Why muscle and bone matter
Muscle and bone decide whether you live independently in your 80s and 90s, and losing them is painless until a fracture.
- 1 in 4 adults 65 and older falls each year (CDC)
- 43,000+ fall deaths among older US adults in 2024 (CDC)
- 22% average one-year mortality after hip fracture (Downey 2019)
- 50% of white women over 50 will have an osteoporotic fracture (BHOF 2022)
Falls are the leading cause of injury death in adults 65 and older, and they cause 88% of hip fracture emergency visits and hospitalizations. After a hip fracture, the risk of death is 5 to 8 times higher in the first 3 months than in peers, and only 40–60% of survivors regain their previous mobility.
Sarcopenia
What it is
Sarcopenia is the age-related loss of muscle mass and strength. In the widely used European definition (EWGSOP2), low muscle strength makes sarcopenia probable; low muscle quantity or quality confirms it; and poor physical performance makes it severe. Depending on the definition, sarcopenia affects 10–27% of people 60 and older.
Strength falls faster than mass: in 1,880 adults in their 70s, leg strength declined 2.6–4.1% a year, about three times faster than leg lean mass, and gaining muscle did not prevent it. Strength and power, not just size, are the targets.
Measuring sarcopenia
Measure muscle before it is low. The optimal plan tracks strength and balance every few months from 30 and lean mass every one to two years, and treats any decline as a reason to train harder; the diagnostic cut-offs below flag sarcopenia only once it has arrived.
| Test | How often | Aim for | Low (EWGSOP2) |
|---|---|---|---|
| Grip strength (hand dynamometer) | Every 3 months from 30 | At or above average for your age and sex; each 5 kg lower meant 16% higher mortality | Under 27 kg (60 lb) men, 16 kg (35 lb) women |
| Five chair rises, arms crossed | Every 3 months from 30 | Well under 15 seconds, and no slower than last year | More than 15 seconds |
| One-leg stand, eyes open | Every 3 months from 30 | At least 10 seconds | Cannot hold 10 seconds |
| DEXA appendicular lean mass index (ALMI) | Every 1–2 years | Top quarter for your age and sex | Under 7.0 kg/m² men, 5.5 kg/m² women |
| Usual walking speed | Every year after 65 | Each 0.1 m/s faster is better | 0.8 m/s (1.8 mph) or slower |
Cut-offs are from EWGSOP2. Gait speed alone is powerful: in 34,485 adults 65 and older, every 0.1 m/s faster was linked to 12% lower mortality. The self-tests are part of the fitness testing routine in Exercise.
Get a whole-body DEXA in your 30s or 40s for a baseline of lean mass, fat, and visceral fat, and repeat it every one to two years, or every 6 to 12 months during major weight loss or on a GLP-1 drug. Prevention-focused clinicians such as Peter Attia rank patients on appendicular lean mass index (arm and leg lean mass divided by height squared) against national reference values for age and sex. Older adults in the top quarter of muscle mass had about 20% lower mortality than those in the bottom quarter (observational). Use the same machine each time; no guideline recommends these scans for healthy adults. Weak Radiation and prices are in DEXA.
Preventing and treating it
International guidelines strongly recommend resistance training for sarcopenia Strong, conditionally recommend a protein-rich diet, and make no recommendation for vitamin D or hormones. No drug is approved for it. How to train is covered in Exercise.
- Protein Moderate. Aim for about 1.6 g per kg of body weight a day while training, since extra protein adds to gains with no further benefit beyond about 1.6 g, and about 0.4 g/kg at each meal after 65. Targets and sources are in Protein.
- Creatine Moderate. In a meta-analysis of 357 older adults, creatine plus resistance training increased lean mass and chest and leg press strength more than training alone. The usual dose in trials is 3–5 g a day of creatine monohydrate, which sports nutrition experts judge safe in healthy people; see Creatine.
Osteoporosis
Osteoporosis is thinning of bone that leads to fragility fractures, breaks from a fall from standing height or less. In 2017–2018, 12.6% of US adults 50 and older had osteoporosis (19.6% of women and 4.4% of men), and another 43.1% had low bone mass. Among white US adults over 50, about half of women and one in five men will have an osteoporotic fracture.
Spine fractures are often silent and show up as lost height or a stooped back; bone specialists suggest spine imaging if you have lost 1.5 inches (4 cm) or more from your peak height. Risk factors include age, female sex, early menopause, a parent who broke a hip, smoking, heavy drinking, low body weight, long-term steroid use, and rheumatoid arthritis.
Bone density testing
Who should be screened
Optimal: a baseline hip-and-spine DEXA in your 40s, for both sexes. Women should get it before or early in the menopause transition, when bone loss speeds up and hormone therapy decisions are made (see Planning ahead); men by 50 at the latest. Go sooner with risk factors such as long-term steroids, early menopause, an eating disorder, celiac disease, low testosterone, or a fracture from a minor fall. A baseline finds the minority with unexpectedly low bone while there is time to build it. Weak
Bone specialists do not advise routine scans for healthy premenopausal women or young men, which is why the baseline waits for the 40s. A body-composition scan's total bone density is no substitute, since it can hide low hip or spine density.
Guideline minimum:
| Group | Recommendation | Source |
|---|---|---|
| Women 65 and older | DEXA screening (grade B) | USPSTF 2025 |
| Postmenopausal women under 65 at increased risk | Use a risk tool first, then DEXA if risk is elevated (grade B) | USPSTF 2025 |
| Men | Evidence insufficient (I statement), not a recommendation against | USPSTF 2025 |
| Men 70 and older; men 50–69 with risk factors | Test | BHOF 2022 |
| Anyone 50+ with a fragility fracture | Evaluate; a hip or spine fracture warrants treatment regardless of density | BHOF 2022 |
The January 2025 USPSTF update is current as of October 2026. It suggests risk tools such as FRAX before scanning younger women and sets no repeat interval.
How often to repeat
Bone changes slowly, and a scan can only detect changes larger than its own error, about 3–6% at the hip and 2–4% at the spine. Repeat by result, not by calendar.
| Your result | Next bone density scan |
|---|---|
| Normal, before 65 | In 3 to 5 years, and early in menopause for women |
| 65 or older | Every 2 years, as BHOF advises and Medicare covers; less often is reasonable if normal |
| T-score −2.0 to −2.5 | Every year; in women 67 and older, about 10% reached osteoporosis within about a year |
| Starting or changing a bone drug | 1 to 2 years after, then as your clinician advises |
Yearly scans with normal results add cost without information: it took about 15 years for 10% of older women with normal density to reach osteoporosis.
Reading your T-score and Z-score
A DEXA scan of the hip and lower spine reports two numbers. The T-score compares your bone density with a healthy young adult; the Z-score compares it with people your own age and sex.
| Result | Meaning |
|---|---|
| T-score −1.0 or higher | Normal |
| T-score between −1.0 and −2.5 | Low bone mass (osteopenia) |
| T-score −2.5 or lower | Osteoporosis |
| Z-score −2.0 or lower | Below the expected range for age; used for premenopausal women and men under 50 |
Definitions follow the BHOF clinician's guide.
FRAX and treatment thresholds
FRAX estimates your 10-year probability of a hip fracture and of any major osteoporotic fracture from age, sex, weight, risk factors, and (optionally) hip bone density. In the US, treatment is generally recommended if you have a T-score of −2.5 or lower, a hip or spine fragility fracture, or low bone mass with a 10-year FRAX risk of at least 3% for hip or 20% for major fracture.
These thresholds are also the optimal plan for most people, with three refinements:
- Women 65 and older with low bone mass should discuss zoledronic acid even below the FRAX thresholds. In a six-year trial of 2,000 such women with a median 10-year hip fracture risk of 2.3%, infusions every 18 months prevented one fracture for every 15 women treated. Strong
- Treat to a target, such as a T-score above −2.5 and no new fractures, as bone specialists endorse, starting with a stronger drug when the target is far off.
- Low density before menopause or 50 calls for a search for a cause, such as vitamin D deficiency, celiac disease, an overactive thyroid or parathyroid, low sex hormones, or steroids (BHOF), plus heavy training, before drugs.
Building and keeping bone
Bone responds to high strains applied quickly, the rationale for heavy lifting and impact training. In the LIFTMOR trial, 101 postmenopausal women with low bone mass did 8 months of supervised twice-weekly heavy lifting (five sets of five above 85% of their maximum) plus impact work. Spine density rose 2.9% versus a 1.2% loss in a low-intensity home program, with one minor adverse event Moderate. In men, the same approach raised spine density 4.1%. These trials were too small to measure fractures.
With osteoporosis, an international consensus recommends resistance and balance training rather than aerobic exercise alone; after a spine fracture, start with a physical therapist.
- Calcium, mostly from food. Aim for about 1,000 mg a day for men 50–70 and 1,200 mg for women 51 and older and men 71 and older, from dairy, fortified plant milks, canned fish with bones, calcium-set tofu, and greens, supplementing only to close a gap. More is not better: in the Women's Health Initiative, calcium plus vitamin D supplements raised kidney stones by 17% without significantly reducing hip fractures. The USPSTF recommends against low-dose supplements for preventing fractures in healthy postmenopausal women (an update is in progress as of October 2026).
- Vitamin D for deficiency, not as insurance Negative. In 25,871 adults not selected for deficiency, 2,000 IU a day for about 5 years did not reduce fractures, and a yearly megadose of 500,000 IU increased falls and fractures in older women. Correcting a true deficiency still matters; see Supplements and Blood tests and biomarkers.
- Avoid the bone thieves. Smoking, alcohol, and very low body weight weaken bone (see Avoiding harm); when losing weight, keep lifting and keep protein up.
Osteoporosis medications
Once fracture risk is high, medication is the main way to cut it. The American College of Physicians recommends bisphosphonates first for postmenopausal women (strong recommendation) and men (conditional), denosumab second, and romosozumab or teriparatide followed by a bisphosphonate for women at very high risk.
| Drug | How it's given | Trial results | Key cautions |
|---|---|---|---|
| Bisphosphonates (alendronate, risedronate, zoledronic acid) | Weekly pill or yearly infusion | Zoledronic acid cut spine fractures 70% and hip 41% over 3 years | Rare atypical thigh fractures and jaw osteonecrosis; review for a drug holiday after 5 years oral or 3 years IV |
| Denosumab | Injection every 6 months | Cut spine fractures 68% and hip 40% | Rebound fractures if stopped or delayed; severe low calcium in advanced kidney disease |
| Romosozumab | Monthly injection for 12 doses | 48% fewer new spine fractures than alendronate | Boxed warning for heart attack and stroke; not within a year of either |
| Teriparatide, abaloparatide | Daily self-injection | Teriparatide cut spine fractures about 65% | Usually limited to about 2 years; follow with another drug |
| Menopausal hormone therapy | Pill, patch, or gel | Estrogen plus progestin: fractures in 8.6% versus 11.1% on placebo | Best started under 60 or within 10 years of menopause; depends on symptoms and other risks |
Fear of rare side effects keeps many people off these drugs. In 196,129 women, 3 years of bisphosphonates in white women prevented 149 hip fractures for every 2 atypical femur fractures (91 versus 8 in Asian women, who have higher risk).
For women under 60 or within 10 years of menopause, The Menopause Society finds hormone therapy a reasonable way to prevent bone loss, alongside strength training; see Planning ahead. Guideline minimum: the USPSTF recommends against hormone therapy for preventing chronic conditions (grade D, 2022).
Preventing falls
Older adult falls lead to about 4.5 million emergency visits and 1.4 million hospitalizations a year. Most have several causes at once: weak legs, poor balance, medications, vision, feet, and home hazards.
Optimal: start long before 65. Balance declines quickly after the mid-50s, and among 1,702 adults aged 51 to 75, those who could not stand on one leg for 10 seconds had 1.84 times the risk of death over about seven years. Practice balance for a few minutes most days from midlife (see Balance training), test your one-leg stand regularly, and from 65 train balance and strength on at least three days a week (WHO). Moderate Guideline minimum: the USPSTF and CDC start at 65.
Screening: CDC STEADI
The CDC's STEADI program asks clinicians to screen adults 65 and older every year with three questions: have you fallen in the past year, do you feel unsteady, and do you worry about falling? A yes leads to simple tests and a targeted plan.
| Test | How | At increased risk if |
|---|---|---|
| Timed Up and Go | Stand up, walk 10 ft (3 m), turn, walk back, sit | 12 seconds or longer |
| 30-second chair stand | Count full stands in 30 seconds, arms crossed | Below age norms, such as under 12 for men or 10 for women at 70–74 |
| 4-stage balance test | Feet together, semi-tandem, heel-to-toe, one leg; 10 seconds each | Cannot hold heel-to-toe for 10 seconds |
What works
- Exercise with balance work Strong. Across 108 trials with 23,407 older adults, exercise reduced the rate of falls by 23%, mainly through balance and functional exercises; the USPSTF recommends it for adults 65 and older at increased risk (grade B, 2024). The Otago home program cut falls by 32%, and therapeutic tai chi by 58% compared with stretching.
- Home safety for people at risk Strong. Home hazard reduction, often with an occupational therapist, cut falls by 38% in higher-risk people but did nothing in unselected people. Typical fixes: grab bars, stair rails, night lights, removing loose rugs, and non-slip strips.
- Vision Moderate. First-eye cataract surgery reduced falls by 34% in 306 women over 70, and single-vision distance glasses for walking outdoors cut falls by 40% in active older people, since multifocals blur the ground. See Eyes, ears, teeth, and skin.
- Medication review. Sedatives, sleeping pills, some antidepressants, antipsychotics, opioids, and blood pressure drugs that cause dizziness on standing raise fall risk at any age. Ask your clinician or pharmacist to check your list against the Beers Criteria and to measure your blood pressure lying and standing.
- Feet and shoes. Weak toe muscles and disabling foot pain independently predicted falls in older adults. Choose shoes that fit, with good traction and low heels.
Fall-detection watches summon help but do not prevent falls; see Wearables.
Joints and back pain
Osteoarthritis
Osteoarthritis (OA) is the gradual breakdown of joint cartilage and underlying bone, most often in knees, hips, and hands. The American College of Rheumatology strongly recommends exercise, weight loss if you are overweight, self-management programs, tai chi, and a cane for knee and hip OA Strong, with anti-inflammatory pain relievers and steroid injections when needed. It strongly recommends against glucosamine, chondroitin, platelet-rich plasma, and stem-cell injections. A BMJ guideline panel recommends against arthroscopic "clean-out" surgery for degenerative knee disease.
Each pound lost removes about four pounds of knee load per step, benefits begin at about 5% of body weight, and in the IDEA trial diet plus exercise produced 11% weight loss and less pain than either alone. In the manufacturer-funded STEP 9 trial of 407 adults with obesity and knee OA, semaglutide produced 13.7% weight loss versus 3.2% and cut pain scores by 41.7 versus 27.5 points on a 100-point scale; see Metabolic health.
Before joint replacement
Joint replacement works well for advanced arthritis, but structured non-surgical care is worth trying first. In a trial of 100 people eligible for knee replacement, surgery plus exercise gave more pain relief than exercise alone but more serious complications (24 versus 6), and three-quarters of the non-surgical group still had not had surgery a year later. Exercise before surgery ("prehab") modestly improved function after hip and knee replacement Moderate.
Back pain
Low back pain affected 619 million people worldwide in 2020, and most acute episodes improve on their own. The American College of Physicians recommends heat, massage, acupuncture, or spinal manipulation first for acute pain, and exercise, yoga, tai chi, mindfulness, or cognitive behavioral therapy for chronic pain, with opioids only as a last resort. Staying active beats bed rest, modestly Moderate. Walking helps prevent the next episode: in the 2024 WalkBack trial of 701 adults, a progressive walking program with physical therapist coaching extended the median time to a recurrence from 112 to 208 days.
Imaging rarely helps: disc degeneration shows up in 37% of pain-free 20-year-olds and 96% of pain-free 80-year-olds. The American College of Physicians advises imaging only for severe or progressive nerve problems or signs of a serious condition.
Posture myths
Feet and footwear
Your feet are part of your balance system, and supportive shoes may let their small muscles weaken. Minimalist or "barefoot" shoes have a wide toe box, a thin flexible sole, and no heel lift. In a trial of 57 runners, 8 weeks of walking in them increased foot muscle size and strength as much as a foot-exercise program, and 6 months of daily wear increased foot strength by 57% in another study Moderate. Whether this prevents falls is untested.
Running in them is riskier: in a 12-week trial of 99 runners, minimalist shoes brought more injuries and shin and calf pain, and after a 10-week transition, 10 of 19 runners showed new bone stress on MRI.