Bone pain - red flag symptoms

How to identify red flags in patients presenting with bone pain, including conducting a clinical examination and useful investigations.

CT scan of osteosarcoma, one of many possible causes of bone pain (Photo: SPL)
CT scan of osteosarcoma, one of many possible causes of bone pain (Photo: SPL)

Red flag symptoms

  • History of malignancy
  • Weight loss
  • Night sweats
  • Reduction in appetite
  • Night pain
  • Pain that is progressive or persistent
  • Pain in children
  • Any history of recent trauma
  • Symmetrical joint swelling
  • Thoracic pain

Bone pain is not an uncommon presentation, particularly in an increasingly ageing population. Patients often refer to pain in their bones, but this is a non-specific symptom and there are a range of differential diagnoses to consider (see table 1).

A detailed description of what the patient means by ‘bone pain’ is crucial. It is also important to establish why the patient has presented at this time and what their ideas, concerns and expectations are.

History

Ask the patient to describe where they feel the pain. Can they localise it, or is it generalised? What sort of pain is it? Bone pain is generally described as a dull, deep-seated pain. Sharp, shooting pains, in contrast, should lead you to focus on a neuropathic aetiology.

Does the pain radiate? Are there aggravating or relieving factors? Is there any pattern of pain, for example is it worse at night or in the morning?

How long has the pain been present? Has it developed suddenly or insidiously? Is it continuous or intermittent?

Is a specific joint affected? If so, is there any associated heat or swelling? Is the arthralgia symmetrical? Are there associated symptoms such as nausea, vomiting, swelling of the affected area, weight loss or pain at night? A sexual history may be relevant if Reiter’s syndrome is suspected.

How is the pain affecting the patient’s quality of life? Is it affecting their work, school, university or hobbies?

What does the patient feel could be the problem and what have they tried to alleviate it? Many patients will have researched their symptoms online and will have developed an idea of why they are experiencing these symptoms.

Ask about any history of malignancy or TB, particularly in patients from migrant populations.

Ask whether the patient takes any regular or OTC medication? Their smoking and alcohol history may be important, as may a family history of osteoporosis.

A systemic review may reveal important information if metastatic bone disease is suspected. Be alert to the malignancies that commonly metastasise to bone. These include breast, renal, lung and prostate. Do not forget melanomas and gynaecological malignancies.

Has the patient experienced any mood disturbance? Widespread bone pain may be a physical manifestation of an underlying psychological problem.

The clinical examination will be guided by the history. Depending on information revealed in the history and systemic review, examination of a specific system may be required.

Possible causes of bone pain

  • Fracture
  • Primary bone cancer, such as osteosarcoma
  • Metastatic bone disease
  • Vitamin D deficiency leading to osteomalacia
  • Multiple myeloma
  • Paget’s disease
  • Osteoporosis
  • Osteoarthritis
  • Hypercalcaemia, for example, secondary to hyperparathyroidism
  • Inflammatory arthropathy, for example rheumatoid arthritis (RA)
  • TB of the bone
  • Psychosomatic
  • Iatrogenic, for example bisphosphonates can cause osteonecrosis of the jaw or prednisolone can cause vertebral fractures

Investigations

  • FBC, U&Es, ESR, calcium, phosphate and LFTs
  • Vitamin D level
  • PSA test, after appropriate counselling
  • Parathyroid hormone level – this generally needs to be sent to the laboratory on ice within an hour
  • If raised alkaline phosphatase is detected, isoenzymes may be required to discover whether this is from a liver or a bone source
  • Myeloma screen to include serum paraprotein and urinary Bence Jones protein
  • Anti-cyclic citrullinated peptide and rheumatoid factor may also be necessary if RA is suspected
  • A plain chest X-ray may be required if bronchogenic carcinoma is suspected
  • A FRAX score may be necessary if osteoporosis is suspected and if appropriate, a DEXA scan to assess bone mineral density
  • Plain X-rays may be necessary if the pain is localised to a specific area
  • Hospital Anxiety and Depression Scale score

Tumour markers can be done but are generally not recommended in primary care. If a malignancy is suspected, appropriate referral under the two-week wait is mandatory. Every locality will differ as to their referral pathways.

  • Dr Singh is a GP in Northumberland

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This is an updated version of an article that was first published in May 2014.

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