• bone pain
• coeliac disease
• myopathy

It is rare for coeliac disease to present only with symptoms of osteomalacia, without the classic symptoms of diarrhoea, steatorrhoea, and abdominal discomfort.^1–5

A 22 year old woman presented with 18 months of a waddling gait disturbance. Hip and back x rays were normal. She experienced bone pain when being hugged, when laughing, or coughing, and had difficulty standing up from a low chair and holding her arms up to blow-dry her hair. She had extreme tiredness and thought she might have lost some weight, but there were no gastrointestinal symptoms.

On examination, she was pale and had difficulty squatting and holding her arms above her head.

Investigations showed a mild anaemia secondary to β thalassaemia minor and iron deficiency. Other investigations disclosed a raised alkaline phosphatase of 1375 U/l (normal 30–120 U/l), reduced red blood cell folate level of 290 nmol/l (>300 nmol/l), corrected calcium of 1.75 mmol/l (2.15–2.65 mmol/l), phosphate 1.0 mmol/l (0.8–1.4 mmol/l), 25-hydroxy vitamin D <5 nmol/l …