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DISH, or to be more precise, diffuse idiopathic skeletal hyperostosis, is a condition characterized by hardening of tendons and ligaments that commonly affects the spine. It is also known as Forestier's disease.

DISH can affect different parts of spine: upper back (thoracic spine), neck (cervical spine), and lower back (lumbar spine). Of course, it can also attack other parts of our body such as tendons and ligaments in the heels, ankles, knees, hips, shoulders, elbows and hands. Men are more likely than women to develop diffuse idiopathic skeletal hyperostosis, especially as older adults. Although symptoms similar to DISH have been noted in medical literature for almost a hundred years, it has been recognized as a disorder as late as 1997. For this reason many physicians are still unfamiliar with the disease, and it is often misdiagnosed. Treatment isn't necessary in most cases, although physical therapy may help. Surgery is sometimes the only possible way out.

Frequency of the condition

In the US, DISH is present in approximately 19% of men and 4% of women older than 50. International frequency shows that about 0.16% Caucasians suffer from this condition. No matter how symptoms are expressed, DISH still appears to be a phenomenon rather than a disease. 

The symptoms of DISH

The symptoms of this condition primary depend on what part of body is affected. Most commonly it’s the upper portion of the back, in which case the symptoms may include:

  • Stiffness in the spine; it may be most noticeable in the morning.
  • Pain,  sometimes sharp, especially with certain movements such as twisting or bending; aggravated by pressure on the spine, relieved through mild activity.
  • Decreased range of motion in the spine. Loss of lateral motion is most noticeable. 
  • Pain and stiffness in other parts of the body. Most commonly affected regions are ankles, knees, hips, shoulders, elbows, and hands.

Risk factors

The definitive cause of DISH is still a mystery. It remains unclear what causes diffuse idiopathic skeletal hyperostosis, which is why it’s hard to identify possible risk factors. Several theories are suggested, listing possible risk factors as:

  • Specific medications: Retinoids, isotretinoin (Accutane®, others) similar to vitamin A can increase the risk of diffuse idiopathic skeletal hyperostosis. It still isn't clear whether a high intake of vitamin A increases risk.
  • Diabetes and similar conditions related to hormone imbalances: People with diabetes are more likely to develop DISH than others. 
  • Heart disease and high blood pressure: Certain heart conditions, such as the coronary artery disease and high blood pressure, also contribute to the chances of developing diffuse idiopathic skeletal hyperostosis.


Diagnosis of DISH

As with any other physical condition, the best way to diagnose DISH is to first do a complete physical examination. The doctor should press lightly on the patient’s spine and joints to feel for abnormalities. Of course, if the patient complains of pain, the doctor will stop pressing, but also gain a clue to a possible diagnosis. 

X-ray imaging: A condition that attacks bones and tendons such as DISH can be diagnosted using spine X-rays. In the thoracic spine, where diffuse idiopathic skeletal hyperostosis is most common, X-rays may show calcification along the vertebrae.

CT and MRI: Other types of imaging, such as computerized tomography (CT) and magnetic resonance imaging (MRI), may be helpful in diagnosing diffuse idiopathic skeletal hyperostosis, and even show better and more detailed results than X-rays.

Treatment of DISH

Unfortunately, there is no cure for diffuse idiopathic skeletal hyperostosis at the moment, but in the great majority of cases, treatment may not be necessary. The  patients learn to live with their disease, finding their own methods of dealing with pain, stiffness, and other symptoms of idiopathic skeletal hyperostosis.
However, this isn't case with all patients. If a patient experiences more serious symptoms of diffuse idiopathic skeletal hyperostosis, his doctor is obligated to recommend treatments to control pain and maintain a range of motion in affected joints.

A first line of treatment – relieving the pain

Relieving the pain caused by DISH is similar to that of other joint ailments. Most commonly prescribed medications are painkillers such as acetaminophen (Tylenol and others) or non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil®, Motrin®, etc). In cases of serious pain problems, sometimes corticosteroid injections may be necessary to relieve it.

Relieving the stiffness

Simple physical therapy is probably the best way to fight this constant stiffness. Special physical therapy can easily and effectively reduce the stiffness associated with DISH.

Physical specialist should prescribe exercises which increase the range of motion in joints. These should be planned individually for every patient.

Possible complications if left untreated

Unfortunately, there are several possible complications which can occur in people diagnosed with DISH. Some of the most common are: 

Severe disability: As mentioned above, a range of motion in the affected joint can be seriously affected. Sometimes the joint can’t be used at all! This could be a serious problem especially if the affected joint is usually very mobile, such as shoulder, hip, or knee. This can make a person almost 100% immobile.

Difficulty swallowing: Also very common, an unpleasant complication of diffuse idiopathic skeletal hyperostosis are swallowing difficulties. Bone spurs associated with DISH in the neck can put pressure on a patient’s esophagus, making it difficult to swallow. In addition, this can also cause other symptoms such as hoarse voice or difficulty breathing, especially when sleeping.

Paralysis: One of the most serious complications of DISH is possible paralysis. If the condition attacks a certain ligament located in the spine (the posterior longitudinal ligament), this can press the spinal cord which results in paralysis.