Falls and Bone Fractures in Older Men May Be Related to Poor Muscle Strength

Senior man wincing in pain beside his walking cane after falling on the floor of his room in an assisted living home
Investigators sought to assess how muscle mass and physical performance contribute to a decline in bone strength and subsequent risk of falls and fractures in older men.

Elderly men with low physical performance scores were found to have an increased likelihood of falls and fractures compared with men who had the highest scores for performance, according to the results of a study published in The Journal of Clinical Endocrinology and Metabolism.

Between 2006 and 2008, investigators enrolled 821 male volunteers 60 years of age and older into the Structure of the Aging Men’s Bones (STRAMBO) study, a prospective, single-center cohort study designed to explore fracture prediction by bone microarchitecture measures in men. Physical performance was measured using the 5-time chair stand test to evaluate hip muscle function and power of vertical motion based on time, as well as a standing balance assessment using a timed stand with feet together for at least 10 seconds (eyes open or eyes closed) with the best score reflecting more than 10 seconds of static standing both with eyes closed and opened.   The investigators also evaluated balance using a tandem walk test both forward and backward for 10 steps (individuals who successfully completed 10 steps in both directions were scored according to time of completion). The final physical performance score totaled all the scores from each of the tests.

The researchers measured bone mineral density of the hips and body composition using dual x-ray absorptiometry. They calculated the relative appendicular lean mass of the lower limbs (RALM-LL) by summing the lean mass of both legs divided by the lower segment length. They also observed bone microarchitecture changes over after a 4- and 8-year follow-up period using high-resolution peripheral quantitative computed tomography to analyze cortical and trabecular bone thickness.

Cortical bone density loss and estimated bone strength declines occurred more rapidly in men with decreased RALM-LL compared with men who had normal RALM-LL (failure load: -0.74±.09 vs. -0.43±.10%/y; P <.005).

The investigators recorded number of falls annually, the number of falls resulting in injury requiring hospitalization, and the number of nonvertebral fragility fractures. Elderly men with the lowest scores measuring physical performance were found to have an increased likelihood of falls (hazard ratio [HR], 3.52; 95% CI, 1.57-7.90; P <.05) and fractures (HR, 2.68, 95% CI: 1.08-6.66; P <.05) compared with men who had the highest scores for performance (41.6% vs 24.4%, respectively).

This study was limited by its inclusion of home-dwelling, White, older men; therefore, the results cannot be applied to other ethnic groups or to women. Another limitation included use of self-reported comorbidities and nonspine fractures. The investigators did not collect any direct measurement of lower extremity strength, such as knee extensor strength. Additionally, according to the researchers, bone microarchitecture assessment may be inaccurate due to partial volume effect. Muscle mass and lifestyle choices were only measured at baseline and not at each annual follow-up, indicating that changes in these factors during the 8-year period may have affected the rate of bone loss.

“Rapid decline of bone microarchitecture and estimated strength in men with poor physical performance and low RALM-LL may contribute to higher fracture risk,” the study authors said.  “From the clinical point of view, efforts to maintain physical performance of the lower limbs are needed to prevent injurious falls and fractures in the elderly.”

Disclosure: This study was supported by a grant from the Roche Pharmaceutical Company.


Wagner PP, Whittier DE, Foesser D, Boyd SK, Chapurlat R, Szulc P. Bone microarchitecture decline and risk of fall and fracture in men with poor physical performance – the STRAMBO study. J Clin Endocrinol Metab. Published online July 12, 2021. doi:10.1210/clinem/dgab506