you and your care team fill in.
Three forces stacking the deck: steroids, inflammation, menopause
Glucocorticoids are the one to take seriously and the one most tied to your rheumatic disease. Van Staa and colleagues, working with a large UK general practice database, reported in 2000 that fracture risk tracks with the daily dose and falls again after you stop. At doses between 2.5 and 7.5 mg of prednisolone a day, the range my patient sits in, hip fracture risk was about 1.8 times that of people not taking steroids, and spinal fracture risk about 2.6 times. Their 2002 pooled analysis put the rise inside the first three to six months of starting.
Crucially, much of that added risk is not explained by bone density. When Kanis and colleagues pooled seven cohorts and 42,500 people in 2004, steroid use came close to doubling fracture risk at age 50, and the estimate barely moved when bone density was taken out of the calculation. Steroids weaken bone in ways a DXA does not fully see, which is exactly why my patient's 5 mg matters even though her scan only said osteopenia.
Inflammation itself thins bone. Active rheumatoid arthritis, lupus and other inflammatory disease drive the cells that break bone down, independent of steroids, which is why RA is built into the FRAX fracture calculator as its own risk factor. Controlling the disease protects bone as well as joints.
And menopause sits on top of all of it. The drop in estrogen speeds bone loss for several years around the transition, so a woman with inflammatory arthritis going through menopause on prednisone has three forces pulling the same direction at once. None of these show up as a single dramatic number. They compound quietly.
What loading actually does, and who the evidence fits
My patient wanted to walk more. Walking is good for you, but for bone it does little on its own: nothing measurable at the spine, and a modest gain at the hip only after six months or more of it. Bone responds to loads it is not used to, meaning resistance heavy enough to be hard, and impact.
The trial worth knowing here is LIFTMOR, run by Watson and colleagues and published in the Journal of Bone and Mineral Research in 2018. One hundred and one postmenopausal women with low bone mass did two supervised 30-minute sessions a week of high-intensity resistance and impact training, the kind of thing patients are usually warned away from: deadlifts, overhead press, squats, jumping. Over eight months, spine density rose 2.9% in the lifting group and fell 1.2% in the control group, who did a gentle home program, and hip density held steady against a 1.9% loss. Function and posture improved. The headline that mattered most to a nervous clinic population was safety: one minor back spasm in the whole trial, in a group everyone assumed was too fragile to lift heavy.
Two honest caveats. LIFTMOR studied otherwise healthy postmenopausal women with low bone density rather than people with active arthritis, and the lifting was supervised and progressed by people who knew what they were doing. That is the model to copy, not a licence to load a swollen, actively inflamed joint under a barbell without guidance. For someone like my patient, the work starts with what her hands and wrists tolerate and builds from there.
The other half of fracture risk is the fall, and it gets far less attention than it should. You do not break a hip from low bone density sitting still. You break it when you go down.
Sherrington and colleagues, in a large Cochrane review in 2019, found that exercise programs cut the rate of falls in older community-dwelling adults by roughly a quarter. Balance-based programs did the work, adding strength to balance probably did more, and there was a lower-certainty signal that exercise cuts fall-related fractures as well. For inflammatory arthritis, where unstable ankles, weak quads, foot pain and some medications all raise fall risk, balance and strength training is doing double duty. The strength half loads bone and the balance half keeps you off the floor.
Who actually gets a bone drug, and why waiting for the scan can be wrong
This is where steroids change the rules. The American College of Rheumatology's 2022 guideline on glucocorticoid-induced osteoporosis, led by Humphrey and published in 2023, makes a point patients rarely hear: if you take 2.5 mg or more of prednisone a day for more than three months, your fracture risk should be assessed early, and if that risk comes out medium or higher, treatment is strongly recommended before your DXA ever crosses into osteoporosis. From age 40, risk is estimated with a tool like FRAX, which folds in your age, prior fractures, steroid use and RA, rather than the T-score alone.
What that means in the room is that the density number is not the gatekeeper it is often treated as. A younger person on long-term prednisone with a prior fragility fracture may need a bone medication with an osteopenia scan, while a 55-year-old with the same scan, no steroids and no prior fracture may need nothing beyond progressive strength work. The scan informs the decision. It does not make it.
What to do, and the conversation to have
Ask your team to estimate your actual fracture risk rather than read you a T-score. Bring your steroid history, any past broken bones from a minor fall, and your family history, because those drive the calculation as much as the scan does. If you are on ongoing glucocorticoids, ask specifically whether you should be on bone protection now rather than waiting for the density to slip further, and ask about calcium and vitamin D, which the guideline recommends getting right for anyone on long-term steroids whether or not a bone drug is added.
Then get into real loading. Push for a referral to a physiotherapist or exercise program that will progress you into genuine resistance and balance work rather than handing you a sheet of stretches. Start at what your joints tolerate on a given day and build. If your disease is active, controlling it is part of the bone plan, so treat a flare as a bone issue as well as a joint one.
Questions for your care team
- Given my steroid dose and how long I've been on it, should I be on a bone-protecting medication now, or is it safe to watch?
- What's my estimated 10-year fracture risk on FRAX Canada or CAROC, including my RA and steroid use, rather than my scan number alone?
- Can you refer me to a program that includes progressive resistance and balance training that's safe for my joints?
- Between visits, what should I track: I'm thinking my steroid dose over time and any falls or near-falls. Is that the right list?
What this does not mean
None of this is a reason to stop your steroids on your own or to skip a bone medication your rheumatologist has prescribed. Exercise and loading sit alongside those decisions; they do not replace them, and stopping prednisone abruptly carries its own serious risks.
References
Siris 2004 - NORA T-scores and fracture risk. Siris ES, Chen YT, Abbott TA, et al. Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med, 2004. Density was measured with peripheral devices at the heel, forearm or finger, and fractures were self-reported over 12 months.
https://pubmed.ncbi.nlm.nih.gov/15159268/
van Staa 2000 - oral corticosteroids and fracture risk. van Staa TP, Leufkens HG, Abenhaim L, Zhang B, Cooper C. Use of oral corticosteroids and risk of fractures. J Bone Miner Res, 2000.
https://pubmed.ncbi.nlm.nih.gov/10841167/
van Staa 2002 - corticosteroid-induced osteoporosis meta-analysis. van Staa TP, Leufkens HG, Cooper C. The epidemiology of corticosteroid-induced osteoporosis: a meta-analysis. Osteoporos Int, 2002.
https://pubmed.ncbi.nlm.nih.gov/12378366/
Kanis 2004 - corticosteroid use and fracture risk independent of BMD. Kanis JA, Johansson H, Oden A, et al. A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res, 2004.
https://pubmed.ncbi.nlm.nih.gov/15125788/
Humphrey 2023 - ACR 2022 guideline on glucocorticoid-induced osteoporosis. Humphrey MB, Russell L, Danila MI, et al. 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheumatol, 2023.
https://pubmed.ncbi.nlm.nih.gov/37845798/
Ma 2013 - walking and bone density in postmenopausal women. Ma D, Wu L, He Z. Effects of walking on the preservation of bone mineral density in perimenopausal and postmenopausal women: a systematic review and meta-analysis. Menopause, 2013.
https://pubmed.ncbi.nlm.nih.gov/24149921/
Watson 2018 - LIFTMOR high-intensity resistance and impact training. Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. J Bone Miner Res, 2018.
https://pubmed.ncbi.nlm.nih.gov/28975661/
Sherrington 2019 - Cochrane exercise for falls prevention. Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev, 2019.
https://pubmed.ncbi.nlm.nih.gov/30703272/
This article is patient education, not medical advice. It cannot account for your individual diagnosis, medications, or history. Use it to ask better questions of your own rheumatology and care team, who know your situation, and do not change any treatment based on it alone.
Angelo Papachristos PT, ACPAC. Advanced Practice Physiotherapist. Co-Founder, RheumAcademy. Co-Founder, Arthros Inc.