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Why Everyone Should Get a Bone Scan
- Alex Winnicki
- 5 days ago
- 8 min read
Out of sight, out of mind...
In many professional teams and sports medicine settings, it’s commonplace for healthcare practitioners—such as physicians, dietitians, and exercise physiologists—to conduct regular assessments to monitor athlete health and wellbeing. Outside of professional sport and collegiate athletics, however, health and wellness testing can run the gamut from non-existent to tracking the wrong metrics, or simply overlooking key risk factors altogether.
Athletes are a unique subset of the population. Blood work, body composition, and bone health all look different in athletes compared to the general population, and they are further shaped by the specific demands of each sport. In this blog, I’m going to make the case that frequent and consistent medical testing is not only good practice for athletes, but a medical necessity—especially when it comes to one of the most commonly overlooked aspects of health: bone.
The issue isn’t that athletes don’t care about their bones; it’s that most of us don’t think twice about them until something goes wrong. When it comes to bone, what’s out of sight is truly out of mind. This challenge is compounded by a general lack of awareness around how and when bone health should be assessed. This is a major problem since poor bone health is both common and largely irreversible. Cyclists, for example, have roughly a seven-fold higher rate of osteoporosis compared to runners, although runners (and swimmers) are also at elevated risk.
Click below to learn more about why this happens, how we can reduce risk, and to understand what bone health actually means.
What Determines Bone Health?
What Determines Bone Health?
When assessing bone health, there are two primary factors to consider: how much bone you have, and how that bone is built. In other words, do your bones contain enough mineral and protein to be strong, and is their internal structure organized in a way that allows them to withstand load and stress?
Bones are made up primarily of calcium, collagen, and water, along with smaller amounts of other minerals. Over the lifespan—particularly during growth and development (under 18 years of age)—the foods you eat, including protein and minerals, are incorporated into bone tissue and contribute to long-term bone strength.
Bone tissue exists in two main forms:
Compact bone (cortical bone): the hard, dense outer layer that provides most of the bone’s strength and resistance to bending
Cancellous bone (trabecular bone): the lighter, spongy inner network that helps distribute force and absorb impact
Together, the shape, geometry, and organization of these tissues make up what is known as bone architecture. Bone architecture describes not just whether bone is present, but how it is arranged—an important determinant of how well bone tolerates stress and resists fracture.
Bone mineral content within this structure is commonly measured as bone mineral density (BMD) or bone mineral content (BMC). BMD reflects how much mineral—primarily calcium and phosphorus—has been deposited into the bone matrix. In general, higher BMD is associated with stiffer, stronger bones and a lower fracture risk.
However, BMD alone does not fully capture bone health. Differences in collagen protein quality, structure, and overall bone organization—collectively referred to as bone architecture—help explain why two individuals with similar BMD values may have very different fracture or injury risk.
Both matter. You need enough bone, and you need bone that is built well.
A simple way to think about it is:
Bone Strength = Bone Quantity (BMD) × Bone Quality (Architecture)
Overview
BMD measures how much mineral (mainly calcium and phosphate) is packed into a given area of bone. It is measured by DXA and reported as T-scores and Z-scores.
Higher BMD generally means stiffer, stronger bones.
Low BMD is strongly associated with fracture risk at the population level.
Bone architecture includes the shape and arrangement of bone matrix and the thickness of various bone components. It is equally as important as BMD and is commonly assessed using Trabecular Bone Score (TBS).
Bone can lose architecture before it loses density.
Limitations
BMD tells you quantity, not quality. Two people can have the same BMD and very different fracture risk.
There is no single definitive metric that predicts bone or stress injury.
Even high BMD and strong bone architecture do not guarantee protection from fracture. Given enough stress, injury can still occur.
How Can I Get My Bone Health Tested?
How Can I Get My Bone Health Tested?
The most common way to assess bone health is through a DXA (or DEXA) scan, which stands for Dual-Energy X-ray Absorptiometry. A DXA scan uses a very low-dose X-ray—far less radiation than a standard diagnostic X-ray—to produce either a total-body image or images of specific skeletal regions. DEXA Scan availability can vary by state, and insurance or HSA can often cover charges for at risk populations. Second Arrow Nutrition' s office is located within DexaFit Greenville, and no insurance approval or referral is needed to self schedule a test and have a dietitian review the results with you.
Testing is is affordable for many at <$180, find out more here.
DXA uses two different X-ray energy levels that are absorbed differently by bone, lean tissue, and fat tissue. These differences in absorption allow for accurate calculation of:
Bone mineral density (BMD)
Bone mineral content (BMC)
Fat mass and lean mass (absolute and percentage)
Accuracy for body composition is typically within ±1%.
From a single scan, you can obtain:
Total and regional Bone Density
Bone health comparisons (Z-Score or T-Score)
Fat mass percentage
Muscle mass amount
Visceral fat mass (fat around the organs that causes inflammation)
Trabecular Bone Score (TBS), which provides additional insight into bone microarchitecture and quality
DXA results also allow your bone values to be compared to reference populations using:
T-scores: Compare your BMD to that of a young, healthy adult. Typically used in adults 50 years and older.
Z-scores: Compare your BMD to individuals of the same age, sex, and ethnicity. Used in individuals under 50, including most athletes.
What Do the Numbers Mean?
*In the general population:
A score of −1.0 is often classified as osteopenia
A score of −2.5 or lower is classified as osteoporosis
A score above +1.0 indicates stronger-than-average bone
A score above +2.0 indicates very strong / dense bone.
*Athlete results should be reviewed differently compared to a normal, non-athletic population.
Special Considerations for Athletes
Special Considerations for Athletes
DEXA results must be interpreted in context—especially for athletes. Due to mechanical loading and repeated stress, athletes are expected to have higher bone mineral density than non-athletes. In fact, athletes in high-impact sports often demonstrate 5–30% higher BMD than sedentary individuals. That said, it is uncommon to see endurance athletes with above-average bone density.
Factors contributing to lower BMD in endurance athletes include leaner body composition, lower muscle mass compared to contact or team-sport athletes, high metabolic demand, and participation in low-impact sports such as cycling, rowing, and swimming. This extends to runners as well, as the forces experienced during steady-state running are far lower than those seen in sports involving jumping, cutting, lateral movement, and rapid changes in speed.
Because of these sport-specific demands placed on bone, the standards used to define “normal” bone health shift in athletic populations. The American College of Sports Medicine (ACSM) and the International Olympic Committee (IOC) define normal bone health in athletes as a Z-score ≥ −1.0, rather than ≥ −2.0 as used in the general population.
This is a helpful starting point, but it’s not perfect. Different sports impact bone differently, and there is currently no universally agreed-upon sport-specific Z-score or T-score. The concept of athlete-specific reference ranges is still evolving and not yet widely implemented.
In sports it's generally believe that:
A T-score or Z-score < −1.0 in athletes warrants further evaluation for secondary risk factors (eating disorders, RED-S, hormonal issues, medical complications, or medication use)
For high-impact sport athletes (football, rugby, etc.), the bar may be even higher, with Z-scores below 0.0 serving as an early warning sign
BMD should be paired with TBS to better understand fracture risk
Bone health assessment should be routine, not delayed until the commonly recommended age 65 y/o or 50+ with risk factors.
These thresholds are intentionally conservative, as early bone compromise in athletes often precedes stress injuries and fractures.
Being proactive with assessing and understanding your bone health, as an athlete or non-athlete, can drastically reduce the chance of devolving injury or osteoporosis.
How Often Should I Assess My Bone Health?
How Often Should I Assess My Bone Health?
How often someone should undergo a DXA scan depends on their goals, medical history, prior results, and the standards followed by the testing facility. There is also a lack of consensus across medical organizations. For example, the National Osteoporosis Foundation recommends monitoring every 1–2 years after initiating therapy, with follow-up every two years thereafter. Some organizations recommend screening intervals as long as 5–10 years. These guidelines are largely designed for individuals already diagnosed with osteoporosis and often mirror pharmaceutical treatment timelines.
In the mid-2010s, a U.S. task force reviewed osteoporosis screening practices and concluded that screening more frequently than every two years did not significantly improve fracture prediction. They also cited evidence suggesting that intervals up to eight years added little predictive value for fracture risk.
The issue with this approach, is that most people would prefer not to develop osteoporosis in the first place. Waiting 5–10 years between screenings increases the likelihood of gaps in care due to insurance changes, provider transitions, missed appointments, or simply forgetting to follow up. Perhaps more importantly, it sends the wrong message about how important bone health actually is.
When testing is spaced out over many years, patients are unlikely to perceive bone health as urgent, actionable, or modifiable. More frequent testing reinforces that bone health matters, that there are meaningful lifestyle interventions beyond medication, and that this is something worth monitoring. DXA also provides valuable information beyond bone alone, including changes in body composition, adipose tissue distribution, and other anthropometrics that offer insight into metabolic health—far beyond what BMI or body weight alone can provide. This can help patients understand long-term trends and allows healthcare providers more opportunity to educate, inform, and act to best help the patient.
Bone adapts slowly, and short-term changes often fall within the margin of error of the machine. While DXA is the gold standard, no test is perfect. From a preventive medicine standpoint, the goal is not to over-interpret single data points, but to identify trends early and match them with lifestyle interventions.
Understanding your fracture risk is important for several reasons. After a fracture, two things commonly happen:
In younger individuals, reduced movement and training can lead to loss of muscle and bone stimulus, increasing future injury risk. At a minimum this also takes you out of sport and inhibits progression.
In older populations, similar declines occur, but with much more drastic consequences. There is a significantly reduce ability to recover fully from trauma, surgery, fractures, and breaks with age and a higher toll placed on the body from injury.
For individuals over 65, mortality risk (risk of death from all causes) increases by as much as 5% within 12 months after a fracture, and up to 25% at one year, depending on fracture location.
Breaking a femur or hip can mean immobility, reduced strength, decreased social connection, and overall reduction in quality of life, all of which contribute to a rapid decline in health and wellbeing. This is why the risk of death increases in such a stark manner with bone injury and aging.
Initial DXA screening can occur as early as the teenage years when assessing bone health. This does not mean that from puberty on testing is needed annually, and considerations around bone assessment, body composition and how this data is communicated should always be handled on a case-by-case basis with a registered dietitian and physician. If you're curious about testing or what your results mean feel free to reach out to secondarrownutrition@gmail.com or contact / apply for coaching using the button below.
For most people, annual DXA screening is appropriate, though frequency may increase for athletes tracking seasonal changes or extend for those with stable bone health and low risk factors. Every case is different. The real question is: what will you do with the data?
Contact us today to discuss more or get a plan together to help you maintain or improve your bone health.
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