Bone pain - red flag symptoms

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

(Photo: Moyo Studio/Getty Images)
(Photo: Moyo Studio/Getty Images)

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, specifically pain that wakes up the patient
  • History of fever

Presentation

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 possible causes box below).

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. This will help to guide your management plan.

Questions to ask the patient

  • Where do you feel the pain?
  • Can you localise it, or is it generalised?
  • What sort of pain is it?
  • 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?
  • Have you tried any analgesia and, if so, has it worked?
  • How long has the pain been present?
  • Has it developed suddenly or insidiously?
  • Is it continuous or intermittent?
  • Is there a history of trauma?
  • 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, fever, swelling of the affected area, weight loss or pain at night?
  • Do you take any regular or over-the-counter medication?
  • Have you experienced any mood disturbance?
  • How is the pain affecting your quality of life? Is it affecting work, school, university or hobbies?

History

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. Widespread bone pain may be a physical manifestation of an underlying psychological problem, such as in a patient presenting with whole body pain.

A sexual history may be relevant if Reiter’s syndrome is suspected. You should also ask about any history of malignancy or TB, particularly in patients from migrant populations.

The patient’s smoking and alcohol history may be important, as may a family history of osteoporosis.

In addition to the questions listed on the previous page, it may be useful to find out what the patient thinks the problem could be and what have they done to try to alleviate it. Many patients will have researched their symptoms online and will have developed an idea of why they are experiencing these symptoms.

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.

Clinical examination: remote and face to face

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.

Examination can occur either remotely via telephone or video consultation, or by face-to-face examination.

Remote examination via telephone will be limited, but establish how much pain the patient is in, and ask if they can send a picture of an affected area, as well as describe any swelling.
When performing a remote video consultation, if a specific joint is involved can you visualise the joint?

Can you ask the patient to do any specific movements for you? Are you able to assess their mental state?

For face-to-face examinations, ensure you wear appropriate PPE. A focused neurological exam may be necessary if the spine is the main area causing problems.

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
  • Osteomyelitis
  • Prolapsed intervertebral disc
  • Frailty can lead to generalised aches and pains 

Investigations and referral

The decision about which investigations to perform will be largely determined by the history and examination.

  • FBC, U&Es, ESR, calcium, phosphate and LFTs
  • Vitamin D level
  • Prostate specific antigen (PSA) test, after appropriate counselling
  • Parathyroid hormone (PTH) 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 to evaluate bone fracture risk may be necessary if osteoporosis is suspected and, if appropriate, a DEXA (dual energy X-ray absorptiometry) scan to assess bone mineral density
  • Plain X-rays may be necessary if the pain is localised to a specific area, such as in the hands or wrists
  • 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 2-week wait is mandatory. Referral pathways will differ across different localities.

  • Dr Pipin Singh is a GP in Northumberland. This article was reviewed and updated by Dr Singh in April 2021

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