The assessment of bone pain along with its history, clinical presentation and investigations are penned down and explained in this article.

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Although many pain complaints emerge from self-limited disorders, a large percentage need prompt and continuous therapy. Prompt effective therapy may help reduce symptoms, avoid impairment, and enhance results. The differential diagnosis is broad, with both laboratory investigations and diagnostic imaging available to assist examine the joint. At the first examination and at each subsequent re-evaluation, there should be attempts to detect harmful conditions and separate conditions with a disease-specific aetiology.

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Assessment of bone pain

Conducting a clinical assessment and performing useful tests can help you figure out what's wrong with people who have pain in their bones.

Symptoms that should raise an alarm

• A history of cancer
• Weight loss
• Night sweats
• Appetite reduction
• Night pain
• Progressive or chronic discomfort
• Swelling of symmetrical joints
• Thoracic discomfort, most notably pain that awakens the patient
• Fever's history

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Clinical presentation

Bone pain is a frequent symptom, especially in an ageing population. This is a non-specific symptom with a wide variety of differentials to evaluate.

Asking the patient the right questions

1. Where do you experience discomfort?
2. Is it localisable, or is it vague?
3. What kind of discomfort are you experiencing?
4. Does the discomfort radiate?
5. Is there anything that aggravates or alleviates the situation?
6. Does the pain have a pattern, such as being worse at night or in the morning?
7. Are you taking painkillers? If so, has it worked?
8. Has the pain been there for an extended period of time?
9. Did it manifest itself abruptly or insidiously?
10. Is it constant or sporadic?
11. Is there a trauma history?
12. Is a particular joint involved? If this is the case, is there any accompanying heat or swelling?
13. Is there symmetry in arthralgia?
14. Are there any accompanying symptoms such as nausea, vomiting, fever, swelling of the afflicted region, weight loss, or nighttime pain?
15. Do you use any prescription or OTC medications?
16. Have you ever had a mood swing?
17. What effect does the pain have on your quality of life? Is it having an effect on your job, school, university, or hobbies??

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History

If Reiter's syndrome is suspected, a sexual history may be pertinent. Additionally, you should inquire about any history of malignancy or tuberculosis. The patient's smoking and alcohol use histories, as well as a family history of osteoporosis, may be relevant.

Along with the questions provided on the preceding page, it may be beneficial to learn what the patient believes the issue is and what they have done to attempt to relieve it. Many patients will have conducted internet research on their symptoms and will have acquired an understanding of why they are experiencing them. If the metastatic bone disease is suspected, a systematic examination may yield critical information. Keep an eye out for malignancies that often metastasize to the bone. These include the breast, the kidneys, the lung, and the prostate. Not to be overlooked are melanomas and gynaecological cancers.

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Clinical assessment remotely during a pandemic

The history will inform the clinical evaluation. Depending on the information obtained from the history and systemic assessment, it may be necessary to examine a particular system.  Examinations may be conducted remotely through a telephone or video consultation, or in person.

While remote examinations by telephone are restricted, they may be used to ascertain the patient's level of discomfort and to request that they email a photograph of the afflicted region, as well as describe any swelling.

When doing a remote video consultation, can you see a particular joint if it is involved? Can you request certain motions from the patient? Are you in a position to ascertain their mental state?

Wear proper personal protective equipment (PPE) for face-to-face inspections. A specialised neurological examination may be essential if the spine is the primary source of discomfort.

Bone pain may have many reasons, such as:

• 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 (eg. rheumatoid arthritis)
• Tuberculosis of bone
• Osteomyelitis
• Intervertebral disc prolapse
• Frailty may result in widespread aches and discomfort

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Conducting investigations and referring

The history and examination will play a significant role in determining which investigations to conduct. Some significant ones include:

1. CBC, U&Es, ESR, calcium, phosphate and LFTs
2. Vitamin D levels
3. Prostate-specific antigen (PSA) tests
4. Parathyroid hormone (PTH) level - Generally, this must be transported to the laboratory on ice within an hour.
5. If elevated alkaline phosphatase is discovered, isoenzymes may be necessary to determine whether it originated in the liver or the bone.
6. Myeloma screen in order to include serum paraprotein and urinary Bence Jones protein
7. If rheumatoid arthritis is suspected, anti-cyclic citrullinated peptides and rheumatoid factor may also be required.
8. If bronchogenic cancer is suspected, a plain chest X-ray may be performed.
9. If osteoporosis is suspected, a FRAX score and, if applicable, a DEXA (dual-energy X-ray absorptiometry) scan to determine bone mineral density may be recommended.
10. If the discomfort is localised to a particular place, such as the hands or wrists, plain X-rays may be warranted.
11. The hospital anxiety and depression scale score should be checked.

While tumour markers may be performed, they are not typically advised in primary care. An appropriate referral is required if malignancy is suspected.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.