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Bone pain

Medicine > Endocrine & metabolic

Differential Diagnosis Schema 🧠

Infectious Causes

  • Osteomyelitis: Often presents with localized bone pain, fever, and systemic symptoms; usually due to Staphylococcus aureus infection.
  • Septic Arthritis: Joint pain with bone involvement, often associated with erythema and fever; requires urgent intervention.
  • Tuberculosis (Pott’s disease): Chronic bone pain with systemic signs such as weight loss and night sweats; often affects the spine.

Neoplastic Causes

  • Primary bone tumors (e.g., osteosarcoma, Ewing’s sarcoma): Often present with localized bone pain, swelling, and may be associated with a palpable mass.
  • Metastatic bone disease: Commonly from breast, prostate, lung, or kidney cancers; presents with persistent, deep bone pain often worse at night.
  • Multiple myeloma: Generalized bone pain, often in the back or ribs, accompanied by anemia, renal impairment, and hypercalcemia.

Traumatic Causes

  • Fractures: Sharp, localized bone pain following trauma, often with deformity or loss of function.
  • Stress fractures: Gradual onset of pain, often in athletes, typically worse with weight-bearing activities.
  • Bone contusions: Localized pain and tenderness without significant structural damage, typically after direct trauma.

Inflammatory Causes

  • Rheumatoid arthritis: Symmetrical joint pain with bone involvement, associated with morning stiffness and systemic symptoms.
  • Ankylosing spondylitis: Chronic back pain with stiffness, typically in younger males, associated with reduced spinal mobility.
  • Osteitis deformans (Paget’s disease): Bone pain due to abnormal bone remodeling, often in the pelvis, spine, or skull.

Metabolic Causes

  • Osteoporosis: Generalized bone pain or focal pain after minimal trauma; often associated with vertebral fractures.
  • Osteomalacia: Diffuse bone pain with muscle weakness, often due to vitamin D deficiency; commonly involves the spine, pelvis, and lower limbs.
  • Hyperparathyroidism: Bone pain with other signs of hypercalcemia (e.g., renal stones, abdominal pain); may lead to bone resorption and fractures.

Key Points in History 🥼

Pain Characteristics

  • Onset: Acute onset may suggest trauma or infection; insidious onset may suggest malignancy or metabolic bone disease.
  • Duration: Chronic pain may be indicative of neoplastic, inflammatory, or metabolic causes.
  • Nature of pain: Sharp pain may suggest fracture; deep, dull pain may be more consistent with malignancy or infection.
  • Aggravating and relieving factors: Pain exacerbated by activity may suggest a fracture or arthritis; night pain unrelieved by rest is concerning for malignancy.
  • Radiation: Radiation of pain could suggest nerve involvement, as seen in conditions like vertebral fractures or spinal metastases.

Background

  • Past medical history: History of cancer, osteoporosis, or chronic infections (e.g., tuberculosis) can provide clues.
  • Drug history: Corticosteroid use is a risk factor for osteoporosis and avascular necrosis.
  • Family history: Family history of metabolic bone diseases, cancer, or autoimmune conditions may be relevant.
  • Social history: Occupation-related physical activity, smoking, and alcohol use can contribute to bone pain (e.g., in stress fractures, osteoporosis).

Possible Investigations 🌡️

Blood Tests

  • Full blood count (FBC): To assess for anemia (e.g., multiple myeloma) or infection (e.g., osteomyelitis).
  • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): Raised in infection, inflammation, and malignancy.
  • Calcium and phosphate levels: Hypercalcemia may indicate malignancy or hyperparathyroidism; hypocalcemia may suggest osteomalacia.
  • Alkaline phosphatase (ALP): Elevated in bone diseases such as Paget’s disease, osteomalacia, and metastasis.
  • Serum protein electrophoresis: To detect monoclonal proteins in multiple myeloma.
  • Vitamin D levels: Low in osteomalacia and osteoporosis.
  • Parathyroid hormone (PTH): Elevated in hyperparathyroidism, a cause of bone pain.

Imaging

  • X-rays: First-line for detecting fractures, osteolytic lesions, and bone deformities.
  • MRI: Superior for soft tissue involvement, spinal cord compression, and early detection of bone marrow infiltration in malignancy.
  • CT scan: Detailed bone imaging, useful for complex fractures and detecting metastases.
  • Bone scan: Sensitive for detecting bone metastases, stress fractures, and infections.
  • DEXA scan: Used to assess bone mineral density in suspected osteoporosis.

Biopsy

  • Bone biopsy: Indicated when malignancy or infection is suspected, provides definitive diagnosis.
  • Bone marrow biopsy: Used in hematological malignancies like multiple myeloma.

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Endocrine & metabolic