At a glance
What it is
Defective mineralisation of newly formed bone matrix (osteoid), causing bones to become soft and prone to deformity or fracture. Distinguished from osteoporosis (reduced bone quantity) by the primary defect in bone quality — osteoid is laid down but not properly mineralised. Most often results from vitamin D deficiency, with contributing roles from calcium deficiency, phosphate wasting, and certain medications.
Symptoms
Diffuse, aching bone pain — most prominent in the lower back, pelvis, hips, legs, and ribs. Pain may worsen at night or with weight-bearing and is rarely fully relieved by rest. Proximal muscle weakness produces a waddling gait and difficulty rising from chairs. Fragility fractures, particularly of the ribs and long bones, in more advanced cases. Early osteomalacia may be asymptomatic and detected incidentally on imaging.
Approach
Identify and treat the underlying cause: vitamin D and calcium supplementation is curative in deficiency-related cases (weeks to months). Treat malabsorption syndromes (coeliac disease, post-bariatric surgery), renal osteodystrophy, and drug-induced forms specifically. Pain management, physiotherapy, and fall prevention during recovery. Monitor bone density and mineral levels during treatment.
What osteomalacia is
Bone is a composite material — an organic matrix (primarily collagen) onto which mineral crystals (mainly hydroxyapatite, composed of calcium and phosphate) are deposited. Osteomalacia occurs when this mineralisation process fails: newly formed osteoid accumulates but is not properly hardened, leaving bones soft, painful, and mechanically weak.
**Causes**
*Vitamin D deficiency* — the most common cause worldwide. Vitamin D is required for intestinal calcium absorption; without it, calcium and phosphate levels fall and mineralisation is impaired. Deficiency results from: - Insufficient sunlight exposure (latitude, indoor lifestyle, cultural dress) - Inadequate dietary intake - Malabsorption: coeliac disease, Crohn's disease, post-gastrectomy or bariatric surgery
*Renal and hepatic causes:* Activation of vitamin D requires hydroxylation steps in the liver and kidney. Chronic kidney disease and liver disease impair these steps.
*Phosphate wasting:* Rare hereditary conditions (X-linked hypophosphataemia) and tumour-induced osteomalacia cause renal phosphate wasting despite normal vitamin D.
*Medications:* Anticonvulsants (phenytoin, phenobarbital) accelerate vitamin D catabolism; prolonged use causes osteomalacia.
**Distinguishing osteomalacia from osteoporosis**
Both conditions increase fracture risk, but the mechanisms differ. Osteoporosis is a reduction in bone mass (the scaffold is normal but there is less of it). Osteomalacia is a mineralisation defect (there is sufficient scaffold but it is not hardened). The two conditions can coexist, particularly in older adults with multiple nutritional deficiencies.
**Diagnosis**
- Blood tests: low 25-hydroxyvitamin D, low calcium, low phosphate, elevated alkaline phosphatase (bone isoform), elevated parathyroid hormone (secondary hyperparathyroidism) - X-ray: pseudofractures (Looser's zones) — radiolucent bands perpendicular to the cortex, most common at the medial femoral neck, pubic rami, ribs, and ulna - Bone densitometry underestimates severity (DEXA signal reflects mineralised bone — unmineralised osteoid is invisible)
**Treatment**
*Nutritional replacement:* Oral vitamin D (cholecalciferol or ergocalciferol) with calcium supplementation for several weeks to months corrects deficiency-related osteomalacia. Maintenance supplementation is usually required long-term.
*Cause-specific treatment:* Malabsorption requires high-dose or intramuscular vitamin D; renal osteodystrophy requires activated vitamin D (calcitriol); phosphate wasting disorders require phosphate supplementation ± calcitriol.
*Pain management and rehabilitation:* Bone pain can be severe before mineralisation is restored. Exercise, physiotherapy, and pain interventions support function and recovery during the treatment period.
Treatment options at Alimran Medical Center
Neuromodulation
Injection therapies
- Botox® injections
- Prolotherapy
- Ozone injection
- Trigger point injections
- Epidural steroid injections
Advanced therapies
Physiotherapy & rehabilitation
- Electrical stimulation
- Short and long wave therapy
- Laser therapy
- Ultrasound therapy
- Exercise and bone-loading rehabilitation
- SpineMED® system
- Sigma
Book a consultation
The secretary schedules first appointments during clinic hours; please have prior imaging, operative notes and a current medication list available at the time of the call.
This page provides general information about osteomalacia and is not a substitute for individual medical assessment. If your symptoms are severe or worsening, contact a clinician promptly.