Sarcopenia and Osteoporotic Fractures

  • Itamar Levinger
  • Steven Phu
  • Gustavo DuqueEmail author
Assessment of bone health
Part of the following topical collections:
  1. Assessment of bone health


Low bone mass is strongly associated with increased fracture risk. However, the importance of low muscle mass and strength—known as sarcopenia—as a risk factor for osteoporotic fractures remains overlooked and sometimes controversial. Bone and muscle are closely interconnected not only anatomically, but also physically, chemically and metabolically. Indeed, a significant proportion of individuals with sarcopenia also suffer from osteopenia/osteoporosis suggesting a link between the two tissues. This subgroup of osteosarcopenic individuals are at higher risk of falls and fractures. Therefore, we suggest that lean mass and muscle strength/function assessments should be an integral part in any fracture prevention protocol. A combination of lean mass quantification by dual-energy X-ray absorptiometry scan and assessment of muscle function by gait velocity could not only confirm the diagnosis of sarcopenia but also optimize any fracture prevention interventions. In the absence of specific therapies for sarcopenia, simple interventions such as resistance (weight-bearing) training, protein supplements and appropriate levels of vitamin D have a dual effect on bone and muscle and could have a significant effect on reducing falls and fractures in this high-risk population.


Osteoporosis Sarcopenia Osteosarcopenia Fractures Falls Elderly 



A/Prof Levinger was supported by a Future Leader Fellowship (ID: 100040) from the National Heart Foundation of Australia.

Compliance with Ethical Standards

Conflict of interest

Itamar Levinger, Steven Phu and Gustavo Duque have no conflict of interest to disclose.

Human and animal rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. All procedures performed in studies involving animals were in accordance with the ethical standards of the institution or practice at which the studies were conducted.


  1. 1.
    Hughes VA, Frontera WR, Roubenoff R, Evans WJ, Singh MA. Longitudinal changes in body composition in older men and women: role of body weight change and physical activity. Am J Clin Nutr. 2002;76:473–81.PubMedGoogle Scholar
  2. 2.
    Lauretani F, Russo CR, Bandinelli S, Bartali B, Cavazzini C, Di Iorio A, Corsi AM, Rantanen T, Guralnik JM, Ferrucci L. Age-associated changes in skeletal muscles and their effect on mobility: an operational diagnosis of sarcopenia. J Appl Physiol. 2003;95:1851–60.CrossRefPubMedGoogle Scholar
  3. 3.
    Bevier WC, Wiswell RA, Pyka G, Kozak KC, Newhall KM, Marcus R. Relationship of body composition, muscle strength, and aerobic capacity to bone mineral density in older men and women. J Bone Miner Res. 1989;4:421–32.CrossRefPubMedGoogle Scholar
  4. 4.
    Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, Martin FC, Michel JP, Rolland Y, Schneider SM, Topinková E, Vandewoude M, Zamboni M, European Working Group on Sarcopenia in Older People. Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010;39:412–23.PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Cederholm T, Cruz-Jentoft AJ, Maggi S. Sarcopenia and fragility fractures. Eur J Phys Rehabil Med. 2013;49:111–7.PubMedGoogle Scholar
  6. 6.
    Kawao N, Kaji H. Interactions between muscle tissues and bone metabolism. J Cell Biochem. 2015;116:687–95.CrossRefPubMedGoogle Scholar
  7. 7.
    Cederholm T, Morley JE. Sarcopenia: the new definitions. Curr Opin Clin Nutr Metab Care. 2015;18:1–4.CrossRefPubMedGoogle Scholar
  8. 8.
    McLean RR, Kiel DP. Developing consensus criteria for sarcopenia: an update. J Bone Miner Res. 2015;30:588–92.CrossRefPubMedGoogle Scholar
  9. 9.
    Fragala MS, Dam TT, Barber V, Judge JO, Studenski SA, Cawthon PM, McLean RR, Harris TB, Ferrucci L, Guralnik JM, Kiel DP, Kritchevsky SB, Shardell MD, Vassileva MT, Kenny AM. Strength and function response to clinical interventions of older women categorized by weakness and low lean mass using classifications from the Foundation for the National Institute of Health sarcopenia project. J Gerontol A Biol Sci Med Sci. 2015;70:202–9.PubMedCentralCrossRefPubMedGoogle Scholar
  10. 10.
    Drey M, Sieber CC, Bertsch T, Bauer JM, Schmidmaier R. FiAT intervention group. Osteosarcopenia is more than sarcopenia and osteopenia alone. Aging Clin Exp Res. 2015.Google Scholar
  11. 11.
    Huo YR, Suriyaarachchi P, Gomez F, Curcio CL, Boersma D, Muir SW, Montero-Odasso M, Gunawardene P, Demontiero O, Duque G. Phenotype of osteosarcopenia in older individuals with a history of falling. J Am Med Dir Assoc. 2015;16:290–5.CrossRefPubMedGoogle Scholar
  12. 12.
    Isaacson J, Brotto M. Physiology of mechanotransduction: How do muscle and bone “talk” to one another? Clin Rev Bone Miner Metab. 2014;12:77–85.PubMedCentralCrossRefPubMedGoogle Scholar
  13. 13.
    Landi F, Calvani R, Cesari M, Tosato M, Martone AM, Bernabei R, Onder G, Marzetti E. Sarcopenia as the biological substrate of physical frailty. Clin Geriatr Med. 2015;31:367–74.CrossRefPubMedGoogle Scholar
  14. 14.
    Hagerman FC, Walsh SJ, Staron RS, Hikida RS, Gilders RM, Murray TF, Toma K, Ragg KE. Effects of high-intensity resistance training on untrained older men I Strength, cardiovascular, and metabolic responses. Biol Sci. 2000;55A:B336–46.Google Scholar
  15. 15.
    Mishra SK, Misra V. Muscle sarcopenia: an overview. Acta Myol. 2003;22:43–7.PubMedGoogle Scholar
  16. 16.
    Fletcher GF, Balady G, Amsterdam EA, Chaitman B, Eckel R, Fleg JL, Froelicher VF, Leon AS, Pina IL, Rodney R, Simons-Morton DG, Williams MA, Bazzarre T. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation. 2001;104:1694–740.CrossRefPubMedGoogle Scholar
  17. 17.
    Oxenham H, Sharpe N. Cardiovascular aging and heart failure. Eur J Heart Fail. 2003;5:427–34.CrossRefPubMedGoogle Scholar
  18. 18.
    Proctor DN, Joyner MJ. Skeletal muscle mass and the reduction of VO2 max in trained older subjects. J Appl Physiol. 1997;82:1411–5.PubMedGoogle Scholar
  19. 19.
    Frost HM. On our age-related bone loss: insights from a new paradigm. J Bone Miner Res. 1997;12:1539–46.CrossRefPubMedGoogle Scholar
  20. 20.
    Caldow MK, Cameron-Smith D, Levinger P, McKenna MJ, Levinger I. Inflammatory markers in skeletal muscle of older adults. Eur J Appl Physiol. 2013;113:509–17.CrossRefPubMedGoogle Scholar
  21. 21.
    Levinger I, Levinger P, Trenerry MK, Feller JA, Bartlett JR, Bergman N, McKenna MJ, Cameron-Smith D. Increased inflammatory cytokine expression in the vastus lateralis of patients with knee osteoarthritis. Arthritis Rheum. 2011;63:1343–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Pawelec G, Goldeck D, Derhovanessian E. Inflammation, ageing and chronic disease. Curr Opin Immunol. 2014;29:23–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Goodman CA, Hornberger TA, Robling AG. Bone and skeletal muscle: key players in mechanotransduction and potential overlapping mechanisms. Bone. 2015;80:24–36.CrossRefPubMedGoogle Scholar
  24. 24.
    Bloomfield AS. Changes in musculoskeletal structure and function with prolonged bed rest. Med Sci Sports Exerc. 1997;29:197–206.CrossRefPubMedGoogle Scholar
  25. 25.
    Convertino VA, Bloomfield AS, Greenleaf JE. An overview of the issues: physical effects of bed rest and restricted physical activity. Med Sci Sports Exerc. 1997;29:187–90.CrossRefPubMedGoogle Scholar
  26. 26.
    LeBlanc A, Schneider V, Shackelford L, West S, Oganov V, Bakulin A, Voronin L. Bone mineral and lean tissue loss after long duration space flight. J Musculoskelet Neuronal Interact. 2000;1:157–60.PubMedGoogle Scholar
  27. 27.
    Leblanc AD, Schneider VS, Evans HJ, Engelbretson DA, Krebs JM. Bone mineral loss and recovery after 17 weeks of bed rest. J Bone Miner Res. 1990;5:843–50.CrossRefPubMedGoogle Scholar
  28. 28.
    LeBlanc AD, Schneider VS, Evans HJ, Pientok C, Rowe R, Spector E. Regional changes in muscle mass following 17 weeks of bed rest. J Appl Physiol. 1992;73:2172–8.PubMedGoogle Scholar
  29. 29.
    Layne JE, Nelson ME. The effects of progressive resistance training on bone density: a review. Med Sci Sports Exerc. 1999;31:25–30.CrossRefPubMedGoogle Scholar
  30. 30.
    Wallace BA, Cumming RG. Systematic review of randomized trials of the effect of exercise on bone mass in pre- and postmenopausal women. Calcif Tissue Int. 2000;67:10–8.CrossRefPubMedGoogle Scholar
  31. 31.
    McCartney N, Hicks AL, Martin J, Webber CE. Long-term resistance training in the elderly: effects on dynamic strength, exercise capacity, muscle, and bone. J Gerontol A Biol Sci Med Sci. 1995;50:B97–104.CrossRefPubMedGoogle Scholar
  32. 32.
    Confavreux CB, Levine RL, Karsenty G. A paradigm of integrative physiology, the crosstalk between bone and energy metabolisms. Mol Cell Endocrinol. 2009;310:21–9.PubMedCentralCrossRefPubMedGoogle Scholar
  33. 33.
    Lee NK, Sowa H, Hinoi E, Ferron M, Ahn JD, Confavreux C, Dacquin R, Mee PJ, McKee MD, Jung DY, Zhang Z, Kim JK, Mauvais-Jarvis F, Ducy P, Karsenty G. Endocrine regulation of energy metabolism by the skeleton. Cell. 2007;130:456–69.PubMedCentralCrossRefPubMedGoogle Scholar
  34. 34.
    Levinger I, Jerums G, Stepto NK, Parker L, Serpiello FR, McConell GK, Anderson M, Hare DL, Byrnes E, Ebeling PR, Seeman E. The effect of acute exercise on undercarboxylated osteocalcin and insulin sensitivity in obese men. J Bone Miner Res. 2014;29:2571–6.CrossRefPubMedGoogle Scholar
  35. 35.
    Pedersen BK, Febbraio MA. Muscle as an endocrine organ: focus on muscle-derived interleukin-6. Physiol Rev. 2008;88:1379–406.CrossRefPubMedGoogle Scholar
  36. 36.
    Booth SL, Centi A, Smith SR, Gundberg C. The role of osteocalcin in human glucose metabolism: marker or mediator? Nat Rev Endocrinol. 2013;9:43–55.PubMedCentralCrossRefPubMedGoogle Scholar
  37. 37.
    Fernandez-Real JM, Izquierdo M, Ortega F, Gorostiaga E, Gomez-Ambrosi J, Moreno-Navarrete JM, Fruhbeck G, Martinez C, Idoate F, Salvador J, Forga L, Ricart W, Ibanez J. The relationship of serum osteocalcin concentration to insulin secretion, sensitivity, and disposal with hypocaloric diet and resistance training. J Clin Endocrinol Metab. 2009;94:237–45.CrossRefPubMedGoogle Scholar
  38. 38.
    Kanazawa I, Yamaguchi T, Yamamoto M, Yamauchi M, Kurioka S, Yano S, Sugimoto T. Serum osteocalcin level is associated with glucose metabolism and atherosclerosis parameters in type 2 diabetes mellitus. J Clin Endocrinol Metab. 2009;94:45–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Kanazawa I, Yamaguchi T, Yamauchi M, Yamamoto M, Kurioka S, Yano S, Sugimoto T. Serum undercarboxylated osteocalcin was inversely associated with plasma glucose level and fat mass in type 2 diabetes mellitus. Osteoporos Int. 2011;22:187–94.CrossRefPubMedGoogle Scholar
  40. 40.
    Levinger I, Scott D, Nicholson GC, Stuart AL, Duque G, McCorquodale T, Herrmann M, Ebeling PR, Sanders KM. Undercarboxylated osteocalcin, muscle strength and indices of bone health in older women. Bone. 2014;64:8–12.CrossRefPubMedGoogle Scholar
  41. 41.
    Levinger I, Lin X, Zhang X, Brennan-Speranza TC, Volpato B, Hayes A, Jerums G, Seeman E, McConell G. The effects of muscle contraction and recombinant osteocalcin on insulin sensitivity ex vivo. Osteoporos Int. 2015.Google Scholar
  42. 42.
    Tsuka S, Aonuma F, Higashi S, Ohsumi T, Nagano K, Mizokami A, Kawakubo-Yasukochi T, Masaki C, Hosokawa R, Hirata M, Takeuchi H. Promotion of insulin-induced glucose uptake in C2C12 myotubes by osteocalcin. Biochem Biophys Res Commun. 2015;459:437–42.CrossRefPubMedGoogle Scholar
  43. 43.
    Cartee GD, Wojtaszewski JF. Role of Akt substrate of 160 kDa in insulin-stimulated and contraction-stimulated glucose transport. Appl Physiol Nutr Metab. 2007;32:557–66.CrossRefPubMedGoogle Scholar
  44. 44.
    Krook A, Wallberg-Henriksson H, Zierath JR. Sending the signal: molecular mechanisms regulating glucose uptake. Med Sci Sports Exerc. 2004;36:1212–7.CrossRefPubMedGoogle Scholar
  45. 45.
    Baumgartner RN, Koehler KM, Gallagher D, Romero L, Heymsfield SB, Ross RR, Garry PJ, Lindeman RD. Epidemiology of sarcopenia among the elderly in New Mexico. Am J Epidemiol. 1998;147:755–63.CrossRefPubMedGoogle Scholar
  46. 46.
    Kull M, Kallikorm R, Lember M. Impact of a new sarco-osteopenia definition on health-related quality of life in a population-based cohort in Northern Europe. J Clin Densitom. 2012;15:32–8.CrossRefPubMedGoogle Scholar
  47. 47.
    Binkley N, Buehring B. Beyond FRAX: it’s time to consider “sarco-osteopenia”. J Clin Densitom. 2009;12:413–6.CrossRefPubMedGoogle Scholar
  48. 48.
    Huo YR, Suriyaarachchi P, Gomez F, Curcio CL, Boersma D, Gunawardene P, Demontiero O, Duque G. Comprehensive nutritional status in sarco-osteoporotic older fallers. J Nutr Health Aging. 2015;19:474–80.CrossRefPubMedGoogle Scholar
  49. 49.
    Ormsbee MJ, Prado CM, Ilich JZ, Purcell S, Siervo M, Folsom A, Panton L. Osteosarcopenic obesity: the role of bone, muscle and fat on health. J Cachexia Sarcopenia Muscle. 2014;5:183–92.PubMedCentralCrossRefPubMedGoogle Scholar
  50. 50.
    Stenholm S, Harris T, Rantanen T, et al. Sarcopenic obesity—definition, etiology and consequences. Curr Opin Clin Nutr Metab Care. 2008;11:693–700.PubMedCentralCrossRefPubMedGoogle Scholar
  51. 51.
    Ryu M, Jo J, Lee Y, Chung YS, Kim KM, Baek WC. Association of physical activity with sarcopenia and sarcopenic obesity in community-dwelling older adults: the Fourth Korea National Health and Nutrition Examination Survey. Age Ageing. 2013;42:734–40.CrossRefPubMedGoogle Scholar
  52. 52.
    Atkins JL, Whincup PH, Morris RW, Lennon LT, Papacosta O, Wannamethee SG. Sarcopenic obesity and risk of cardiovascular disease and mortality: a population-based cohort study of older men. J Am Geriatr Soc. 2014;62:253–60.CrossRefPubMedGoogle Scholar
  53. 53.
    Ilich JZ, Kelly OJ, Inglis JE, Panton LB, Duque G, Ormsbee MJ. Interrelationship among muscle, fat, and bone: connecting the dots on cellular, hormonal, and whole body levels. Ageing Res Rev. 2014;15:51–60.CrossRefPubMedGoogle Scholar
  54. 54.
    Hita-Contreras F, Martínez-Amat A, Cruz-Díaz D, Pérez-López FR. Osteosarcopenic obesity and fall prevention strategies. Maturitas. 2015;80:126–32.CrossRefPubMedGoogle Scholar
  55. 55.
    Cruz-Jentoft AJ, Landi F, Topinkova E, Michel JP. Understanding sarcopenia as a geriatric syndrome. Curr Opin Clin Nutr Metab Care. 2010;13:1–7.CrossRefPubMedGoogle Scholar
  56. 56.
    Evans WJ, Campbell WW. Sarcopenia and age-related changes in body composition and functional capacity. J Nutr. 1993;123:465–8.PubMedGoogle Scholar
  57. 57.
    Landi F, Liperoti R, Russo A, Giovannini S, Tosato M, Capoluongo E, Bernabei R, Onder G. Sarcopenia as a risk factor for falls in elderly individuals: results from the ilSIRENTE study. Clin Nutr. 2012;31:652–8.CrossRefPubMedGoogle Scholar
  58. 58.
    Srikanthan P, Karlamangla AS. Relative muscle mass is inversely associated with insulin resistance and prediabetes. findings from the third National Health and Nutrition Examination Survey. J Clin Endocrinol Metab. 2011;96:2898–903.CrossRefPubMedGoogle Scholar
  59. 59.
    LaStayo PC, Ewy GA, Pierotti DD, Johns RK, Lindstedt S. The positive effects of negative work: increased muscle strength and decreased fall risk in a frail elderly population. J Gerontol A Biol Sci Med Sci. 2003;58:M419–24.CrossRefPubMedGoogle Scholar
  60. 60.
    Oliveira A, Vaz C. The role of sarcopenia in the risk of osteoporotic hip fracture. Clin Rheumatol. 2015;34:1673–80.CrossRefPubMedGoogle Scholar
  61. 61.
    Bijlsma AY, Meskers MC, Molendijk M, Westendorp RG, Sipilä S, Stenroth L, Sillanpää E, McPhee JS, Jones DA, Narici M, Gapeyeva H, Pääsuke M, Seppet E, Voit T, Barnouin Y, Hogrel JY, Butler-Browne G, Maier AB. Diagnostic measures for sarcopenia and bone mineral density. Osteoporos Int. 2013;24:2681–91.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  1. 1.Australian Institute for Musculoskeletal Science (AIMSS)Western Health and University of MelbourneSt. AlbansAustralia
  2. 2.Clinical Exercise Science Research Program, Institute of Sport, Exercise and Active Living (ISEAL), College of Sport and Exercise ScienceVictoria UniversityMelbourneAustralia
  3. 3.Department of Medicine, Melbourne Medical School – Western CampusThe University of MelbourneSt. AlbansAustralia

Personalised recommendations