What is the appropriate workup for a 34-year-old female presenting with bone pain?

Workup for Bone Pain in a 34-Year-Old Female

The appropriate workup for a 34-year-old female with bone pain should begin with plain radiographs of the affected area, followed by MRI if radiographs are inconclusive or if a bone tumor is suspected. 1, 2

Initial Evaluation

First-Line Imaging

• Plain radiographs (X-rays) in two planes of the affected area should always be the first investigation 1, 2
  • Look for: bone destruction, new bone formation, periosteal swelling, soft tissue swelling
  • Note: A "normal" X-ray does not exclude primary malignant bone tumors (PMBTs) 1

Laboratory Tests

• Complete blood count (FBC)
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP)
• Biochemical profile including alkaline phosphatase (ALP) 1
• Consider calcium and vitamin D levels if osteoporosis is suspected 3

Secondary Evaluation

When Initial X-rays Are Normal But Pain Persists

• MRI of the affected area is the next appropriate step 1, 2
  • MRI is superior for evaluating soft tissue involvement, bone marrow changes, and early bone lesions
  • Should include the whole compartment with adjacent joints for suspected tumors 2

When Initial X-rays Show Abnormalities

1. For suspected bone tumor:

   • Urgent referral to a bone sarcoma center before biopsy 1, 2
   • MRI of the whole affected compartment including adjacent joints 2

2. For suspected infection:

   • MRI to evaluate for osteomyelitis
   • Consider bone biopsy for culture 1

3. For suspected metabolic bone disease:

   • Bone density scan (DEXA)
   • Additional laboratory tests: parathyroid hormone, thyroid function tests 3

Special Considerations for a 34-Year-Old Female

At this age, the most common causes of bone pain include:

1. Primary bone tumors - more common in the 5-40 year age group 2

   • Night pain is a significant "red flag" requiring further investigation 1

2. Stress fractures - especially in athletic individuals

   • May not be visible on initial X-rays 1

3. Inflammatory conditions - including early arthritis

4. Metabolic bone diseases - including early osteoporosis 3

When to Consider Advanced Imaging

• CT scan: Only when there is diagnostic uncertainty to better visualize calcification, periosteal bone formation, cortical destruction 2

• Bone scintigraphy (bone scan): Consider when symptoms persist but initial imaging is negative, or to evaluate for multifocal disease 1

• PET/CT: Not indicated as initial imaging but may be useful for evaluating extent of disease if malignancy is confirmed 1

Common Pitfalls to Avoid

1. Attributing symptoms to trauma without appropriate imaging workup - this can delay diagnosis of malignancy 2

2. Performing biopsy before referral to a specialized center - improper biopsy technique can complicate future surgical management 1, 2

3. Failing to investigate persistent pain despite normal initial radiographs 1

4. Overlooking night pain as a significant red flag for possible malignancy 1

5. Incomplete imaging of the affected area - ensure imaging includes the entire bone and adjacent joints 2

By following this systematic approach, clinicians can ensure timely diagnosis and appropriate management of bone pain in young adults, potentially identifying serious conditions at an earlier, more treatable stage.