Bone pain: Information for clinicians

You should suspect that pain is of bony origin if there are known bone metastases or a cancer which commonly spreads to bone e.g. breast, lung, renal, prostate.

Bone pain can be extremely debilitating because it affects function in so many ways. The treatment priorities are first getting pain relieved to allow sleep, then when sitting up and finally when moving about.

Red flags

The two things to bear in mind are:

  1. Cord compression from worsening vertebral metastases. Symptoms are worsening pain or heavy legs. 
  2. Risk of pathological fracture in a long bone. Symptoms are sudden worse pain on weight bearing.

Consider urgent scanning for rapidly changing pain.

Clinical features

Bone pain is usually well localised, might be worse on weight bearing (depending on site) and may be tender to touch. Often throbs at night.

An initial approach to treatment
  • Apply hot or cold packs
  • Paracetamol and NSAIDs - alongside a PPI.
  • A COX-2 inhibitor such as Celecoxib may be a good option
  • Titration of a strong opioid - e.g. titrate oral Morphine solution from 2.5mgs 4 hourly
  • A prn dose of analgesia before planned activity may help e.g. before a walk
  • Consider a trial of Lidocaine 5% plaster if the bone pain is very superficial e.g. a rib metastasis
  • Urgent control for severe bone pain - Dexamethasone 6mg a day for 5 days and then review (a good response to steroids may be an indication to refer for radiotherapy)
Specialist care
  • Radiotherapy is always considered for persistent metastatic bone pain. Often a single fraction is used. May cause a pain flare initially - cover with steroids.
  • Bisphosphonates intravenously (eg Zometa) to reduce skeletal events due to bone metastases, but can also help pain. There may be a role for oral bisphosphonates. 
  • Denosumab is a subcutaneous option that oncologists may recommend instead of bisphosphonates, but is much more costly
  • Prophylactic surgery can be dramatically helpful to prevent a pathological fracture and help pain

Recommended Resources

The BMJ Clinical Review - Cancer induced bone pain

Published 29th January 2015

ESMO Cancer pain Guidelines

Published 24th July 2018

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Related Services

Brent North Community Palliative Care Team - based at St Luke's
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Brent North Community Palliative Care Team - based at St Luke's

T. 020 8382 8013

North Brent Community Specialist Palliative Care Nurse team provides advice and visiting to palliative care patients in North Brent. The team is based at St Lukes Hospice.

Areas: Queensbury, Fryent, Welsh Harp, Barnhill, Kenton, Northwick Park, Preston, Sudbury, Wembley Central, Alperton, Tokyngton

The team can be contacted for referrals Monday to Sunday 8.30am to 4.30pm. 

After 4.30pm the Out of Hours Telephone Advice line 020 8382 8000 operates and calls will be taken by a nurse on St Lukes inpatient unit

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4 (DOCX)

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