diffuse idiopathic skeletal hyperostosis (DISH)?

Manish Suthar , md.

DISH (sometimes called Forestier’s disease) is considered a form of degenerative arthritis and is characterized by excessive bone growth along the sides of the vertebrae of the spine. It is also associated with inflammation and calcification (bone growth) at other areas of the body where tendons and ligaments attach to bone, such as at the elbow, knee and the heel of the foot. These can lead to bone spurs. Heel spurs, for example, are common among people with DISH.

How common is DISH?

• DISH is very common, affecting between six and 12 percent of North Americans.
• It rarely occurs among people younger than 50.
• It affects more men than women.

DISH is thought to be the second most common form of arthritis after osteoarthritis. It affects between six and 12 percent of North Americans, almost always occurring among people older than 50. Unlike most types of arthritis, DISH occurs more often among men (65%) than women (35 %), and affects 28 percent of men over the age of 80.

What are the warning signs of DISH?

• Back pain and stiffness, especially in the middle area of the back
• Sharp pain associated with bending or twisting of the back
• Problems with swallowing and neck movement
• What seems like “tendonitis” in the shoulder, elbow, knee or ankle.
• DISH is characterized by excessive bone growth along the sides of the vertebrae of the spine
• It also involves inflammation and bone growth where tendons and ligaments attach to bone, such as at the elbow, knee and the heel of the foot.
• Bone spurs are common among people with DISH

Symptoms of DISH include intermittent back pain and particularly stiffness of the back, especially in the area from below the neck to the middle of the back. Stiffness is often worst in the morning and after long periods of sitting. It can also increase with wet weather. Pain is sometimes sharp, especially with certain movements such as twisting or bending. Back pain associated with DISH is often relieved through mild activity.

Some people with DISH may have difficulties with swallowing and moving their necks. And because DISH can affect the points where tendons insert into the arms and legs, some people with DISH experience recurring bouts of what seems like tendonitis in such places as the shoulder, elbow, knee or ankle. This “tendonitis” of course, is due to DISH.

Although the symptoms peculiar to DISH have been noted in medical literature for almost 100 years, the disease has only been recognized as a distinct disorder since 1997. For this reason, many physicians are still unfamiliar with the disease and it is often misdiagnosed. It is likely that many patients who experience regular back pain may have DISH without knowing it. The disease is usually confirmed through x-rays of the thoracic (upper) spine or chest, which reveal the characteristic bony outgrowths of DISH along the vertebrae.

What causes DISH?

The exact cause of DISH is not known, but people who have been overweight since childhood may be at greater risk of developing the disease.

What can you do about DISH?

• Your doctor may recommend non-steroidal anti-inflammatory drugs (NSAIDs - pronounced EN-seds) to reduce pain and the inflammation of tendons and ligaments.
• Your doctor may also recommend a drug to lower your risk of developing stomach problems (e.g. bleeding) as a result of using an NSAID. 
• Stay active and get regular exercise. Walking, stretching and yoga are good exercises for managing the symptoms of DISH. 
• Individualized physiotherapy programs may help if your symptoms are particularly bad. 

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen (Naprosyn) or high dose ibuprofen (Advil, Motrin) are often used to treat the inflammation of tendons and ligaments and the pain that occur with DISH. The hope is that minimizing inflammation of the tendons and ligaments will help the patient to maintain their mobility. NSAID use, however, is associated with a problematic side effect: stomach bleeding. And because people over 60 are at higher risk of bleeding from the stomach and most people with DISH are over 60, some doctors prefer using NSAIDs together with drugs which are known to reduce this side-effect. Such drugs include Cytotec, the proton pump inhibitors, and the newer cox-2 selective drugs (Celebrex).

People with DISH are encouraged to stay active and to get regular exercise. Walking is considered a good form of exercise for the disease. Stretching or yoga can also help, as can aerobic exercise programs suited to the patient’s age and capabilities. Individualized physiotherapy programs appear to help some people with DISH when their symptoms are particularly bad.  Overall, the objective of exercise for people with DISH is to regularly stretch the ligaments affected by the disease in order to keep them functioning properly and to help reduce inflammation.

Additional Tips For Living Well

v     The Arthritis Society offers a variety of programs and services that can be helpful.

v     You can reach the Society at 1-800-321-1433 from anywhere in Canada .

Along with the physical symptoms of arthritis, many people experience feelings of helplessness and depression. Learning daily living strategies to manage your arthritis gives you a greater feeling of control and a more positive outlook. To get the best results, people affected by arthritis need to form close ties with their doctors and therapists, and become full partners in their treatment. From our perspective, it's all part of 'living well with arthritis.' There are several resources you can use in finding out how best to manage your own arthritis.