DISH Disease: Symptoms, Diagnosis and What It Means

By: Dr. Kamran Aghayev

Last updated November 4, 2026 · Spotted a mistake? Tell us

DISH, or diffuse idiopathic skeletal hyperostosis, is a condition in which bone forms where ligaments and tendons attach to the skeleton. It is also called Forestier’s disease. In the spine, the extra bone usually grows along the front and side of the vertebrae and can join several of them into one stiff segment. Some people have no symptoms and learn about DISH from a scan taken for another reason; others have pain, stiffness or, less often, a complication that needs treatment.^{1, 2}

If you already know you have DISH and want to know what can help, read about DISH treatment options and when surgery may help.

In this guide: What DISH is · Symptoms · Diagnosis and scans · Where it affects the spine · DISH or ankylosing spondylitis? · Causes · Outlook and treatment

What is DISH?

The places where ligaments, tendons and joint capsules attach to bone are called entheses. In DISH, calcium is deposited at these sites and bone gradually forms there. Along the spine this mostly follows the anterior longitudinal ligament, the band that runs down the front of the vertebral bodies.

An outgrowth of bone is called an osteophyte or bone spur. Some DISH osteophytes stay separate; others grow toward each other and form bridges between neighboring vertebrae, which stiffens that part of the spine. The amount of bone on a scan does not predict symptoms well. Extensive bridging may cause little trouble, while a smaller growth next to an important structure may need careful assessment.^{1, 2}

“Idiopathic” means the cause is not known. “Diffuse” and “skeletal” reflect the fact that DISH can affect attachment sites around the pelvis and limbs as well as the spine. DISH becomes more common with age and is more frequent in men. Reported frequencies vary widely between populations and with the criteria used.²

Is Forestier’s disease the same as DISH?

Yes. Jacques Forestier and Jaume Rotés-Querol described the condition in 1950 as “senile ankylosing hyperostosis of the spine”, and Forestier’s disease remains a common name for it. Ankylosing hyperostosis is an older term with the same meaning. The name DISH came later, once it was clear that the condition can involve the skeleton beyond the spine.^{3, 4}

Symptoms and when to seek help

Symptoms depend on where the bone forms and what else is happening in the spine. The most common are:

stiffness, often in the mid-back, that makes turning and bending harder;
pain over the spine or just beside it;
pain at tendon attachments outside the spine, such as the heel or elbow.

DISH develops over many years, so stiffness is easy to put down to age. Research comparing people with DISH, people with axial spondyloarthritis and healthy volunteers found that the DISH group had clearly reduced spinal mobility and physical performance, of a similar degree to the spondyloarthritis group. DISH is not only a finding on a scan.⁵

Some people develop a complication from bone pressing on a nearby structure or from a coexisting spinal problem. These need their own assessment, because other conditions can cause the same symptoms:

Symptom	What may need checking
Difficulty swallowing, a change in voice, or noisy breathing	Large neck osteophytes near the throat and esophagus, among other causes
Weakness, numbness, clumsiness or unsteady walking	Pressure on the spinal cord or nerves, often from coexisting degeneration
New neck or back pain after a fall or minor injury	A fracture through the stiff segment

Sources: clinical review,² cervical review,⁶ fracture guidance.⁷

Get urgent care for new severe pain after an injury, new weakness or loss of walking, or sudden difficulty breathing or swallowing. Tell the team that you have DISH: a fracture in a fused spine can be unstable and easy to miss on plain X-rays.⁷

How serious is DISH?

The same diagnosis covers very different situations. A person whose DISH was noticed on a chest scan has different needs from someone with swallowing obstruction, spinal cord compression or a fracture. Most people live with stiffness and some pain rather than a complication. When symptoms do appear, a good assessment asks whether they match a structural finding, and whether something else is responsible.²

How DISH is diagnosed

Diagnosis combines your history, an examination and imaging. The imaging pattern is usually what establishes DISH. The history and examination show whether it explains the symptoms, or whether degeneration, a joint problem or another condition is involved.

The classic Resnick–Niwayama criteria describe flowing bone along the front and side of at least four neighboring vertebrae, with relatively preserved disc spaces, and without the sacroiliac joint erosion or fusion and facet joint fusion typical of ankylosing spondylitis.¹ These criteria remain the reference point, but they have limits. CT studies show that some people with DISH do have partial bridging or fusion around the sacroiliac joints, so no single feature settles the diagnosis in every case. Newer criteria based on CT have also been proposed.^{8, 9}

A scan can show DISH clearly and still not explain a particular pain. That link has to come from the history and examination.

X-ray

An X-ray of the spine can show flowing bone along the front of the vertebrae, bridges between them and the overall alignment. It is often where DISH is first noticed. Because it compresses a three-dimensional spine into a flat image, some levels and the relationship between bone and nearby structures can be hard to see.

CT scan

CT builds the spine slice by slice. The slices can be viewed in any plane or combined into a three-dimensional image, which shows the exact size, shape and position of each osteophyte. This matters when a clinician needs to know how close bone lies to the esophagus, a nerve or a blood vessel.

Three-dimensional CT reconstruction of the thoracic spine with dense, flowing osteophytes along its right front side — Three-dimensional CT reconstruction of the thoracic spine in DISH. Dense, flowing osteophytes run along the right front side of the vertebrae.

MRI and other tests

MRI shows the spinal cord, nerves and soft tissues. It is used when there are neurological symptoms or a possible fracture, rather than to diagnose DISH itself. Swallowing difficulty usually calls for a swallowing study alongside imaging.^{6, 7}

Where DISH affects the spine

Illustration of the spine with the cervical and thoracic regions highlighted — DISH most often affects the thoracic (mid-back) and cervical (neck) regions highlighted here. The lumbar spine and areas outside the spine can be involved too.

Thoracic spine

The thoracic spine is the most common site, especially its middle and lower levels. In the classic pattern, osteophytes grow on the right side of the vertebrae, while the descending aorta runs down the left. A CT study of 101 patients traced how this changes. From T5 to T10 the osteophytes were mainly on the right. Lower down, as the aorta moves toward the middle of the spine, they formed on both sides, and those lying beside the aorta were flatter or curved around it. The study describes this relationship; it does not prove how the aorta influences bone formation.¹⁰

Axial CT of a lower thoracic vertebra with an osteophyte on the patient's right and the aorta circled on the left — Lower thoracic level, seen in cross-section from below. The white arrow marks an osteophyte on the patient’s right; the circle marks the aorta on the left. As in all such images, the patient’s right appears on the left of the picture.

Axial CT at the thoracolumbar junction with osteophytes on both sides of the vertebra and the aorta in front — At the junction of the thoracic and lumbar spine, the aorta (dashed circle) sits closer to the middle and osteophytes (white arrows) form on both sides. The yellow curve marks the area beside the aorta, which is free of bone growth in this patient.

As neighboring osteophytes grow, some join to form a continuous bridge with a flowing, wave-like outline. Others stay separate, with a pointed “bird beak” shape. The bridges stiffen the thoracic spine, which already moves less than the neck or lower back.

Side-view CT of the thoracic spine showing joined, wave-like osteophytes and separate beak-shaped ones — Thoracic osteophytes in DISH. Some have joined into a wave-like bridge; others remain separate, with a bird-beak shape.

Nerves run close to these osteophytes. Sympathetic nerve branches, which help regulate internal organs, cross the front and side of the thoracic vertebrae. A large cadaver study found osteophytes pressing on them in about two-thirds of the spines examined. One published patient’s mid-back and upper-abdominal pain improved after an osteophyte pressing on such a nerve was removed. This anatomy explains why some thoracic symptoms are worth investigating. It does not show that DISH commonly causes heart or digestive problems.^{11, 12} The treatment guide explains the assessment of thoracic osteophytes and the limits of the evidence.

Why a stiff segment matters

When several vertebrae fuse, the levels above and below take more of the movement and load. DISH often coexists with disc degeneration and spinal stenosis there, which can compress nerves or the spinal cord and need treatment in their own right. A long fused segment also acts as a lever, so a fall that would bruise a flexible spine can fracture a stiff one.^{2, 13}

Cervical spine

In the neck, osteophytes grow on the front of the vertebrae and are usually more symmetrical than in the thoracic spine. Neck pain, stiffness and reduced movement are the usual symptoms. Large osteophytes can press on the esophagus, causing difficulty swallowing, and occasionally on the airway.⁶ As in the thoracic spine, the levels next to a fused segment can degenerate and compress the spinal cord or nerve roots, causing arm or leg numbness, weakness or unsteady walking.

Lumbar spine

DISH reaches the lower back less often. Osteophytes here tend to form on both sides, and DISH frequently coexists with lumbar stenosis.¹⁰ Recognizing it before an operation for stenosis is useful: DISH extending into the lumbar spine has been linked to a higher risk of needing another operation.¹⁴

Outside the spine

DISH can affect ligament and tendon attachments around the pelvis, the heel, the knee, the elbow and the hand. These changes often cause few symptoms, though some attachment sites become painful. Bone growth in the hands can look like osteoarthritis, and the two conditions often occur together.⁴

DISH or ankylosing spondylitis?

Both conditions can fuse the spine. Ankylosing spondylitis belongs to the axial spondyloarthritis group: it is an inflammatory disease that usually starts in younger adults, typically with inflammatory back pain and sacroiliac joint involvement. DISH is usually diagnosed later in life and is generally classed as non-inflammatory, although research into the biology of bone formation in DISH continues. Imaging patterns differ on average but overlap.^{2, 8}

	Typical DISH	Typical ankylosing spondylitis
Usual age at diagnosis	Older adults	Younger adults
Nature of the condition	Generally non-inflammatory bone formation at attachment sites	Inflammatory disease of the spine and sacroiliac joints
Bridging on the front of the spine	Thick, flowing, “candle-wax” bone	Thinner, smooth bridging
Sacroiliac joints	Bridging around the joints is common; partial fusion occurs in some people	Complete fusion is more characteristic
Facet joints	Fusion uncommon	Fusion more common

Sources: comparative CT study of 111 people with DISH and 27 with ankylosing spondylitis;⁸ clinical review.² In that study, 63% of the DISH patients had partial or complete sacroiliac fusion, and 11% had the smooth bridging more typical of ankylosing spondylitis. Clinicians therefore weigh the whole picture, not one feature.

Diagram comparing a healthy spine with an inflamed and fused spine in ankylosing spondylitis — Ankylosing spondylitis: inflammation and fusion of the spinal joints, shown beside a healthy spine. The diagram does not show DISH.

DISH or disc degeneration?

Disc degeneration is very common with age and also produces osteophytes. In degeneration, the disc space narrows, and the osteophytes sit at the affected discs, most often in the neck and lower back. In classic DISH, the disc spaces are relatively preserved and the bone flows continuously over several levels, most often in the thoracic spine.¹

The two often coexist, and DISH may add to the strain on the levels next to a fused segment. Finding DISH on a scan does not rule out a separate degenerative cause of pain or nerve compression.²

Causes and associated conditions

The cause of DISH is not fully understood. Age and male sex are the clearest risk factors. DISH is also associated with obesity, type 2 diabetes, high blood pressure and abnormal blood fats. It is not yet known whether these conditions contribute to DISH or whether they share underlying causes.²

Research is looking at genes and at the chemistry that normally stops soft tissue from mineralizing. One line of work concerns ENPP1, an enzyme that makes pyrophosphate, a natural brake on mineralization. Changes in the ENPP1 gene have been found in a small number of people with DISH and early-onset osteoporosis.¹⁵ This does not mean DISH is usually inherited, and there is no routine genetic test for it. What this research may mean for treatment is covered in the treatment guide under Is there a new treatment for DISH?

Outlook and treatment

How quickly does DISH progress?

DISH develops slowly, usually over years. For many people, stiffness and pain stay manageable for a long time; for others, movement becomes increasingly limited. Changes on scans and symptoms do not necessarily move together, and there is no reliable way to predict one person’s course. Follow-up should depend on your symptoms and any complications, not on a fixed schedule.²

Does DISH affect life expectancy?

DISH on its own does not give a personal life-expectancy estimate. What matters more are its complications, especially fractures after falls, and the health conditions associated with it. People with DISH have, on average, more coronary artery disease; that is an association, and it is a reason to look after heart health rather than evidence that the bone growth itself damages the heart.^{7, 16}

Is DISH a disability?

DISH can limit movement and daily activities considerably in some people. Whether it counts as a disability for benefits or work depends on the documented limitations and the rules of the country or scheme. The diagnosis alone does not settle it.

How is DISH treated?

Treatment targets the problem DISH is causing. Stiffness and pain are usually managed with exercise, physiotherapy and suitable pain relief. Surgery is considered for specific problems: neck osteophytes that block swallowing, pressure on the spinal cord or nerves, an unstable fracture, and, in selected cases, thoracic osteophytes pressing on nearby structures. A DISH diagnosis on its own is not a reason for an operation. The DISH treatment guide explains each option, what surgery can and cannot do, and how assessment works.

If symptoms are limiting your life, the diagnosis is unclear, or a scan suggests a complication, a specialist opinion can help. You can request an online consultation with Dr. Kamran Aghayev or book an appointment in Istanbul, and read about Dr. Aghayev’s background and publications.