Do osteochondromas cause pain?

Do Osteochondromas Cause Pain?

Yes, osteochondromas can cause pain, particularly when they grow rapidly, undergo malignant transformation, or compress surrounding structures, though many are asymptomatic. 1

Understanding Osteochondromas

Osteochondromas are the most common benign bone tumors, presenting as cartilage-capped bony outgrowths on the external surface of bones. They can be:

• Solitary (85% of cases)
• Multiple, as part of hereditary multiple exostoses/osteochondromas (HMO) (15% of cases) 2

Pain Mechanisms in Osteochondromas

Osteochondromas can cause pain through several mechanisms:

1. Malignant transformation:

   • Evidence of rapid growth, increasing pain, and/or a bulky cartilage cap >2.0-3.0 cm on MRI or CT suggests progression to chondrosarcoma 1
   • Pain is a key warning sign that should prompt immediate investigation 1

2. Mechanical causes:

   • Compression of adjacent nerves or blood vessels 2
   • Fracture of the osteochondroma stalk 2
   • Bursa formation over the osteochondroma 2
   • Impingement on surrounding muscles, tendons, or other structures 3

3. Location-specific symptoms:

   • Scapular osteochondromas can cause shoulder pain, limited range of motion, and scapular winging 4, 3
   • Distal tibial osteochondromas can cause nerve entrapment syndromes with associated pain 5

Clinical Significance of Pain in Osteochondromas

Pain in an osteochondroma warrants careful evaluation as it may indicate:

1. Potential malignancy:

   • Malignant transformation to chondrosarcoma occurs in 0.5-5% of cases in HMO 6
   • Pain at the site of a cartilaginous lesion may indicate malignancy 7

2. Need for intervention:

   • Surgical resection is indicated for symptomatic lesions, complications, cosmetic reasons, or suspected malignant transformation 2
   • Excision with free margins is the treatment of choice 2

Monitoring and Management

For patients with osteochondromas:

1. Regular monitoring:

   • Annual physical examinations starting in childhood 1
   • Early investigations for increasing pain or rapid growth 1
   • Consider baseline skeletal survey at early adolescence (around 12 years) 1

2. Warning signs requiring immediate attention:

   • New onset of pain
   • Rapid growth, especially after growth plate closure
   • Cartilage cap thickness >2 cm in adults or >3 cm in children 2

3. Follow-up recommendations:

   • For low-grade lesions: physical examination and imaging every 6-12 months for 2 years, then yearly 7
   • For high-grade lesions: more frequent monitoring (every 3-6 months) 7

Special Considerations

1. Asymptomatic osteochondromas:

   • Many osteochondromas are asymptomatic and may not require intervention 2
   • They typically grow during the first decade of life and cease growing when growth plates close at puberty 6

2. Location-specific management:

   • Consider regular regional MRI (every 2-3 years) of osteochondromas in the pelvis or scapula, as transformation is more common in these locations 1
   • Orthopedic providers should be involved in monitoring 1

In summary, while many osteochondromas are painless, the presence of pain should always prompt thorough evaluation to rule out malignant transformation or mechanical complications requiring intervention.