🦴 Bone Pain is a common but non-specific symptom with a wide differential diagnosis. It can arise from local pathology (fracture, infection, tumour), systemic disorders (osteoporosis, vitamin D deficiency, autoimmune disease), or referred pain. Understanding the underlying cause is crucial — ranging from benign to life-threatening conditions.

📊 Categories of Causes

⚙️ Mechanical/degenerative: Osteoarthritis, fractures.
🧬 Metabolic: Osteoporosis, osteomalacia, Paget’s disease.
🦠 Infective: Osteomyelitis.
🎯 Malignant: Bone metastases, multiple myeloma.
🔥 Inflammatory/autoimmune: Rheumatoid arthritis.
🧠 Central sensitisation: Fibromyalgia.

🩺 Clinical Toolkit: Causes, Tests, Management

Cause	Diagnostic Tests	Management
Osteoarthritis	Clinical; X-ray: joint space narrowing, osteophytes	NSAIDs, physiotherapy, joint replacement if severe
Osteoporosis	DEXA scan; serum calcium/vitamin D	Bisphosphonates, vit D & calcium, weight-bearing exercise
Bone Metastases	Bone scan, PET-CT, biopsy	Radiotherapy, bisphosphonates/denosumab, analgesia
Osteomyelitis	CRP/ESR, MRI/CT, bone biopsy	Prolonged antibiotics, surgical debridement
Fractures	X-ray, CT/MRI for occult fractures	Immobilisation, ORIF surgery, pain relief
Paget’s Disease	↑ ALP, X-ray: cortical thickening, bone scan	Bisphosphonates, calcitonin, NSAIDs for pain
Multiple Myeloma	Serum/urine electrophoresis, marrow biopsy, X-ray: lytic lesions	Chemotherapy, bisphosphonates, stem cell transplant
Fibromyalgia	Diagnosis of exclusion, tender point exam	Exercise therapy, antidepressants, pregabalin/gabapentin
Rheumatoid Arthritis	RF, anti-CCP, X-ray erosions, ↑ CRP/ESR	DMARDs (methotrexate), biologics, NSAIDs, steroids
Vitamin D Deficiency (Osteomalacia)	Low 25(OH) vit D, Looser’s zones on X-ray	Vit D & calcium supplements, sunlight exposure

🔬 Investigations in Bone Pain

📖 Basic Tests (first-line):
- FBC → anaemia (myeloma, chronic disease), WCC (infection).
- U&E, calcium, phosphate, ALP → metabolic and malignant clues.
- CRP/ESR → infection, inflammatory disease, myeloma.
🩻 Imaging:
- X-ray → first-line for fracture, lytic/sclerotic lesions.
- DEXA → osteoporosis screening.
- MRI → marrow infiltration, osteomyelitis, stress fractures.
- Bone scan/PET → metastases, multifocal disease.
🧪 Specialist Tests:
- Serum/urine electrophoresis → myeloma (M-protein, Bence Jones protein).
- Autoantibodies → RF, anti-CCP (RA); ANA (SLE).
- Bone biopsy → suspected malignancy, osteomyelitis.
- 25(OH) vitamin D → osteomalacia.
❤️ Systemic Assessment: Since bone pain can be a “red flag” for systemic disease, always consider malignancy screen (CXR, PSA, breast exam, etc.) when appropriate.

⚠️ Red Flags in Bone Pain

Night pain not relieved by rest.
Weight loss, fever, or systemic symptoms.
Pathological fractures.
Focal bone tenderness with swelling.
History of malignancy.

🧑‍⚕️ Case Examples

Case 1: 👩 A 68-year-old woman presents with hip pain after a minor fall. X-ray shows a femoral neck fracture and DEXA scan confirms osteoporosis (T-score –3.0). ✅ Managed with surgical fixation, bisphosphonate therapy, calcium/vit D supplementation, and fall-prevention strategies.

Case 2: 👨 A 55-year-old man with weight loss and back pain has lytic lesions on X-ray. Serum electrophoresis reveals an IgG paraprotein. Diagnosis: Multiple myeloma. ✅ Management: chemotherapy, bisphosphonates, and stem cell transplantation assessment.

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