Dear DOCTOR Owen:

A recent bone density test did not show osteoporosis, but I have been complaining of bone pain. My doctors said that I have “fibromyalgia” and that I must be under stress. I certainly cannot sleep because of the pain, and nothing seems to help. I had gastric bypass for obesity more than a decade ago, but have had no problems from this other than occasional diarrhea. Could the obesity surgery be related?

Bare Bones

Dear “BB”:

Be sure your doctor checks you for osteomalacia. In children, this is also known as rickets; in grown-ups, it is sometimes known as “adult rickets.” This condition is caused by a deficiency in Vitamin D. Osteomalacia is more common than most physicians realize and should always be considered in patients with unexplained pain—especially the kind you describe.

The pain of osteomalacia is typically difficult to localize. All the bones are tender—especially the long ones in the legs and arms—because of inflammation of the nerve fibers imbedded in the lining of the bone (called the periosteum). When Vitamin D is deficient, the lining of the bone becomes activated, causing more bone to be absorbed and replaced at an accelerated rate. This is similar to the “growing pains” experienced by adolescents who are going through the growth spurt.

 In diagnosed cases of osteomalacia, 94% of patients complain of pain; 94% complain of muscle weakness; 88% complain of bone tenderness with pressure on touch; 24% complain of a waddling gait and muscle cramps; and, there is a higher incidence of fracture than expected for age—even in bones that test “normal” on the DEXA bone density test.

It is very difficult these days to become deficient in Vitamin D because it is frequently supplemented in foods. Most vitamin preparations also contain Vitamin D. The most common cause of osteomalacia with apparently normal nutrition is bowel disorders, as in your case. Your bowel was bypassed, which can cause malabsorption of nutrients, including vitamins. The most common bowel disorder is celiac sprue, also known as gluten sensitivity. Gluten is present in wheat. Celiac disease may be present in as much as 5% of the population and is often confused with irritable bowel syndrome.

Researchers at the Henry Ford Health System reporting in The American Journal of Medicine, Vol.108, 296–300, looked at the causes of osteomalacia in patients they have seen with stomach surgery (for ulcers), gastric stapling, intestinal bypass, intestinal removal, removal of the pancreas and pancreatitis, and celiac disease. Most of these patients had their symptoms for more than two years. The average time for symptoms to develop from diagnosing the intestinal problem was 14 years! It is easy to see how physicians could overlook this condition, as these changes develop slowly over time. Additionally, these patients get passed on from physician to physician and often get labeled as chronic complainers or malingerers. The “label” itself, like fibromyalgia, can mislead subsequent physicians.

Simple blood tests should help the doctor make the diagnosis. The bone density test you’ve had reveals bone loss, but that deficiency is not due to osteoporosis. Unfortunately, though, doctors often mistakenly treat patients for osteoporosis based on test results such as yours. Indeed, people who take this test may have osteomalacia and osteoporosis. However, the osteomalacia “accidentally” gets better when Vitamin D and calcium are prescribed for the osteoporosis. Osteoporosis does not usually cause generalized bone pain or tenderness.

Doctors in the “good ole days” would probably have made the diagnosis of osteomalacia very quickly. Rickets was common prior to 1940, as were nutritional diseases. Today, osteomalacia and rickets are relatively rare, so some of us doctors who are “youngsters” (age 40 or so) may not have seen many cases.

If you have unexplained bone pain, ask your doctor to check for osteomalacia or adult rickets.