Everything You Need to Know About Trabecular Bone Score (TBS)

Updated: October 17, 2022

Ladies hiking

Lifelong friends Jane and Barbara are very similar…

They’re both in their late 60s. They both eat a healthy diet. And they both love to hike with their grandchildren.

But Jane has suffered several low-impact fractures in the last few years. And Barbara? None. 

The two ladies have a similar bone density, though, so what gives?

Well, we tend to think of osteoporosis in terms of bone density, and we should. Yet there’s something else at play that’s just as important…

Bone quality.

Today, I’d like to show you the difference between bone density and bone quality, and how by knowing both, you can get the clearest picture of your overall bone health.

How is Bone Quality Different from Bone Density?

Bone density refers to the amount of minerals in your bone tissue. It’s calculated by looking at your mineral bone mass per volume of bone.

Bone quality refers to the composition and structure of your bones which contribute to bone strength independently of bone mineral density. This includes several parameters but we will focus here on the structural one, also known as your microarchitecture. 

As we’ll cover in a moment, it’s the combination of density and quality which produces the strongest bones.

Like bone density, several factors can affect whether your bone quality is good or poor. Things like certain medications, prior illnesses, and not consuming enough bone-building nutrients to support healthy bone strength.

Until recently, the best way to know your bone structure, or quality, was by having a bone biopsy. A bone biopsy is a costly surgical procedure requiring sedation and a possible hospital stay. And it only looks at a certain part of your bone that’s typically non-weight bearing and unlikely to fracture. 

That’s why Medimaps Group, the medical company I co-founded, developed TBS iNsight®. It’s a software tool that makes it easy to get a trabecular bone score (TBS) test –– a test which will estimate the structural part of your bone quality. Best of all, it’s painless, radiation free, and only takes a few seconds! 

Take a look at the short video-chat with me and Lara Pizzorno, AlgaeCal’s Resident Bone Health Expert, where I talk more about bone quality and provide an everyday example to demonstrate…

Apologies about the video quality. I was calling Lara over my PC!

Using my chair analogy from the video, a chair with a sound framework of legs and “scaffolding” bars better supports you, just like bones with a strong structure provide better support. And that’s what bone quality is all about in our context here. You see, bones can be mineral-dense yet poorly structured. That’s why Jane’s bones are more prone to fracturing than Barbara’s — her bone quality is poorer.

How Does a TBS Bone Quality Test Work?

TBS iNsight works by estimating a surrogate (TBS) of your bone quality and then using that information to calculate your fracture risk. It does this by analyzing how well-structured or poorly structured your trabecular bone appears, how much connective tissue it has, and its thickness. These things, combined with your bone mineral density, determine in majority the strength of your bone and your risk of fracture.

What’s your trabecular bone? 

Well, there are two “kinds” of bone: cortical and trabecular. Think of an M&M candy… the cortical bone is the hard outer shell, and the trabecular bone is the soft chocolate inside. Bone resorption, or bone breakdown, occurs along bone surfaces in the trabecular bone.    

A TBS result greater than 1.310 is considered normal, 1.230–1.310 indicates partially degraded bone, and less than 1.230 is considered degraded bone at high risk of fracture. A high TBS means you have a strong, fracture-resistant bone structure, while a low score means a weak, fracture-prone bone structure. But you shouldn’t count on your TBS results alone… instead, they should be interpreted along with your DEXA results, and the clinical context.

Trabecular Bone

TBS + DEXA = A Winning Combination

Make no mistake… TBS doesn’t replace regular dual-energy X-ray absorptiometry (DEXA) scans, and I wholeheartedly recommend them. In fact, measuring your bone density with a DEXA scan is still the “gold standard” for diagnosing osteoporosis. To learn more about DEXA scans and their benefits, click here.

Rather, TBS complements your DEXA results. The beauty of having both tests is that you get a better picture of your bone health: bone density and bone quality.

In fact, two large-scale studies on older women, one with 29,407 women and another with 1,007 women, came to the same conclusion: The combination of TBS and DEXA was better at predicting fractures than either test alone, both in osteoporotic and non-osteoporotic women, and thus independently of most of the clinical risk factors.

But what about FRAX?

You may have heard about the Fracture Risk Assessment Tool (FRAX) or may have even had a FRAX test yourself. You answer a set of 12 questions about your current bone density, family history, medications you take, lifestyle routine (whether you smoke, for example), and others. Then the FRAX formula uses your answers to calculate an estimate of your fracture risk. 

FRAX doesn’t look inside your bones, and that’s where TBS shines. It builds on the information provided by FRAX and fine-tunes it. So if you’ve already had FRAX, getting a TBS test can give you a more refined prediction than FRAX alone.

How to Get A Trabecular Bone Score

DEXA scan review

Besides giving you the peace of mind that comes from knowing your bone quality, TBS offers another big benefit, and that’s convenience!

You can get your TBS test at the same time you get your DEXA scan. That’s because they’re done on the same machine and use the same images. You see, the software that calculates your TBS result (TBS iNsight) is installed directly on DEXA scanners, or on a remote workstation. So the images that your doctor uses to determine your DEXA results are the same ones used for your TBS calculation. 

Not all facilities offer TBS yet, but you can check here to see if a clinic near you does. You’ll also want to check with your health insurance company to see if it covers TBS; if not, the cost is about $50–$150 U.S. dollars. 
So, I highly suggest getting a TBS test with your next DEXA scan. After all, if you’re worried about your bones, there’s nothing more empowering than knowing both your bone density and bone quality. Because the more information you have about your bone health, the better equipped you are to make the right decisions for you. And the better equipped your healthcare provider is to advise you.

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  1. Karen

    November 28, 2020 , 8:57 am

    Very interesting. Trying algaecal , yoga and anything possible to strengthen my bones.

  2. Blaire AlgaeCal

    November 30, 2020 , 1:22 pm

    So great to hear this, Karen! Keep up the fantastic work taking care of your bones ❤️

    – Blaire @ AlgaeCal

  3. Molly

    November 29, 2020 , 9:45 am

    I was interested in seeing where I can get a TBS scan in the UK but the form won’t take my details. Can I get this some other way please?

  4. Blaire AlgaeCal

    November 30, 2020 , 1:49 pm

    Hi Molly,

    Thank you for letting us know! We’re so sorry to hear about the trouble with the form.

    Please email [email protected] and they will be happy to help you! Your doctor may also be able to provide information on this for you ❤️

    – Blaire @ AlgaeCal

  5. Cheryl Ewing

    November 29, 2020 , 10:27 am

    I have been unable to contact medimaps through their site as the communication gets hung up at the captcha “I’m not a robot”. Would love to find a DXA + TBS location near me.

  6. Blaire AlgaeCal

    November 30, 2020 , 1:50 pm

    Hi Cheryl,

    We apologize for this inconvenience! Please email [email protected] and they will look into this for you ?

    – Blaire @ AlgaeCal

  7. Carol

    November 29, 2020 , 4:09 pm

    So, what do you do if both the DEXA and TBS show low bone density and low bone quality?

  8. Blaire AlgaeCal

    November 30, 2020 , 1:41 pm

    Hi Carol,

    That’s a great question!

    Thankfully, it’s never too late to reclaim your bone health. AlgaeCal is clinically supported to increase bone density, no matter the severity of bone loss, and this is supported by 3 human clinical studies. We have many wonderful success stories (including before and after DEXA scans) you can see here.

    There are also many other things you can do to support your bone health, such as implementing weight-bearing exercise and the right nutrition into your diet. Our blog has everything you need to make these changes for free, including nutrition information, recipes, and exercises!

    Feel free to contact our Bone Health Consultants at 1-800-820-0184 if you have any questions ?

    – Blaire @ AlgaeCal

  9. Beverly Northeast

    November 30, 2020 , 7:31 am

    I would appreciate more info on the CBD oil and what that can do for my bone health.

  10. Blaire AlgaeCal

    November 30, 2020 , 1:19 pm

    Hi Beverly,

    Thanks for reaching out!

    We have an article on CBD oil and bone health here.

    Hope you find it helpful! ?

    – Blaire @ AlgaeCal

  11. Nancy Quarry

    November 30, 2020 , 8:38 am

    THANK YOU for this information.

  12. Blaire AlgaeCal

    November 30, 2020 , 1:21 pm

    Our pleasure, Nancy! ?

    – Blaire @ AlgaeCal

  13. Sonja

    December 4, 2020 , 12:42 pm

    As indicated in one of your reports that strontium supplement will skew the measurement of a DEXA scan, does the same apply for the TBS reading?

  14. Lara Pizzorno

    December 14, 2020 , 2:23 pm

    Hi Sonja! Strontium does not affect TBS readings as it does DEXA. DEXA is a measure of bone quantity, and strontium does affect the quantity reported, inflating results from 6-10% depending upon which type of DEXA machine is used. TBS, however, is a measure of bone quality, i.e., trabecular number and connectivity, both of which strontium improves. Strontium does not cause TBS results to be inflated. https://pubmed.ncbi.nlm.nih.gov/20872215/

  15. Janet M. Anderson

    December 7, 2020 , 10:21 am

    Scanned the internet and can not find a location to get a TBS test? I live in San Luis Obispo, California and called my Radiology diagnostic provider and ask them to add it to their protocol. Where does one go to get a TBS test?

  16. Megan AlgaeCal

    December 8, 2020 , 3:17 pm

    Hi Janet!

    Unfortunately, not all facilities offer TBS yet, but you can check if there’s a clinic nearby on the Medimaps website here.

    Hope this helps! 🙂

    -Megan @ AlgaeCal

  17. Sara Vargas

    December 20, 2020 , 6:16 am

    I was told 30 years ago, that I was allergic to injectable Iodine. That is why even when I broke one rib before, the doctors told me that because of this,, it was difficult for them to read the X-rays.
    After reading the article, I am hopeful . I want to now where I can go near my me to get this done since I was diagnosed with osteoporosis 5 years ago.
    Thank you.

  18. Megan AlgaeCal

    December 21, 2020 , 12:27 pm

    Hi sara, thanks for sharing and reaching out!

    Unfortunately, not all facilities offer TBS yet, but you can check if there’s a clinic nearby on the Medimaps website here. ❤️

    -Megan @ AlgaeCal

  19. Linda C

    February 2, 2021 , 3:49 pm

    Just came from my doctor who didn’t know anything about the TBS and told me that she assumed that Medicare here in the US will not pay for the test. I have Achalasia which challenges my ability to get food down especially when my esophagus is blocked. AlgaeCal and Strontium have been a god-send so I would feel so relieved to have both tests to see the effects of the calcium regiment even with my impaired swallowing.

  20. Megan AlgaeCal

    February 3, 2021 , 9:04 am

    Hi Linda, thanks for taking the time to share.

    We’re so glad you found AlgaeCal and decided to give it a try! To see if there’s a clinic in your area that offers TBS, you can fill out this Medimaps form here. Hope this helps and feel free to reach out to us at 1-800-820-0184 if you have any questions 🙂

    -Megan @ AlgaeCal

  21. Karen A Whaley

    June 19, 2021 , 8:02 am

    I have been taking AgaeCal & StrontiumBoost for almost 6 years and will be due my DexaScan November 2021. Is the TBS test available near me?

  22. Megan AlgaeCal

    June 21, 2021 , 3:16 pm

    Hi Karen!

    You can contact the MediMaps Groups to see if there’s a clinic offering TBS nearby. You can do this here.

    Hope this helps 🙂

    -Megan @ AlgaeCal

  23. Melissa B

    February 20, 2021 , 5:17 am

    I live in CT. Where is the closest TBS testing? I am getting my DEX test soon would like both.

  24. Blaire AlgaeCal

    February 22, 2021 , 9:31 am

    Hi Melissa,

    Thanks for reaching out to us!

    If you’d like to find a clinic that offers TBS in your area, you can fill out this Medimaps form here.

    Please don’t hesitate to give us a call at 1-800-820-0184 if you have further questions! ?

    – Blaire @ AlgaeCal

  25. Betty

    June 19, 2021 , 3:20 pm

    I’ve been on the Algaecal and strontium program for at least 3 years yet I fell and fractured my left hip. Surgeon inserted rod and long screw to reattach femur. Started pt to rehabilitate leg and hip. What more can I do to prevent right hip from breaking? I was limited in exercise due to collapse of T10 and then T6. My bones seem to be brittle. Would appreciate any suggestions for better health.

  26. Megan AlgaeCal

    June 24, 2021 , 9:05 am

    Hi Betty, sorry to hear about your recent fracture.

    Although our program is clinically supported to increase bone density in as little as 6 months, it can take time to work your way back to a normal, healthy bone density. So even though AlgaeCal is helping to strengthen your bones right now, the risk of fracture can remain until your bones are healthy again. In saying that, you’re definitely taking the right steps to prevent your hip from breaking again! Continue following your PT’s exercise program and continue providing your bones with the nutrients in AlgaeCal, as these are both crucial to increasing bone strength. Focusing on a bone-healthy diet will also help. We provide plenty of tips and recipes on our blog here (under the Nutrition and Recipes categories).

    We also have a Bone Fracture Healing Guide you may find helpful here.

    Lastly, Betty, have you joined the AlgaeCal Community on Facebook yet? If not, we’d love for you to join! It’s a wonderfully supportive community with many resources to guide you along your bone health journey. You can learn how to join here.

    Hope this helps and please don’t hesitate to reach out to us at 1-800-820-0184 (USA & Canada toll free) with any further questions. Wishing you a speedy recovery! ❤️

    -Megan @ AlgaeCal

  27. Dolly Hayes

    June 20, 2021 , 7:42 am

    Do you have any information that addresses the best foods to increase healthy bone?
    Thank you

  28. Megan AlgaeCal

    June 24, 2021 , 9:08 am

    Absolutely, Dolly!

    Check out our Nutrition articles here and our recipes here.

    Hope you enjoy browsing through these! 😀

    -Megan @ AlgaeCal

  29. Betty Hindley

    June 20, 2021 , 11:38 pm

    this is the first time I have commented .I have enjoyed taking the full medication since the September 2020.
    At the moment the arthritis in both my hands and wrists and am on steroid medication for 4 months . Not very happy about it but my Doctor says we need to break the cycle so I am hoping that my bone density will continue to improve .I don’t have a bone density until later in the year.

  30. Megan AlgaeCal

    June 28, 2021 , 3:19 pm

    Hi Betty, thanks for reaching out!

    Sorry to hear that you’re experiencing arthritis. If you’re interested, we have an article on natural remedies for arthritis you may find helpful here. You may also benefit from our product called Triple Power Fish Oil! It eases inflammation through a combination of EPA + DHA omega 3s, turmeric, and astaxanthin. You can learn more here.

    Hope this helps, Betty! ❤️

    -Megan @ AlgaeCal

  31. Jayne Champion

    June 25, 2021 , 9:34 am

    Please send information as to where I can have this TBS done.

  32. Megan AlgaeCal

    June 28, 2021 , 3:24 pm

    Hi Jayne!

    Currently, TBS isn’t as widely available as we’d hope for it to be, but you can check to see if nearby clinics offer TBS by filling out the form here.

    Hope this helps 🙂

    -Megan @ AlgaeCal

  33. Lynn

    July 9, 2021 , 2:21 pm

    Is the TBS ( trabecular bone score), made with a different imageing machine or with CT or dexa equipment, just using increased software? Will contact all local imaging places to see whats available and encourage TBS testing.
    Noticed when called 1 last year they used Dexa (wo Dr prescrip) for seeing where/amount fat/muscle in body ! Guess it al depends on the software used.

  34. Megan AlgaeCal

    July 13, 2021 , 8:39 am

    Hi Lynn!

    Yes, the facility must have TBS software available – if they do, they simply need to run your DEXA x-rays through this software program.

    It would be wonderful for more places to start offering TBS! If you’re interested in finding clinics with TBS, you can reach out to MediMaps here.

    Hope this helps 🙂

    – Megan @ AlgaeCal

  35. Nonna

    July 26, 2021 , 8:40 pm

    I just had DEXA test done in one of the specialty imaging facilities here in WA State. There was no mention about TBS, not by the referring physician not by the DEXA technician, not by the radiologist’s report. Is there a way for me to have my DEXA produced images to be evaluated post factum for bone quality? If so, how can I go about it? I highly doubt that the facility which performed by DEXA scan has the necessary software.

  36. Megan AlgaeCal

    July 29, 2021 , 10:54 am

    Hi Nonna, good question!

    Yes, it’s possible to have your images be evaluated afterward. Your DEXA scans will just need to be sent to a facility that has TBS software available. Unfortunately, TBS software is not as widely available as we would hope for it to be at this time. To check if there are any clinics offering this in your area, you can fill out a form on the medimaps website here.

    Hope this helps a bit!

    – Megan @ AlgaeCal

  37. Kathy Herbert

    May 15, 2022 , 12:24 pm

    I’m a Radiologic Technologist, and I know about cortical vs trabecular bone.

  38. Elaine

    October 5, 2022 , 9:44 am

    link to the sites for the test is broken

This article features advice from our industry experts to give you the best possible info through cutting-edge research.

Prof. Didier Hans
PHD, MBA - Head of Research & Development Center of Bone Diseases, Lausanne University Hospital CHUV, Switzerland,
Lara Pizzorno
MDiv, MA, LMT - Best-selling author of Healthy Bones Healthy You! and Your Bones; Editor of Longevity Medicine Review, and Senior Medical Editor for Integrative Medicine Advisors.,
Dr. Liz Lipski
PhD, CNS, FACN, IFMP, BCHN, LDN - Professor and Director of Academic Development, Nutrition programs in Clinical Nutrition at Maryland University of Integrative Health.,
Dr. Loren Fishman
MD, B.Phil.,(oxon.) - Medical Director of Manhattan Physical Medicine & Rehabilitation and Founder of the Yoga Injury Prevention Website.,
Dr. Carole McArthur
MD, PhD - Professor of Immunology, Univ. of Missouri-Kansas City; Director of Residency Research in Pathology, Truman Medical Center.,