15.2 Geriatric Musculoskeletal and Bone Health

Quick Answer: In older adults, treat multi-joint OA with progressive strength, load management, and function—not passive-only care. For osteoporosis, promote safe loading and falls prevention while avoiding high-risk flexion/rotation after suspected vertebral fragility fracture. Integrate polypharmacy into mobility reasoning and rebuild after fracture within orthopaedic orders.

Musculoskeletal presentations dominate many older-adult physiotherapy caseloads and appear frequently in APC Written Assessment cases. Geriatric MSK reasoning is not ‘adult MSK with grey hair added’. Multi-joint osteoarthritis, reduced physiological reserve, osteoporosis, polypharmacy, fear of falling, and slower tissue recovery reshape assessment priorities, loading decisions, and goal timelines. This section focuses on osteoarthritis across joints, bone health and osteoporosis loading safety, vertebral fracture suspicion, medication effects on mobility, and post-fracture rehabilitation caution.

Multi-Joint Osteoarthritis in Older Adults

Osteoarthritis (OA) commonly affects knees, hips, hands, and the lumbar and cervical spine. Many older adults have radiographic OA at multiple sites; symptoms and function—not imaging alone—drive physiotherapy decisions. Typical features include activity-related pain, morning stiffness that is not prolonged like inflammatory disease patterns, crepitus, reduced range, and reduced activity tolerance. Night pain, unexplained weight loss, fever, progressive neurological deficit, or trauma history require red-flag thinking beyond ‘simple OA’.

Assessment priorities:

• Which joints most limit sit-to-stand, gait, stairs, and self-care today?
• Strength (quadriceps, gluteals, trunk), joint range, and pain behaviour with load
• Falls risk interaction (pain-avoidance limp, reduced step length, fear)
• Obesity, diabetes, cardiovascular disease, and deconditioning as co-drivers
• Psychosocial factors: pain catastrophising, low self-efficacy, social isolation

Intervention principles for multi-joint OA:

1. Education that movement is safe and beneficial when dosed well; OA is not ‘bone on bone means stop forever’ for most people.
2. Progressive resistance training for periarticular and global lower-limb musculature—often the highest-yield physio tool for function.
3. Aerobic activity within joint tolerance (walking programs, cycling, aquatic exercise when available and preferred).
4. Load management and pacing—activity–rest cycling, footwear, and temporary aid use during flares.
5. Manual therapy as an adjunct when it facilitates exercise adherence, not as a sole long-term strategy.
6. Weight management liaison and medical review for analgesia/injection/surgical pathways when indicated—within interprofessional scope.

When multiple joints hurt, design programs that deliver shared benefits: sit-to-stand practice loads quads and functional capacity for both knee OA and falls prevention; hip abductor strength helps hip OA stability and gait; trunk endurance supports spinal symptoms and upright posture. Avoid endless passive modalities without progressive loading.

Australian community and private-practice cases often mix OA with ‘I fell because the knee gave way’—assess true giving-way, pain inhibition, and falls risk together rather than treating only local joint stiffness.

Osteoporosis and Loading Safety

Osteoporosis is low bone mass and microarchitectural deterioration with increased fracture risk. Physiotherapists contribute through safe physical activity, falls risk reduction (because most fractures follow falls), posture and strength training, and secondary prevention after fracture. You do not diagnose osteoporosis from a single session, but you do reason from known diagnoses, DEXA history if available, prior fragility fractures, long-term corticosteroid use, early menopause history, and very low body weight as risk context.

Loading principles (entry-level):

• Encourage progressive resistance training and weight-bearing activity appropriate to the person’s fracture risk and medical advice—bone and muscle respond to progressive mechanical stimulus.
• Avoid high-risk movements when vertebral fracture risk is high or recent: end-range loaded spinal flexion with rotation (e.g., sit-up style loading, heavy toe-touch under load), sudden high-impact if contraindicated, and unsupervised maximal lifts with poor form.
• Promote thoracic extension awareness, scapular stabilisers, hip hinge patterns, and safe sit-to-stand mechanics.
• Coordinate with medical/osteoporosis pathways (calcium/vitamin D, anti-resorptive therapy)—outside physio prescribing, but education on adherence and activity myths is in scope.

People with osteoporosis are not ‘too fragile for exercise’. The greater risk for many is inactivity plus falls. The art is selecting stimulus that builds capacity without creating fracture-risk movements.

Vertebral Fragility Fracture: When to Suspect

Suspect vertebral compression/fragility fracture when an older adult develops sudden severe thoracic or lumbar pain after a minor event (cough, bend, lift light object), or progressive height loss and kyphosis with acute-on-chronic pain. Pain may be localised, worse with flexion and transitions, and may radiate around the trunk. Red flags for alternative serious pathology (malignancy, infection, cauda equina) still apply: night pain with systemic features, progressive neurology, saddle anaesthesia, bladder/bowel change, unexplained weight loss, fever, history of cancer.

Physiotherapy behaviour if suspicion is high:

• Do not force aggressive flexion-based exercise or high-load spinal mobilisation as first-line ‘treatment’ before medical assessment/imaging as indicated.
• Prioritise pain control strategies within scope, log-roll/bed mobility education, safe transfers, and walking as tolerated once medically appropriate.
• Teach hip-hinge patterns and avoid end-range loaded flexion early.
• Progress thoracic extension, gentle activation, and lower-limb strength when pain and medical status allow.
• Collaborate with medical team on bracing only if prescribed; bracing is not a universal physio default.

Delayed recognition of vertebral fracture can lead to inappropriate loading and prolonged disability. Over-medicalising every back ache as fracture is also unhelpful—use history, age/risk, mechanism, and neurological screen.

Polypharmacy and Mobility

Older adults commonly take multiple medications. Physiotherapy-relevant effects include:

• Sedatives/hypnotics/antipsychotics: slowed reaction time, drowsiness, increased falls
• Antihypertensives and diuretics: orthostatic hypotension, dizziness on standing, urgency-related rushing to toilet
• Opioids and strong analgesics: sedation, constipation-related discomfort, reduced dual-task attention
• Anticholinergics: confusion risk, blurred vision, dry mouth—cognitive and safety impact
• Corticosteroids (long-term): myopathy, osteoporosis risk

Practical physio responses: check postural blood pressure when orthostasis is plausible; schedule sessions away from peak sedation when possible; rise in stages; communicate mobility change after new meds to the team; do not unilaterally stop medications, but do flag concerns. A ‘worsening balance’ vignette after a new night sedative is a classic APC-style reasoning trap if you only treat ankle proprioception and ignore the drug.

Post-Fracture Rehabilitation Caution

Common older-adult fractures: distal radius, proximal humerus, vertebrae, pelvis, and proximal femur (hip). Post-fracture rehab principles:

1. Know the orthopaedic plan—weight-bearing status, ROM limits, surgical construct, DVT prophylaxis context, and review timeline.
2. Protect healing while preventing avoidable deconditioning of uninvolved systems.
3. Restore safe transfers and gait with appropriate aids early, especially after hip fracture—delayed mobilisation increases medical complications.
4. Rebuild strength, balance, and confidence progressively; hip fracture survivors have high subsequent falls/fracture risk.
5. Address bone health and falls as secondary prevention, not as an afterthought once the cast is off.
6. Watch for complications: infection, DVT/PE red flags, neurovascular change, uncontrolled pain, delirium post-hospitalisation, and pressure injuries from reduced mobility.

Hip fracture pathways in Australian settings often involve orthogeriatric care, early physio, and discharge planning to home with support, rehabilitation, or residential care depending on premorbid function and carer resources. Goals should be person-centred: return to prior residence and meaningful activities when possible, or maximise dignity and safe mobility within a new care setting.

Upper-limb fractures can devastate independence (feeding, dressing, gait aid use). If the dominant arm is injured and the person previously used a stick, reassess gait aid choice and falls risk immediately.

Integrating MSK with Frailty and Falls

An 79-year-old with bilateral knee OA, osteoporosis, and two falls needs a program that strengthens, challenges balance safely, respects spinal loading, and accounts for meds—not three disconnected protocols. If knee pain limits walking, improve strength and consider aquatic options or graded walking, while still addressing sit-to-stand power. If vertebral fracture is acute, shift emphasis to safe mobility and lower-limb strength before advanced spinal loading.

APC Exam Lens

Expect choices between unsafe spinal flexion loading in suspected vertebral fracture, passive-only OA care without progressive strength, ignoring sedative contribution to falls, and over-aggressive post-hip-fracture exercise against weight-bearing orders. The competent answer respects healing constraints, builds function with progressive load, and integrates bone health and falls prevention as one clinical story.

Closing Exam Anchor

Multi-joint OA needs progressive strength and shared functional goals; osteoporosis needs safe loading plus falls prevention; sudden post-minor-load spinal pain means fracture suspicion first; meds change mobility; post-fracture rehab follows orders while fighting deconditioning.