OBJECTIVE To discuss the diagnostic criteria, clinical findings and radiographic findings of diffuse idiopathic skeletal hyperostosis (DISH). METHODS DISH is a disease that affects elderly persons and is characterized by a bone-forming tendency with prominent radiographic findings, including proliferation of bone throughout the ligaments and tendons of the spine and extremities. Clinical symptoms are often mild and include mild pain and stiffness. DISH can coexist with other articular diseases, such as degenerative joint disease and rheumatoid arthritis, or can be complicated with myelopathy and fracture. RESULTS All four patients were men over the age of 75 and had DISH with associated neurological signs and symptoms. Three patients showed improvement after chiropractic manipulative treatment. One patient was referred for a surgical consultation for atlantoaxial instability from rheumatoid arthritis and was subsequently lost to follow-up. CONCLUSIONS DISH is a common disease of the elderly; clinicians should recognize its radiographic and diagnostic features.