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Diffuse Idiopathic Skeletal Hyperostosis

Synonyms of Diffuse Idiopathic Skeletal Hyperostosis

  • Diffuse Idiopathic Skeletal Hyperostosis
  • DISH
  • Forestier's Disease
  • Spinal Diffuse Idiopathic Skeletal Hyperostosis
  • Spinal DISH
  • Vertebral Ankylosing Hyperostosis

Disorder Subdivisions

  • No subdivisions found.

General Discussion

Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease, affects the ligaments around the spine. Sections of the ligaments turn into bone in this disorder, which is considered to be a form of degenerative arthritis.

The conversion of ligamental tissue to bone usually extends along the sides of the vertebrae of the spine. (This may be called flowing calcification.) Also, DISH is associated with inflammation (tendinitis) and calcification of the tendons, especially at the points at which the tendon attaches to the bones. When this happens, the patient is said to have developed bone spurs, especially in the heel and ankles (heel spurs).

DISH affects three or more vertebrae that are most often located in the chest or in the spine between the chest and pelvis. It is a disorder of older patients, more often affecting men than women ages 50-60. The disorder is often found in association with diabetes, high blood pressure, heart disease and obesity.


Because bone spurs are so often associated with DISH, intermittent stiffness of the spine, especially in the evening and upon arising in the morning, is often a sign of the disorder. Many people with DISH have trouble swallowing and moving their necks or backs. Usually such signs occur when bony overgrowths place pressure on nearby nerves (nerve compression or entrapment) causing irritation. DISH progresses slowly, and calcification may take several years to complete its course.


The exact cause of diffuse idiopathic skeletal hyperostosis is unknown. Changes in cartilage may cause the bony overgrowths to occur. This may be due to aging, trauma, or wear and tear in the course of a lengthy sports career. Disorders that involve disturbances in cartilage metabolism, such as diabetes mellitus or acromegaly, or certain inherited connective tissue disorders may also lead to DISH. (For more information, choose "diabetes mellitus," "acromegaly," or "connective tissue" as your search terms in the Rare Disease Database).

Affected Populations

Diffuse idiopathic skeletal hyperostosis is a common subtype of osteoarthritis. About 19% of men older than 50 years present with DISH while only about 4% of women over the age of 50 years do so. For unknown reasons, a major ligament of the spine (posterior longitudinal) is calcified in 2% of a Japanese population while only about 0.16% of a similar Caucasian population will present with DISH in this same ligament.

DISH has been described as a phenomenon rather than a disease. Double-blind controlled studies have shown that DISH is not associated with any other pathology. Patients with DISH show no greater tendency towards arthritis, bursitis, tendinitis and back pain than do the control subjects. Patients diagnosed with DISH who have back pain show no difference in the character and duration of the pain.

Related Disorders

Symptoms of the following disorders can be similar to those of Forestier's Disease. Comparisons may be useful for a differential diagnosis:

Osteoarthritis is a very common degenerative joint disease characterized by loss of cartilage, deformities of bones and joints, and thickening of the surrounding ligaments and membranes at the joint margins with areas of bony outgrowths. Osteoarthritis develops when cartilage repair does not keep pace with cartilage degeneration. It may occur as a result of trauma to the bone, aging, obesity, or other underlying diseases which cause damage to the joint or its cartilage such as congenital dislocation of the hip or Rheumatoid Arthritis. Osteoarthritis is suspected to be an autoimmune disease. In these types of disorders the body's natural defenses against foreign substances (e.g. antibodies or lymphocytes) attack healthy tissue for unknown reasons.

Spondylosis is osteoarthritis of the spine. It is characterized by a breakdown of the spinal discs in between the vertebrae; this does not occur in Forestier's Disease. (For more information on disorders involving osteoarthritis, choose "osteoarthritis" as your search term in the Rare Disease Database.)

Ankylosing Spondylitis is a chronic progressive form of arthritis primarily involving the spine and paraspinal structures. It is distinguished by inflammation and eventual immobility (ankylosis) of a number of spinal joints. Onset is usually gradual with episodes of low back pain, especially in the region of the tailbone and hips (sacroiliac), and the lower (lumbar) spine. Morning back stiffness often occurs. Symptoms commonly become progressively worse, spreading from the low back into the mid-back and occasionally the neck. (For more information on this disorder, choose "Ankylosing Spondylitis" as your search term in the Rare Disease Database.)

Rheumatoid Arthritis is also suspected of being an autoimmune disease. It is characterized by lack of appetite (anorexia), tiredness, painful and deformed joints, early morning stiffness chiefly in the hands, knees, feet, jaw, and spine. Once affected, a patient's joints remain painful or uncomfortable for weeks, months, or even years. (For more information choose "Rheumatoid Arthritis" as your search term in the Rare Disease Database.)

Standard Therapies

The diagnostic criteria for DISH are fairly strict in order to distinguish this disorder from degenerative disc and joint disease and ankylosing spondylitis. At least the following must be present:

1. Calcification of at least four (4) contiguous vertebrae
2. Absence of disc disease and no compression of the discs
3. Vertebral joints should be mobile and free of packing pressure

Anti-inflammatory drugs, including non-steroid anti-inflammatory drugs (NSAIDS) are often prescribed. In relatively rare cases, surgery to correct deformities may be prescribed. Other treatment is symptomatic and supportive.

Investigational Therapies

Information on current clinical trials is posted on the Internet at All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.

For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:

Tollfree: (800) 411-1222
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For information about clinical trials sponsored by private sources, contact:

Diffuse Idiopathic Skeletal Hyperostosis Resources



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Kelley WN, Harris ED, Ruddy S, et al. Textbook of Rheumatology. 4th ed. W. B. Saunders Company. Philadelphia, PA; 1993:955.

Mader R. Diffuse idiopathic skeletal hyperostosis: a distinct clinical entity. Isr Med Assoc J. 2003;5:506-08.

Olivieri I, Salvarani C, Cantini F, et al. Ankylosing spondylitis and undifferentiated spondyloarthropathies: a clinical review and description of a disease subset with older age onset. Curr Opin Rheumatol. 2001;13:280-84.

Belanger TA, Rowe DE. Diffuse idiopathic skeletal hyperostosis: musculoskeletal manifestations. J Am Acad Orthop Surg. 2001;9:258-67.

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Troyanovich SJ, Buettner M. A structural chiropractic approach to the management of diffuse idiopathic skeletal hyperostosis. J Manipulative Phsiol Ther. 2003;26:202-06.

Mader R. Clinical manifestations of diffuse idiopathic skeletal hyperostosis of the cervical spine. Semin Arthritis Rheum. 2002;32:130-35.

Mears T. acupuncture for back pain ina patient with Forestier's disease (diffuse idiopathic skeletal hyperostosis/DISH). Acupunct Med. 2002;20:102-04.

Ozgocmen S, Kiris A, Kocakoc E, et al. Osteophyte-induced dysphagia: report of three cases. Joint Bone Spine. 2002;69:226-29.

Kiss C, Szilagyi M, Paksy A, et al. Risk factors for diffuse idiopathic skeletal hyperostosis: a case control study. Rheumatology (Oxford). 2002;41:27-30.

Coaccioli S, Fatati G, Di Cato L, et al. Diffuse idiopathic skeletal hyperostosis in diabetes mellitus

Vidal P. A paleoepidemiologic study of diffuse idiopathic skeletal hyperostosis. Joint Bone Spine. 2000;67:210-14.

Epstein NE. Simultaneous cervical diffuse idiopathic skeletal hyperostosis and ossification of the posterior longitudinal ligament resulting in dysphagia or myelopathy in two geriatric North Americans. Surg Neurol. 2000;53:427-31.

McKusick VA, Ed. Online Mendelian Inheritance In Man (OMIM). The Johns Hopkins University. Ankylosing Vertebral Hyperostosis with Tylosis. Entry Number; 106400: Last Edit Date; 3/11/2003.

Rothschild BM. Diffuse Idiopathic Skeletal Hyperostosis. emedicine. Last Updated: December 31, 2002. 7pp.

Nakhoda K. Greene G. Diffuse Idiopathic Skeletal Hyperostosis. emedicine. Last Updated: April 30, 2002. 9pp.

Diffuse Idiopathic Skeletal Hyperostosis (DISH). nd. 3pp.

Shiel WC Jr. Diffuse Idiopathic Skeletal Hyperostosis ("DISH" or Forestier Disease) Last Editorial Review: 4/30/02. 2pp.

Hyperostosis. The Encyclopedia of Medical Imaging. Volume III:1. nd. 2pp.

The information in NORD’s Rare Disease Database is for educational purposes only. It should never be used for diagnostic or treatment purposes. If you have questions regarding a medical condition, always seek the advice of your physician or other qualified health professional. NORD’s reports provide a brief overview of rare diseases. For more specific information, we encourage you to contact your personal physician or the agencies listed as “Resources” on this report.

Report last updated: 2008/05/05 00:00:00 GMT+0

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