J Bone Miner Metab (2014) 32:101–109
DOI 10.1007/s00774-013-0531-0
REVIEW ARTICLE
The relationship between osteoarthritis and osteoporosis
Gun-Il Im • Min-Kyu Kim
Received: 13 July 2013 / Accepted: 6 October 2013 / Published online: 7 November 2013
Ó The Japanese Society for Bone and Mineral Research and Springer Japan 2013
Abstract The relationship between osteoarthritis (OA)
and osteoporosis (OP), the two most common skeletal
disorders related to aging, is controversial. Previous
studies suggest that OA is inversely related to OP when
studied cross-sectionally and systematically. However,
there are differences in the results depending on the
parameter used to define OA. The purpose of this review
is to analyze and summarize the literature, and derive
possible answers to three key questions along with a
brief introduction on underlying mechanisms: (1) Is OA
correlated to a high bone mineral density (BMD)? (2)
Does OA influence the progression of OP or osteoporotic
fractures? (3) Does high BMD affect the incidence and
progression of OA? A review of the literature suggests
that OA is inversely related to OP in general when
studied cross-sectionally and systematically. However,
when analyzed in individual bones, the BMD of the
appendicular skeleton in OA-affected joints may
decrease, particularly in the upper extremities. On
whether OA influences bone loss or osteoporotic frac-
tures, differences are observed according to the affected
joints. The risk for osteoporotic fracture does not seem
to decrease despite a high BMD in patients with OA,
probably due to postural instability and muscle strength.
Low BMD at the lumbar spine is associated with a lower
incidence of knee OA although it does not arrest the
progression of knee OA.
G.-I. Im (&)
M.-K. Kim
Department of Orthopaedics, Dongguk University Ilsan
Hospital, Goyang 410-773, Republic of Korea
e-mail: gunil@duih.org
Keywords Osteoarthritis
Osteoporosis

Relationship
Incidence
Progression
Introduction
The relationship between osteoarthritis (OA) and osteopo-
rosis (OP), the two most common skeletal disorders related
to aging, is controversial. Numerous cross-sectional studies
have indicated that OA is associated with increased bone
mineral density (BMD) [1–6]. However, although several
longitudinal studies have found that higher axial BMD is
associated with an increased risk of incident OA of the knee
when defined by osteophytes and Kellgren–Lawrence (K–L)
grade [7–9], no definite relationship has been established
when OA is defined by joint space narrowing (JSN) [3, 4].
Some studies have shown that higher BMD is rather pro-
tective for OA progression [10, 11]. In contrast, the increased
bone mass with radiographic changes seen in OA appears not
to confer a reduced risk for fractures in other investigations
[12, 13]. These diverse arguments lead to assumptions that
the relationship between OP and OA is complicated, and may
differ by disease site or stage [14, 15].
Although in vitro experimental studies and in vivo
animal models suggest a clue to answer these questions, a
synopsis of the clinical investigation can provide a direct
answer to these questions. The purpose of this review is to
analyze and summarize the literature, and to formulate the
nearest possible answer to three key questions along with
brief introduction of underlying mechanisms: (1) Is OA
correlated with a high BMD? If so, which OA parameters
(JSN, K–L grade, alignment) are correlated with BMD in
different parts of the body? (2) Does OA influence the
progression of OP or osteoporotic fractures? (3) Does high
BMD affect the incidence and progression of OA?
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Is OA correlated with a high BMD? If so, which OA
parameters are correlated with BMD in different parts
of the body?
The correlation between OA and OP has been studied
cross-sectionally for the last 40 years since first mentioned
by Foss and Byers who reported that osteoarthrosis of the
hip is rarely found in patients with fractures of the upper
end of the femur [1]. Many of these studies are large series
with [1,000 participants (Table 1).
The correlation between femoral neck BMD and hip and
knee OA has been investigated in the Rotterdam study
group, a prospective population-based cohort study.
Radiographic OA (ROA) was associated with significantly
increased femoral neck BMD with the exception of knee
OA in men. BMD increased significantly according to the
number of affected sites and the K–L score [2]. In the
Framingham Study cohort, the association between proxi-
mal femur and radius BMD and knee OA was investigated.
Mean femoral BMD at the 3 proximal femur sites was
5–9 % higher in men and women with knee OA compared
with those with no knee OA. Radius BMD was not asso-
ciated with knee OA. This study suggested that femoral
BMD is higher among women with osteophytosis of the
knee, and that BMD is not necessarily associated with JSN
[3]. In the Chingford study, individuals who had spine,
knee, carpometacarpal (CMC), distal interphalangeal (DIP)
joint respectively had significantly higher BMD at the
lumbar spine than that of controls. Femoral neck BMD also
increased in the CMC, knee, and the lumbar spine OA
groups [4]. The relationship between axial and hip BMD
and radiographic changes in knee OA was examined in the

Table 1 Correlation between osteoarthritis (OA) and osteoporosis (OP)

Name of study Number of Focus of study Key findings Ref.
or article studied
patients

Rotterdam Study 2,745 Relation between femoral neck BMD and hip Radiographic OA was associated with high BMD [2]
(M:1,121, and knee OA and increased rate of bone loss.
F:1,624)
Framingham 1,154 Relation between proximal femur and radius Among women, femoral BMD is higher in those [3]
Study BMD and knee OA with osteophytosis of the knee, and that BMD is
not necessarily associated with JSN.
Chingford Study 979 (F) Relation between OA and OP (BMD of lumbar Small increases in spine and femoral neck BMD are [4]
spine and femoral neck) present in middle aged women with early
radiological OA of the hands, knees and lumbar
spine.
Baltimore 649 (M:402, Relation between spine and hip BMD and Both men and women with radiographic knee OA [5]
Longitudinal F:247) radiographic changes of knee OA have higher levels of adjusted spine but not hip
Study of Aging BMD.
Study of 4,855 Relation between hip OA and BMD of the hip, Women with moderate to severe radiographic hip [6]
Osteoporotic spine, and appendicular skeleton OA had higher BMD in the hip, spine, and
Fractures appendicular skeleton than did women without hip
OA.
Ichchou et al. 277 Relation between signs of spine OA and spine Severity of disc narrowing, but not osteophytes, is [16]
BMD associated with a generalized increase in BMD
and a decreased rate of bone resorption.
Glowacki et al. 35 Difference in femoral neck BMD of OA hip The femoral neck BMD for the OA hip was higher [17]
scheduled for total hip replacement and than those of the contralateral unaffected hip.
contralateral unaffected hip
Lingard et al. 199 Prevalence of OP among patients with OA Osteoporosis was more commonly detected in the [18]
awaiting total knee arthroplasty or total hip forearm than the proximal femur of the index side
arthroplasty (8.2 %).
Akamatsu et al. 135 Relation between lumbar spine and proximal No significant association between the knee varus [19]
femur BMD and varus deformity caused by and lumbar spine BMD. A weak but significant
knee OA negative correlation existed between varus and
BMD at the proximal femur and lateral tibial
condyle.
Kim et al. 180 Relation between forearm BMD and varus Patients with radiographic hand OA had lower distal [21]
deformity caused by knee OA radius BMD when compared with controls.
Guler-Yuksel 181 The association between metacarpal BMD loss Accelerated metacarpal BMD loss is associated [20]
et al. and progressive hand osteoarthritis (OA) with progressive hand OA.

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Baltimore Longitudinal Study of Aging. Adjusted mean
lumbar spine BMD was higher in subjects with knee os-
teophytes in both sexes. No differences in the level of
adjusted hip BMD were observed in the presence of any
OA radiographic features in either men or women [5]. The
cross-sectional association between radiographic features
of hip OA and BMD of the hip, spine, and appendicular
skeleton were examined in the Study of Osteoporotic
Fractures. Women with moderate to severe radiographic
hip OA have higher BMD in the hip, spine, and appen-
dicular skeleton than do women without hip OA [6]. The
relationship between spine OA and BMD parameters was
also studied in a recent cross- sectional study of 277
postmenopausal women. An increase in BMD with
increasing severity of disc narrowing was observed at the
examined sites, but no association between severity of
osteophytes and BMD was observed [16].
In addition to the large-scale studies described above,
several small-scale studies have investigated the relation-
ship between OP and OA in special situations. Glowacki
et al. [17] measured bilateral hip BMD in 34 subjects
scheduled for hip replacement for advanced unilateral hip
OA. The femoral neck BMD and T-score for the hip with
OA was higher than those of the contralateral unaffected
hip. Lingard et al. studied the prevalence of OP among
patients with OA awaiting total knee arthroplasty or total
hip arthroplasty. OP was more commonly detected in the
forearm than in the lumbar spine or proximal femur of the
index side, suggesting that a significant proportion of
patients with end-stage OA have OP at sites distant from
joints affected by OA [18]. In a Japanese cross-sectional
study, the relationship between BMD and varus deformity
caused by knee OA was assessed in 135 postmenopausal
female patients. After adjusting for age and body mass
index, no significant association was found between varus
inclination of the tibial plateau and lumbar spine BMD
[19].
The relationship between OA and OP in small joints of
the upper extremities has also been investigated. In a recent
study, the association between metacarpal BMD loss and
progressive hand OA was studied over 2 years. BMD loss
was independently associated with progressive hand OA
compared with non-progressive hand OA [20]. In a Korean
study, patients with hand OA had lower distal radius BMD
when compared with that of controls [21].
In summary of above literatures, OA is inversely related
to OP in general when studied cross-sectionally and sys-
tematically. However, there is a difference in the results
depending on the parameter used to define OA (JSN or
osteophytes). It may be due to a difficulty in defining JSN
and osteophytes. JSN is evaluated by a 2-dimensional
method in X-ray, not by a 3-dimensional procedure. While
osteophytes are observed in OA patients, bony changes
103
after compression or subchondral fracture can mimic os-
teophytes. On the other hand, other parameters such as
cartilage matrix quality are difficult to measure noninva-
sively. In addition, when individual bones are analyzed, the
BMD of the appendicular skeleton in OA-affected joints
may decrease, particularly in the upper extremities.
Does OA influence the progression of OP
or osteoporotic fractures?
As mentioned in the previous section, the cross-sectional
finding that OA is associated with a high BMD does not
mean that the presence of OA will increase BMD in
affected patents or the incidence of osteoporotic fractures.
Longitudinal observations, particularly with a large number
of patients, are necessary to answer the question.
Several studies have investigated the longitudinal effect
of OA on BMD (Table 2). The longitudinal Michigan Bone
Health Study was conducted to determine whether Cau-
casian women with newly defined OA would have greater
BMD and less bone turnover over time than women
without OA. Women with incident knee OA had greater
average BMD and less change in their average BMD z-
score (mean of proximal femur, lumbar spine, and total
body) than women without knee OA. Average BMD z-
scores for women with prevalent knee OA were greater
than for women without knee OA [7]. In contrast, a recent
prospective study by Ding et al. showed opposite results.
Older subjects with radiographic hip and knee OA have
higher total hip bone loss over 2.6 years regardless of
symptoms [22]. In data from the Baltimore Longitudinal
Study of Aging, women with OA of the hand had a sig-
nificantly greater adjusted rate of bone loss at the radius
than women with normal hand radiographs, but no such
differences were noted in men for hand OA. No significant
differences in adjusted rate of bone loss at the radius in
men or women were observed by the presence of radio-
graphic knee OA [9].
Other longitudinal studies have investigated the effect of
OA on the incidence of osteoporotic fractures. In a cohort
of 5,552 elderly women from the Study of Osteoporotic
Fractures, the subjects with OA did not have a significantly
reduced risk for osteoporotic fractures despite increased
BMD compared with controls, although there was a trend
toward a reduced risk of femoral neck fractures in subjects
with severe radiographic OA [12]. The authors suggested
that the failure of the observed increase in BMD to trans-
late into a reduced fracture risk may have been due, in part,
to the number and type of falls sustained by the subjects
with OA. Among a study population of 1,101 women and
720 men in the Dubbo Osteoporosis Epidemiology Study,
individuals with OA, despite higher BMD, are not
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Table 2 Influence of OA on OP or osteoporotic fracture

Name of study Number of Focus of study Key findings Ref.
or article studied
patients

Longitudinal 601 (F) Whether newly defined OA would have greater Women with radiographically defined knee OA [7]
Michigan BMD and less bone turnover over time than have greater BMD than do women without knee
Bone Health would women without OA. OA and are less likely to lose that higher level of
Study BMD.
Baltimore 441 Whether persons with radiographic features of OA Women with radiographic OA of the hand had a [9]
Longitudinal (M:298, of the hands and knees had different rates of significantly greater bone loss at the radius than
Study of F:139) bone loss than subjects with normal knee women with normal hand radiographs; no such
Aging radiographs differences in men for hand OA. There were no
significant differences in adjusted rate of bone loss
at the radius in men or women by presence of
radiographic knee OA.
Ding et al. 867 Association between hip and knee radiographic Older subjects with radiographic hip and knee OA [22]
(F:49 %) OA and change in total hip BMD over 2.6 years have higher total hip bone loss.
Study of 5,552 (F) Whether OA reduces fracture risk Despite having increased BMD compared with [12]
Osteoporotic controls, subjects with OA did not have a
Fractures significantly reduced risk of osteoporotic fracture.
Dubbo 1,821 Relationship between self-reported OA, bone Subjects with OA had higher bone density at both [13]
Osteoporosis (M:720, density, postural stability measures, and the femoral neck and lumbar spine. Self-reported
Epidemiology F:1,101) atraumatic fractures OA had no predicted change in fracture risk.
Study
Rotterdam 2,773 Association between prevalent radiographic OA of Knee ROA is associated with an increased risk of [8]
Study the knee and incident vertebral and nonvertebral incident vertebral and nonvertebral fractures,
fractures independent of BMD.

protected against nonvertebral osteoporotic fractures,
apparently due to worsened postural stability and thus an
increased tendency to fall [13]. In a sample of 2,773 sub-
jects drawn from the Rotterdam Study, although women
with OA had higher BMD, their incident fracture risk
increased compared with those without OA. In men, no
significant increased fracture risk in the presence of knee
OA was observed [8].
In summary, there are disagreements on whether OA
leads to reduced or increased bone loss and there are dif-
ferences according to affected joints, i.e., knee or hand.
Risk of osteoporotic fracture does not seem to decrease in
patients with OA despite a high BMD, probably due to
postural instability and decreased muscle strength.
Does high BMD affect the incidence and progression
of OA?
In addition to OA affecting OP, it is also interesting to see
whether OP prevents the occurrence and progression of OA
(Table 3). The association between bone mass and incident
and progressive disease and whether prior fractures influ-
ence the development of knee OA were determined in the
Chingford study. No difference was seen in spine BMD
between the women whose knee osteophytes progressed
and the non-progressors, but hip BMD decreased modestly
in progressors. The women who had incident JSN of the
knee had higher baseline spine BMD, and no difference
was seen for women whose JSN had progressed. Women
with a peripheral fracture had a reduced risk of subse-
quently developing incident knee OA [10]. In a sample
drawn from the Rotterdam Study, the incidence of knee OA
in subjects with the highest quartiles of femur neck BMD
and lumbar spine BMD was significantly higher than in
those in the lowest quartiles. The same trend was seen for
the association between lumbar spine BMD and the pro-
gression of knee OA, but no association was found between
femoral neck BMD and the progression of OA. The com-
bined incidence and progression of knee ROA in subjects
with a prevalent vertebral fracture was eight times lower
than that of subjects without a fracture [23]. Separate
analyses for men and women both showed significant
increased risks in the presence of high baseline BMD, with
higher odds ratios in men than in women [23]. In the
Miyama study, a 10-year follow-up of a population-based
cohort of Japanese subjects, causal relationship between
OP and OA at the lumbar spine was investigated. OP at the
lumbar spine significantly reduced the cumulative inci-
dence of lumbar OA in women, but not in men [24].
The association between BMD and incident and pro-
gressive tibiofemoral OA was also tested in a large pro-
spective study of men and women aged 50–79 years with
or at risk for knee OA. Higher femoral neck and whole

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Table 3 Influence of OP on OA incidence and prevalence

Name of study Number Focus of study Key findings Ref.
or article of studied
patients

Chingford Study 830 (F) Association of bone mass with Spine and hip BMD was higher in women [10]
incident and progressive OA who develop incident knee OA, defined by
osteophytes, Low BMD at the hip is weakly
related to progression of OA.
Rotterdam Study 1,403 Association of bone mass with Incidence of knee ROA of subject in the [23]
(M:574, F:829) incident and progressive OA highest femur neck BMD and lumbar spine
BMD was significantly higher than of those
in the lowest quartiles. Lumbar spine BMD
and the progression of knee ROA was also
correlated. Prevalent vertebral fracture has
a protective effect.
MOST 1,754 Association of BMD with incident In knees without baseline OA, higher femoral [25]
and progressive tibiofemoral OA neck and whole body BMD were associated
with an increased risk of incident OA. In
knees with existing OA, progression was
not significantly related to BMD.
Baltimore 441 Whether persons with normal knee Higher BMD at the lumbar spine but not at [9]
Longitudinal Study (M:298, F:139) radiographs who had higher adjusted the femoral neck was associated with an
of Aging levels of BMD were at greater risk of increased risk of developing incident
developing radiographic features of knee radiographic knee OA.
OA
Framingham Study 473 (F) The relations of femoral neck BMD Women who gained femoral neck BMD were [11]
and change in BMD to risk of incident at increased risk of incident but at a
and progressive radiographic knee OA significantly decreased risk of progressive
knee OA.
Miyama Study 400 (M:200, Causal relationship between lumbar A significant relationship was demonstrated [24]
F:200) OP and OA between the presence of lumbar OP at the
baseline and low cumulative incidence of
lumbar OA in women, but not in men.

body BMD were associated with an increased risk of
incident OA and increases in JSN grade and osteophytes in
knees without OA. Progression was not significantly rela-
ted to BMD in knees with existing OA [25]. In data from
the Baltimore Longitudinal Study of Aging, higher BMD at
the lumbar spine but not at the femoral neck was associated
with an increased risk for developing incident radiographic
knee OA after adjusting for age, gender, and body mass
index, supporting a role for higher bone mass in the
development of radiographic knee OA [9]. An analysis
from the Framingham Study showed different results.
Women who gained BMD were at increased risk of inci-
dent knee OA compared to those who lost BMD over the
follow-up period, but they were at a significantly decreased
risk for progressive knee OA [11].
In summary of the above studies, high BMD, particu-
larly that in the lumbar spine rather than the hip, is related
to a high incidence of knee OA. However, high BMD does
not seem to accelerate the progression of already-estab-
lished knee OA. Low BMD at the lumbar spine is associ-
ated with a lower incidence of knee OA.
Underlying mechanisms for higher BMD affecting
OA incidences
The mechanism underlying the increased BMD and risk of
developing OA has been the focus of numerous investi-
gations since the potential role of subchondral bone in the
initiation and progression of OA was first proposed [26].
These studies can be summarized and reviewed from
molecular, genetic and biomechanical aspects.
Molecular events related to OA and OP
Higher concentrations of insulin-like growth factors (IGFs)
and transforming growth factor (TGF)-b have been iden-
tified in bone matrix from the iliac crest in patients with
hand OA [27]. Elevated serum IGF-I levels were found in
women with bilateral knee OA or OA of DIP joint, but no
associations between serum IGF-I and OA at other sites
[28]. A 4-fold increase in TGF-b in OA subchondral bone
from femoral head was also reported [29]. Functional and
phenotypic differences were also found in osteoblasts from

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OA bone in comparison with those derived from normal
bone including increased IGF-I, alkaline phosphatase
(ALP), and osteocalcin (OC) expression [30]. While these
results, if confirmed, provide a certain insight to the rela-
tionship between increased BMD and OA pathogenesis,
others studies failed to find any difference in the level of
growth factors in knee OA [31, 32] .
A dynamic balance between bone formation and bone
resorption is tuned by a complex network of calciotropic
hormones. When calciotropic hormones, parathyroid hor-
mone (PTH), 25(OH) and 1,25(OH)2 vitamin D were
investigated in OA patients versus normal patients, no sig-
nificant differences were found [33]. Bone remodeling and
bone loss are controlled by a balance between osteoproteg-
erin (OPG), and osteoclast differentiation factor (ODF).
Higher levels of OPG and higher ODF/OPG ratio have been
reported from serum [34], bone specimen [35] and osteoblast
[36, 37] from OP patients compared with those from OA
patients. Increased Wnt activity was also found in bone
samples and osteoblast cultures from patients with OA in
comparison with osteoporotic hip fractures [38].
Several other studies compared various bone markers
and matrix proteins from OA and OP patients. Greater
expression of Runx-2, osterix and OC were demonstrated
from bones of OA patients than in gender-matched OP
patients undergoing hip arthroplasty [39]. Lower levels of
OC and osteopontin were found in femoral heads of oste-
oporotic hip fracture compared with those from hip OA
[40]. Higher leptin was shown in the serum of postmeno-
pausal women with OA, whereas lower serum OC and
higher urine deoxypyridinoline cross-links were noted in
those with OP [34]. OC and ALP were also higher in
mesenchymal stem cells from the proximal femur of OA
donors than those from OP donors [37]. Early adhesion-
mediated events such as cell adhesion, attachment and
focal adhesion kinase (FAK) signaling was decreased in
OP osteoblasts compared with OA osteoblasts [41].
A recent study compared the expression of the genes of
apoptosis and osteogenesis in 6 femoral heads with OP and
6 with OA. The OP group had low expression of these
genes, suggesting that osteoporotic bone had a lower
capacity for differentiation and osteoblastic activity as well
as a lower rate of apoptosis than osteoarthritic bone [42].
Genetic markers and risk of OA and OP
The existence of a common genetic factor in both OA and OP
has been recognized from family studies. The risk of hip
fracture was reduced in the mothers of patients with hip OA
[43]. Peak bone mass in the hip is increased in daughters of
women with OA [44]. Twins with hip osteophytes were
found to have a higher femoral neck BMD than their co-twins
who were not unaffected with OA [45].
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Several studies have attempted to identify genetic
markers for OA and OP, mostly using single nucleotide
polymorphisms (SNPs). Morrison et al. [46] first demon-
strated an association between DNA polymorphisms in the
vitamin D receptor (VDR) gene and bone density. Fol-
lowing studies found significant associations between OA
and polymorphic markers in the COL2A1, COL1A1, VDR,
estrogen receptor (ER)-a, TGF-b1, and IGF-I, and between
OP and DNA polymorphisms in these genes [47, 48]. DNA
polymorphisms of the same set of genes (VDR, ERa,
COL1A1) were studied in postmenopausal women with
OA of the hip [49] and OP with hip fracture [50], showing
no difference between the affected patients and the control.
On the other hand, from investigation of TGF-b1 genotype
in Japanese women, C-allele was much more prevalent in
spinal osteophytosis while its frequency is much lower in
OP patients [51]. In addition, specific alleles of a novel
gene, klotho, were associated with bone density and
spondylosis in Japanese postmenopausal women [52].
Material and mechanical properties
Thickening of subchondral bone precedes cartilage fibril-
lation in spontaneous OA animal models [53, 54]. There is
an increased bone activity, as seen by radiographic studies
and MR imaging before cartilage degradation [55].
Another important piece of evidence for the role of stiff
subchondral bone is a high risk of OA (27 %) found in
osteopetrosis [56, 57].
Subchondral bone is hypomineralized despite increased
BMD in OA as verified in both cancellous and subchondral
cortical bone [58, 59]. This is explained by the local
increased bone turnover rate in OA, resulting in younger,
less highly mineralized bone and greater amounts of oste-
oid [60, 61]. However, BMD is apparently higher in OA
because of the increased number of trabeculae and reduced
separation between trabeculae [58, 62]. Histomorphometric
and micro-CT studies have reported significant difference
in bone volume, bone volume/tissue volume, trabecular
thickness between the femoral heads obtained from hip OA
and osteoporotic fractures [63–66]. Biomechanical differ-
ences are also identified in subchondral cancellous bone
from postmenopausal women with hip OA and osteopo-
rotic fracture. Both the ultimate stress and the elastic
modulus were significantly higher in OA patients [67].
Conclusions
The relationship between OA and OP is very elusive.
While most cross-sectional studies have reported an
inverse relationship between OA and OP, the series of
longitudinal studies have reported a more complicated
J Bone Miner Metab (2014) 32:101–109
relationship. OA is associated with more bone formation as
seen in subchondral sclerosis, and the tendency to accu-
mulate bone in the subchondral area can increase the onset
of OA. In contrast, once OA is established, the pain and
reduced mobility reduce bone mass, particularly in the
affected limb. A greater amount of bone mass already
accumulated in OA-affected patients leads to higher mea-
sured BMD in these patients even after the progression of
OA compared with subjects without OA. This explains the
correlation between the presence of OA and higher BMD
in cross-sectional studies. However, pain and loss of joint
function from OA can result in muscle loss and postural
instability, which subsequently increase fracture risk. In
this sense, the relationship between OA and OP should be
considered a very complex and circumstantial association,
and each patient affected with one condition must be
evaluated individually for the future occurrence of the
other disease on an individual basis.
Acknowledgments This study was supported by a grant from the
National Research Foundation of Korea (2009-0092196).
Conflict of interest No potential conflicts of interest were
disclosed.
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