What is the appropriate evaluation and management for a patient presenting with pelvic bone pain?

From the Guidelines

Pelvic bone pain should be evaluated with a systematic approach, starting with plain radiographs of the pelvis, as the initial imaging modality, due to its availability and low cost, despite its low sensitivity, especially in older or osteoporotic patients 1. The evaluation and management of pelvic bone pain require a thorough history and physical examination to identify the underlying cause. Initial assessment should include detailed pain characterization, trauma history, and review of systems for associated symptoms. Diagnostic imaging typically starts with plain radiographs of the pelvis, as stated, followed by more advanced imaging such as MRI, CT scan, or bone scan depending on clinical suspicion 1. Laboratory tests should include complete blood count, inflammatory markers (ESR, CRP), calcium levels, and possibly tumor markers if malignancy is suspected. Treatment depends on the underlying etiology but often begins with conservative measures including analgesics such as acetaminophen (500-1000mg every 6 hours) or NSAIDs like ibuprofen (400-800mg three times daily) for pain control. Some key points to consider in the evaluation and management of pelvic bone pain include:

• Identifying the underlying cause of the pain, which can range from trauma, infection, inflammatory disorders, to malignancy 1
• Using advanced imaging modalities, such as MRI or CT scans, if initial radiographs are negative or indeterminate 1
• Considering the patient's overall health status, including any underlying medical conditions, such as osteoporosis, and pregnancy status 1
• Developing a treatment plan that addresses the underlying cause of the pain, and may include conservative measures, such as physical therapy, or more invasive procedures, such as surgery 1. The most recent and highest quality study 1 supports the use of a systematic approach to evaluating and managing pelvic bone pain, with a focus on identifying the underlying cause and developing a treatment plan that addresses this cause.

From the Research

Evaluation of Pelvic Bone Pain

To evaluate a patient presenting with pelvic bone pain, the following steps can be taken:

• A comprehensive history should be taken, including questioning regarding the patient's pain complaint and a thorough history and review of any body system that may be involved 2
• The physical examination should follow a focused systems-based approach and includes examination of gastrointestinal, dermatologic, neurologic, and musculoskeletal (including lumbosacral spine, sacroiliac joints, pelvis, and hips) systems, and the pelvic floor (internal and external examination, including neuromuscular anatomy) 2
• Radiography of the hip and pelvis should be the initial imaging test 3
• If plain radiograph is non-diagnostic and symptoms remain unresponsive, a bone scan, and then, if necessary, computerized tomography or magnetic resonance imaging can be obtained 4

Differential Diagnosis

The differential diagnosis for pelvic bone pain includes:

• Intra-articular etiologies, such as labral tear or femoroacetabular impingement in younger adults or osteoarthritis in older adults 3
• Extra-articular etiologies, such as hip flexor injuries 3
• Referred pain from intra-abdominal or intrapelvic causes 3
• Greater trochanteric pain syndrome, which includes gluteus medius tendinopathy or tear, bursitis, and iliotibial band friction 3
• Deep gluteal syndrome with sciatic nerve entrapment, ischiofemoral impingement, and hamstring tendinopathy 3
• Malignant primary bone tumors of the pelvis 4
• Osteoporosis 5, 6

Diagnostic Criteria

The following characteristics may alert the clinician to the possibility of underlying pelvic bone malignancy in a patient with low back pain:

• Age > or = 45 years
• Insidious onset of symptoms without antecedent trauma
• Prolonged symptoms for more than 1 month
• Progressive pain that fails conservative therapy
• Presence of anorexia, malaise, or night pain 4