Is Bone Pain a Sign of Cancer?

This page is for anyone with an aching bone who wonders if it could be cancer, and for people already in cancer treatment. It explains the usual causes, the one pattern that needs emergency care, and what doctors check.

MedlinePlus makes a point that gets lost in symptom searches. Bone pain is less common than joint pain and muscle pain. It is a deeper, duller ache. It does not follow a joint line. Sometimes the source is obvious, such as a fracture after a fall. Sometimes it is not. Cancer that has spread to bone sits on that less obvious list.

That list is long. Most of it is not cancer. MedlinePlus names injury and overuse. It names osteomyelitis, an infected bone. It names osteoporosis, a loss of bone mineral. It names lost blood supply, as in sickle cell anemia, and toddler fracture. It also names leukemia, bone cancer, and cancer that has spread to bone.

So the answer to the question in the title is: often not. But MedlinePlus says to take bone pain seriously and to see your provider about any bone pain you cannot explain. The pattern around the pain helps show how fast to act.

One pattern needs emergency care. In spinal cord compression, cancer in or beside a bone of the spine presses on the spinal cord. The American Cancer Society (ACS) lists its signs:

• back pain, sometimes with pain going down one or both legs.
• numbness of the legs or belly.
• leg weakness or trouble moving your legs.
• loss of control of urine or stool, or problems passing urine.

ACS calls spinal cord compression an oncology emergency. If it is not treated right away, the person can become paralyzed. That is why this pattern needs emergency care, not a next-available appointment. A history of cancer makes it more urgent to be checked.

In the lower spine, pressure on the nerve roots is called cauda equina syndrome. The same urgency applies.

ACS says radiation is often part of the treatment, sometimes with a steroid, and is often started within the first 12 to 24 hours. Some people need surgery first. Your treating team decides this, so there is nothing here for you to arrange yourself. What matters on your side is getting seen fast.

Outside that emergency, cancer can cause bone pain in other ways. Three routes lead here, and they behave differently.

Cancer that starts in bone is rare and skews young. In osteosarcoma, about half of tumors arise in the femur. Of those, 80% are in the distal femur, just above the knee. The next sites in order are the proximal tibia, proximal humerus, pelvis, jaw, and fibula. Osteosarcoma occurs mostly in teenagers and young adults, and more than half of these tumors in children and teens arise around the knee.

Blood cancers reach bone from inside the marrow. In multiple myeloma, plasma cells hollow out areas of bone called lytic lesions. A painful collapse of a vertebral body is a known trigger for radiation. Myeloma is also why bone pain and blood calcium are checked together. A calcium level more than 1 mg/dL above the reference range is one of the myeloma-defining events.

Solid tumors spread to bone through the bloodstream. NCI's pain summary lists what that produces: pain, fractures, cord compression, and a need for bone radiation. In one myeloma trial, monthly pamidronate cut skeletal-related events to 38%, against 51% with placebo.

Two common causes of bone pain in someone already in treatment have nothing to do with the cancer growing.

The first is G-CSF. Filgrastim and pegfilgrastim raise neutrophil counts. NCI reports bone aching in 20% to 71% of people given them. The timing is specific. It starts within 2 days of a pegfilgrastim dose. It lasts 2 to 4 days.

In a phase III trial, naproxen 500 mg twice daily for 5 to 8 days cut both the pain and how long it lasted. A trial of loratadine 10 mg daily showed no clear benefit. Ask your own team before reaching for either. Naproxen is hard on the stomach and kidneys and can interact with a low platelet count. The plan they write for you outranks these trial figures.

The second is a radiation pain flare. Pain in a treated area can briefly get worse after radiation for bone metastases. In one trial, a short steroid course starting on the day of radiation and running a few days after it cut how often flares happened. If your team wants you to do this, they will prescribe the tablets and tell you how many days to take them.

Knowing both patterns saves a lot of alarm. Both mimic progression. Neither is progression.

Whatever the cause, the visit starts with questions. MedlinePlus lists the questions asked first. Where the pain is. When it started. Whether it is getting worse. What else is happening. The tests follow from those answers. They include a CBC and differential, bone X-rays and a bone scan, CT or MRI, hormone level tests, and urine tests.

The details worth writing down are the ones that shift a decision. Pain that is worse at night or at rest is not the same as pain that is worse with use. Pain fixed in one spot is not the same as pain that moves. A known cancer history changes the bar for imaging more than any other fact. So does being unable to bear weight, which raises the risk of a fracture.

Bone pain has a treatment ladder of its own, separate from treating the cancer.

Radiation is the workhorse. One trial of re-irradiation compared a single 8 Gy dose with 20 Gy over 5 days. Response rates at 2 months were similar. A review of 15 re-irradiation studies reported complete response in 20% and partial response in 50%.

Bone-modifying drugs are the second tool. Pamidronate and zoledronic acid cut cancer-related bone pain and painkiller use. Denosumab is an antibody given as a shot under the skin. Across six trials it delayed worsening pain longer than zoledronic acid. It causes less kidney harm but more low blood calcium. It needs no dose change for kidney function, though NCI notes low calcium is more likely when kidney function is poor. Both classes carry a risk of osteonecrosis of the jaw.

More background sits in what a bone lesion means on a scan and what bone metastasis means. For the wider symptom picture, see symptoms of cancer.

• Call 911 or go to an emergency department if back or neck pain arrives with any of these: weakness in a leg, numbness spreading across more than one band of skin, an unsteady walk, trouble starting a stream of urine, or any loss of bladder or bowel control. ACS warns that without prompt treatment this can cause paralysis. Do not drive yourself.
• Call your care team the same day if a bone gives way under your weight, or pain follows a minor knock and will not settle. Also call the same day if bone pain comes with a fever, which can mean an infected bone. If you are getting chemotherapy, CDC says a temperature of 100.4°F (38°C) or higher is a medical emergency: call your care team right away.
• Call your care team within a day or two if a deep ache stays fixed in one spot, is worse at night or at rest, or keeps building over weeks. Also call if it turns up in someone with a past cancer diagnosis.

• NCI — Symptoms of Cancer
• NCI PDQ — Cancer Pain (Health Professional Version)
• American Cancer Society — Bone Metastases
• CDC — Fever During Chemotherapy
• MedlinePlus — Bone pain or tenderness
• NCI PDQ — Osteosarcoma and Undifferentiated Pleomorphic Sarcoma of Bone Treatment (Health Professional Version)
• NCI PDQ — Plasma Cell Neoplasms Including Multiple Myeloma Treatment (Health Professional Version)