A marked decrease in bone mineral density is a well recognized, if not always fully addressed, spinal cord injury-related comorbidity. The bone loss starts shortly after paralysis onset, and the loss rate is steep. The diverse etiology includes mechanical, neurologic, endocrine, vascular, and pharmacologic factors. Dual x-ray absorptiometry is available and affordable to quantify the degree of bone loss and follow changes related to treatment. Fragility/low impact fractures occur frequently and can induce significant morbidity. Physical modalities and pharmacologic interventions can be employed to stave off and/or reverse bone loss with variable success rates.