Keeping Bones Strong for Life
The skeleton is the structural foundation of every movement, every athletic performance, and every independent moment of daily life — and it is one of the most overlooked systems in preventive medicine until something goes wrong.
THE BASICS
How Bone Works — and Why It Changes With Age
Bone is living tissue, constantly being broken down and rebuilt through the coordinated activity of two cell types. Osteoclasts resorb old bone. Osteoblasts lay down new bone in its place. In youth, osteoblast activity dominates, and the skeleton gains density rapidly. Peak bone mass is reached somewhere between ages 25 and 30, and what you accumulate by that point becomes the reserve you draw on for the rest of your life. After midlife, the balance shifts — breakdown begins to outpace formation, and most adults lose somewhere between 0.5 and 1 percent of bone density per year as a baseline trajectory. In women, menopause accelerates that loss substantially, with estrogen withdrawal driving up to 20 percent reduction in bone density in the first five to seven years following the transition. Men are not exempt — testosterone decline with age produces a parallel, if more gradual, pattern of bone loss that is frequently underrecognized and undertreated.
The clinical consequence of sustained bone loss is osteopenia and eventually osteoporosis — a state in which bone microarchitecture has deteriorated to the point where fracture risk rises significantly with loads that a healthy skeleton would tolerate without consequence. Hip and vertebral fractures in particular carry serious downstream effects including prolonged disability, loss of functional independence, and meaningfully elevated mortality risk in older adults. The challenge is that bone loss is entirely silent until a fracture occurs, which is why proactive testing and risk assessment matter so much.
CLINICAL EVIDENCE
Testing, Diagnosis, and Understanding Your Risk
The gold standard for measuring bone health is the DEXA scan — dual-energy X-ray absorptiometry — which quantifies bone mineral density at the lumbar spine and hip. Results are reported as a T-score, which compares your bone density to that of a healthy young adult at peak bone mass. A T-score at or above negative 1.0 is considered normal. Between negative 1.0 and negative 2.5 represents osteopenia — reduced bone density that warrants attention and lifestyle intervention. A T-score at or below negative 2.5 meets the diagnostic threshold for osteoporosis. The Z-score, which compares you to individuals of the same age, sex, and body size, provides additional context about whether your bone loss is occurring faster than expected for your demographic. Current guidelines recommend DEXA screening beginning at age 65 in women and 70 in men, with earlier testing warranted in the presence of known risk factors including prolonged corticosteroid use, family history of osteoporotic fracture, low body weight, smoking, or significant alcohol use. Repeat scanning every two years is standard practice, with more frequent monitoring following a fracture, a major medication change, or evidence of accelerated loss.
The FRAX score is a complementary tool that uses clinical risk factors alongside bone density data to estimate your 10-year probability of a major osteoporotic fracture. A FRAX score of 20 percent means that 20 out of 100 people with your risk profile will sustain a fracture over the next decade — a number that has direct implications for treatment decisions and the threshold at which pharmacological intervention is warranted.
PATIENT SELECTION
What You Can Do — and When Medicine Is Needed
The single most powerful lifestyle intervention for bone health across the lifespan is resistance training. Mechanical loading through weight-bearing exercise and progressive strength work signals the skeleton to maintain and increase density — a stimulus that no supplement can replicate. Weight-bearing cardiovascular activities including walking, hiking, stair climbing, and dancing contribute as well, though resistance training carries the stronger osteogenic signal and the additional benefit of building the muscle mass and neuromuscular coordination that reduce fall risk. Nutritional support for bone health requires adequate calcium — approximately 1,200 milligrams per day from food sources or supplementation — along with sufficient vitamin D to support calcium absorption, typically 400 to 800 IU daily at maintenance levels and higher in documented deficiency. Protein intake is frequently overlooked in this context, but adequate dietary protein is essential for both bone matrix formation and the preservation of muscle mass that protects against falls. Smoking and excessive alcohol consumption both accelerate bone loss through mechanisms that are well-established and directly modifiable.
When lifestyle measures are insufficient — and in many patients with established osteoporosis or high fracture risk, they will be — pharmacological treatment is appropriate and evidence-supported. Available options include bisphosphonates, denosumab, selective estrogen receptor modulators, parathyroid hormone analogues, romosozumab, calcitonin, and hormone replacement therapy in appropriate candidates. The choice among these agents depends on fracture risk profile, comorbidities, medication tolerance, and the specific mechanism of bone loss driving the clinical picture. This is a decision that warrants individualized evaluation rather than a protocol-driven approach.
FOR REFERRING CLINICIANS
Bone health evaluation and management is an area where physiatry, sports medicine, and interventional spine medicine intersect in clinically meaningful ways. Patients presenting with vertebral compression fractures, osteoporotic spine pain, or sarcopenia-related fall risk benefit from a comprehensive musculoskeletal evaluation that addresses both the skeletal and muscular components of fragility. I offer DEXA interpretation, FRAX-guided risk stratification, spine fracture assessment including vertebral augmentation evaluation when appropriate, and individualized bone health optimization programs that integrate exercise prescription, nutritional guidance, and pharmacological management in coordination with the referring provider and endocrinology when indicated. I welcome direct physician-to-physician consultation.
PERSPECTIVE
Bone Health as a Lifelong Investment
Osteoporosis and sarcopenia — bone loss and muscle loss — frequently develop in parallel, and their combined effect on fall risk, fracture risk, and functional independence is greater than either produces alone. Strength training addresses both simultaneously, which is why I consider it the single most important modifiable variable in healthy aging. It is not a niche recommendation for athletes or a supplementary activity for people who already exercise — it is foundational medicine for anyone who wants to remain physically capable and independent across the full arc of their life. The patients I see who fracture a hip or a vertebra in their seventies rarely arrive at that moment because of bad luck. They arrive there because bone loss went undetected, muscle mass was not maintained, and the structural reserve built in youth was spent without being replenished. That trajectory is not inevitable, and it is not too late to change at almost any point. Your bones are the framework of your independence. Keeping them strong is not an aesthetic goal — it is a clinical one, and it deserves the same level of deliberate attention as any other system in the body.
DISCLOSURE & REFERENCES
This article is for educational purposes and reflects clinical experience and interpretation of published literature. It is not a substitute for individualized medical evaluation. Key references: Kanis JA et al. (FRAX development and validation, Osteoporos Int); Cosman F et al. 2014 (NOF Clinical Practice Guidelines, Osteoporos Int); Lems WF & Raterman HG 2017 (sarcopenia and osteoporosis, Nat Rev Rheumatol); Watson SL et al. 2018 (heavy resistance training and bone density, J Bone Miner Res); Compston JE et al. 2019 (osteoporosis, Nat Rev Dis Primers).
ABOUT THE AUTHOR
Dr. Mahajer is a double board-certified physiatrist and sports medicine physician, fellowship-trained in Interventional Spine & Sports Medicine at the Icahn School of Medicine at Mount Sinai. He is an Assistant Professor of Neuroscience at FIU Herbert Wertheim College of Medicine. He is the Immediate Past President of the American Osteopathic College of Physical Medicine and Rehabilitation (AOCPMR), holds medical licenses in Florida, New York, and California, and has been recognized as a Top Physiatrist and Top Doctor in both Florida and New York.
