Bone Pain: Causes and When to Worry

What bone pain feels like

Bone pain tends to be deep, penetrating, dull or boring, and well localized to one spot. It often persists at rest and at night. Pressing on the bone usually makes it worse.

Common causes of bone pain

Injuries and fractures

A break causes sudden pain, swelling, bruising and difficulty using the limb. A bone bruise (bone contusion) is a deep injury without a break and can ache for weeks.

Stress fractures

Repeated loading causes tiny cracks, most often in the shin, foot (metatarsals) and heel. Pain builds during exercise, eases with rest, and there is tenderness on one spot of bone. Runners, military recruits, dancers and people with low energy intake or low bone density are at risk. See stress fracture.

Osteoporosis fractures

Osteoporosis itself is painless, but it causes fractures from minor falls or even coughing. Spinal compression fractures cause sudden back pain, loss of height and a stooped back. Wrist and hip fractures are also common.

Growing pains

Common in children aged 3 to 12: aching in both legs, typically the shins, calves or thighs, in the evening or night. The child is well in the daytime, does not limp and the pain responds to rubbing. Pain in one leg only, limping, swelling or fever are not growing pains.

Vitamin D deficiency and osteomalacia

Low vitamin D softens bone (osteomalacia in adults, rickets in children). It causes widespread aching bone pain, especially in the lower back, hips, pelvis and legs, with muscle weakness and a waddling walk. Risk factors include little sun exposure, darker skin at northern latitudes, malabsorption and kidney disease.

Serious causes of bone pain

Bone infection (osteomyelitis)

Osteomyelitis causes worsening pain, tenderness, warmth and swelling over a bone, often with fever. It follows open fractures, surgery, diabetic foot ulcers or spread through the blood, especially in children and people who inject drugs.

Cancer

• Bone metastases: cancers of the breast, prostate, lung, kidney and thyroid commonly spread to bone, causing persistent, progressive pain, often at night, and fractures. See bone metastases.
• Multiple myeloma: a blood cancer in older adults causing back or rib pain, fractures, tiredness, kidney problems and high calcium.
• Leukemia: bone pain in children with pallor, bruising, fevers and tiredness.
• Primary bone cancers (osteosarcoma, Ewing sarcoma): rare, mostly in teenagers and young adults, with pain and a swelling near the knee or upper arm.

Sickle cell disease

Blocked blood vessels cause sudden, severe bone pain crises in the back, chest, arms and legs. See sickle cell disease.

Other causes

• Paget's disease of bone in older adults: enlarged, deformed bones with aching pain
• Avascular necrosis: loss of blood supply, often the hip, linked to steroids and alcohol
• Hyperparathyroidism: high calcium with bone pain, kidney stones and fatigue
• Bone cysts and benign tumors, such as osteoid osteoma, classically causing night pain relieved by NSAIDs

Red flags

See a doctor promptly for bone pain that:

• wakes you at night or is worse at rest
• keeps getting worse over weeks
• comes with fever, weight loss, night sweats or fatigue
• occurs in someone with a history of cancer
• comes with a lump, swelling or a fracture after minor force

How doctors find the cause

A doctor will ask where and when it hurts, about injuries, activity changes, diet, medicines (especially steroids), cancer history and general symptoms. They will press over the bone and check nearby joints and nerves.

Tests may include:

• X-ray: first-line for fractures, tumors and bone changes; early stress fractures can be invisible
• Blood tests: blood count, inflammation markers (ESR, CRP), calcium, alkaline phosphatase, vitamin D, kidney function, PSA, and protein electrophoresis for myeloma
• MRI: the best test for stress fractures, infection and tumors
• Bone scan or CT: to look for spread of cancer
• DEXA scan: to measure bone density
• Biopsy: if infection or a tumor is suspected

Treatment

• Injuries and stress fractures: rest, ice, immobilization in a cast or boot, and a gradual return to activity.
• Osteoporosis: calcium and vitamin D, weight-bearing exercise and bone-strengthening medicines.
• Vitamin D deficiency: vitamin D replacement.
• Infection: weeks of antibiotics, sometimes surgery to remove dead bone.
• Cancer: treatment of the cancer; radiotherapy, bone-strengthening drugs and surgery to relieve pain and prevent fractures.
• Pain relief: acetaminophen (paracetamol) or NSAIDs such as ibuprofen; follow the label dose. Avoid NSAIDs with kidney disease, stomach ulcers or blood thinners.

Frequently asked questions

What does bone pain feel like?

Bone pain is usually a deep, dull, boring or aching pain in one spot, often worse at night and not much relieved by resting or changing position. Pressing on the bone typically hurts. Muscle pain, by contrast, is more spread out and worse when you use the muscle.

When should I worry about bone pain?

See a doctor if bone pain wakes you at night, lasts more than 2 weeks, keeps getting worse, or comes with fever, weight loss, night sweats, a lump or a history of cancer. Get urgent care for a deformed limb or bone pain with fever and swelling.

Can vitamin D deficiency cause bone pain?

Yes. Severe vitamin D deficiency softens bones (osteomalacia), causing widespread aching in the lower back, hips, pelvis, ribs and legs, along with muscle weakness. A blood test confirms it, and vitamin D supplements usually relieve the pain over weeks to months.

Is bone pain at night a sign of cancer?

Not usually, but persistent night pain is one of the warning signs doctors take seriously. Infections, stress fractures and benign bone tumors can also cause night pain. Bone pain at night that lasts more than a couple of weeks should be assessed with an exam and X-ray.

What causes bone pain and swelling on the side of the wrist and hand?

Common causes include a fracture of the scaphoid or wrist bones after a fall, tendon inflammation such as de Quervain's tenosynovitis, a ganglion cyst, or arthritis. Swelling with redness and fever may mean infection. Any wrist pain after a fall onto an outstretched hand needs an X-ray.