Bones are complex living tissues comprised of an inner “spongy” bone surrounded by solid “compact” bone. Soft marrow, which produces bone and blood cells, lies in the center of many bones.

There are many causes of bone pain, ranging from a bone bruise or fracture, to less common (albeit very serious) causes, such as bone cancer or infection.

Associated symptoms and the quality of your pain (e.g. sharp and stabbing versus dull and achy) can provide clues as to the “why” behind your bone pain, imaging and/or blood tests are often needed to pin down the exact diagnosis.

After a diagnosis, a treatment plan will follow, which may entail one of many therapies, such as medication to ease pain, physical therapy, and/or surgery.

Common Causes

To understand the potential causes of bone pain, it’s best to start with the two most common causes—a bone bruise and a bone fracture:

Bone Bruise

A bone bruise most commonly occurs when a bone hits a hard surface, as in a fall from a great height. This impact creates tiny breaks in the outer layer of the bone, in addition to bleeding underneath the periosteum—a thin layer of tissue that covers bone.

Besides significant bone pain with exquisite tenderness to the touch, swelling and discoloration often occur.

Keep in mind, other than trauma or injury, osteoarthritis is a common culprit behind bone bruises. This is because as the cartilage between bones wears away or degenerates, the bones begin to rub against each other—a trauma that can eventually develop into a bruise.

Fracture

A fracture refers to a broken bone, which may occur as a result of trauma, bone weakening from osteoporosis, or repetitive stresses on the bone. Besides a sharp, stabbing pain that worsens with movement or when pressure is applied, swelling and bruising around the fracture may occur. In some cases, the area involving the fracture will appear deformed.

Less Common Causes

Here are some less common causes of bone pain, many of which are serious and require the care of more than one specialist (for example, an orthopedic surgeon and an oncologist).

Vertebral compression fractures—also called spinal fractures—cause back pain and are most common in individuals with osteoporosis. These fractures may result from simple tasks like performing a household chore, sneezing, or coughing.

Osteomalacia

Osteomalacia refers to decreased bone mineralization and subsequent bone softening. This bone condition most commonly occurs as a result of vitamin D deficiency. While not always present, the dull, aching bone pain of osteomalacia tends to be worse with activity and bearing weight.

In addition to generalized bone pain and tenderness, a person with osteomalacia may experience the following:

  • Muscle weaknessMuscle spasms and crampsFracturesDifficulty walking and a waddling gaitFractures due to excessive bone weakening

Paget’s Disease

Paget’s disease is a chronic bone condition that affects older adults. In this disease, the bone remodeling process (in which old bone is removed and new bone is formed) goes awry. This leads to the formation of excess bone that is brittle or abnormally shaped.

While many people with Paget’s disease have no symptoms—their condition is often found incidentally on an X-ray performed for another purpose—if symptoms do occur, bone pain is the most prominent one.

Keep in mind that while Paget’s disease can affect any bone in the body, it most commonly targets the spine, pelvis, femur (thighbone), humerus (upper arm bone), and skull. 

Primary Bone Cancer

Bone pain is the most common symptom of bone cancer. The pain usually comes and goes at first and then becomes constant. Besides a deep or dull aching pain that is worse at night and during activity, swelling around the bone, weight loss, and fatigue may occur with bone cancer.

Primary bone cancers, ranging from most to least common, include:

  • Osteosarcoma
  • Ewing’s sarcoma
  • Chondrosarcoma

Metastatic Bone Cancer

Metastatic bone cancer refers to cancer that begins in another organ (most commonly, the breast, lung, thyroid, kidney, and prostate) and spreads (metastasizes) to the bone. Cancer that spreads to the bone weakens it, causing pain and making the bone more prone to breaking.

Both osteosarcoma and Ewing’s sarcoma are more common in children and adolescents. Chondrosarcoma is most common in adults older than 40 years. 

Multiple Myeloma

Multiple myeloma is a cancer of plasma cells, a type of immune system cell that normally produces antibodies. These cells grow abnormally and uncontrollably within the bone marrow and eventually cause a multitude of symptoms including:

  • Bone pain (felt most commonly in the back or chest and triggered by movement)FracturesAnemiaInfectionKidney problemsNeurologic problems

Leukemia

With leukemia, abnormal blood cells grow uncontrollably within a person’s bone marrow. This excess growth of cancer cells leads to overcrowding within the bone marrow, which causes bone and joint pain. The aching bone pain—which is most common in acute lymphoblastic leukemia, but may also occur in acute myeloid leukemia or myelodysplastic syndrome—is usually felt in the long bones of the arms and legs, as well as the ribs.

Infection

An infection of the bone—called osteomyelitis—causes dull bone pain, along with swelling, warmth, redness, and tenderness around the affected area. A fever may also be present.

Osteomyelitis may occur as a result of bacteria within the bloodstream seeding the bone or from an infection that spreads to the bone from an adjacent soft tissue or joint.

Osteonecrosis

Osteonecrosis occurs when a bone’s blood supply is compromised, resulting in death of bone and bone marrow cells and subsequent bone collapse. In addition to pain, limited use of the affected area is common. For instance, with osteonecrosis of the hip, a person may limp and require the use of a cane or walker.

Besides serious injury or trauma, the most common risk factors for developing osteonecrosis include:

  • Corticoisteroid use, especially with prolonged use and high doses
  • Excessive alcohol use
  • Having certain underlying medical conditions, like systemic lupus erythematosus (SLE)

Vaso-Occlusive Crisis From Sickle Cell Anemia

Sickle cell anemia is an inherited disease caused by a mutation in the gene that codes for hemoglobin, a protein that delivers oxygen within your red blood cells to your organs and tissues. The abnormal hemoglobin in people with sickle cell anemia (called hemoglobin S) leads to crescent-shaped red blood cells that are sticky and stiff.

Unfortunately, these sticky, stiff cells get stuck to the walls of small blood vessels, eventually blocking blood flow and oxygen delivery—a phenomenon called a vaso-occlusive crisis (VOC).

Bone pain from a VOC can be intense and felt in the legs, arms, and back.

Triggers are variable and often unknown, but may include:

  • DehydrationWeather or air conditions like cold, windy, or low humidityTravel to high-altitude placesStressInfection

When to See a Healthcare Provider

It’s important to seek medical attention for any type of bone pain, especially (and more urgently) if your pain is severe, persistent, worsening over time, or associated with swelling, redness, warmth, a fever, unintentional weight loss, or a palpable mass or lump.

Because sickle cell anemia is a genetic disease, vaso-occlusive crises may begin in babies as young as 6 months old and last throughout life.

Diagnosis

The diagnosis of bone pain usually involves a detailed medical history, physical examination, and one or more imaging tests. Depending on a healthcare provider’s underlying suspicion, blood tests or a biopsy may be warranted.

Medical History

During your appointment, you can expect your healthcare provider to ask you several questions related to your bone pain.

Examples of potential questions include:

  • Where is your pain located?When did your bone pain first become noticeable?Have you experienced any recent trauma or injury?Is your pain constant or does it come and go?Does anything make your pain worse or better?Does your pain wake you up at night?Are you experiencing other symptoms (e.g., fever, weight loss, or muscle weakness)?

Physical Examination

During the physical exam, your healthcare provider will inspect and press on (palpate) the location of your pain in order to assess for tenderness, swelling, discoloration, warmth, masses/lumps, and deformity.

Your healthcare provider will also examine surrounding muscles and joints and evaluate your ability to bear weight and move the affected bone.

Blood Tests

For many bone pain diagnoses, blood tests are warranted. For instance, in order to confirm a diagnosis of Paget’s disease, your healthcare provider will order an alkaline phosphatase blood level (which will be elevated due to the high rate of bone turnover going on).

For a suspected bone cancer diagnosis, several blood tests will be ordered by an oncologist, especially if the cancer is metastatic and the primary cancer site is unknown.

While certainly not an exhaustive list, some of these blood tests that may be ordered include:

  • Complete blood count
  • Basic metabolic panel
  • One or more tumor markers (e.g., prostate specific antigen (PSA), carcinoembyronic antigen (CEA), etc.)

Lastly, to diagnose multiple myeloma, your healthcare provider will order a blood and urine protein electrophoresis. These tests look for the abnormal protein produced by plasma cells called a monoclonal (M) protein.

Biopsy

If certain conditions are suspected, such as bone cancer, an infection, or Paget’s disease, a biopsy of the bone may need to be taken. A biopsy entails removing a small piece of the affected bone and sending it off to a laboratory for examination under a microscope.

To diagnose a cancer of the bone marrow, such as leukemia or multiple myeloma, your healthcare provider will perform a bone marrow aspiration and biopsy.

Imaging

Various imaging tests may be ordered to diagnose the culprit behind your bone pain.

These tests may include:

  • X-rays
  • Bone scan
  • Computed tomography (CT) scan
  • Combined positron emission tomography (PET)/CT scan
  • Magnetic resonance imaging (MRI)

Differential Diagnoses

In certain cases, it can be tricky to distinguish bone pain from joint pain or muscle pain, for which there are many possible causes. The good news is that along with an examination by a healthcare provider, imaging tests (often, an X-ray or MRI) can definitively sort out whether bone or soft tissue is causing your pain.

Treatment

Your treatment regimen will depend on your underlying diagnosis. Keep in mind, for many bone-related diagnoses, the treatment plan may be quite complex, involving more than one intervention.

Self-Care Strategies

While most bone pain diagnoses require more advanced therapies, a bone bruise can be treated with simple self-care strategies (once a fracture is ruled out):

  • Rest: In order to allow for optimal healing, resting the affected bone is extremely important.
  • Ice: Applying a cold compress, bag of ice, or bag of frozen peas over the bruised bone can reduce swelling, stiffness, and pain.
  • Support: If the bruised bone is near a joint (for example, your knee), wearing a knee brace can provide support and stability.

Medications

Besides alleviating your bone pain, your healthcare provider may use various drugs to address the underlying cause.

Painkillers

To ease your bone pain, your healthcare provider may recommend Tylenol (acetaminophen) or a non-steroidal anti-inflammatory drug (NSAID) like Advil (ibuprofen). For more severe pain, like that associated with cancer, fracture, or a vaso-occlusive crisis, your healthcare provider may prescribe opioids, which are much stronger pain medications.

Bisphosphonates

A type of medication called a bisphosphonate is used to treat osteoporosis, Paget’s disease, and bone damage caused by cancer. Bisphosphonates work by blocking the absorption of bone.

Antibiotics

Antibiotics, given through the vein (intravenous), are necessary to treat a bone infection.

Vitamin D

Treatment of osteomalacia depends on the underlying cause, but if due to vitamin D deficiency (most common), aggressive vitamin D supplementation under the care of your provider is essential. Thankfully, with vitamin D repletion, the improvement in bone pain can be significant, occurring within weeks.

Cancer Therapies

Chemotherapy is the main treatment for acute leukemias, and is also used in the treatment of bone cancer. Depending on the type of cancer, other therapies may be utilized.

For example, the treatment of multiple myeloma is complex and often entails a regimen of multiple drugs including:

  • A proteasome inhibitor—a drug that target cells, like plasma cells, that make a lot of proteinAn immunomodulatory drug—a medication that uses your own immune system to target the cancerA steroid

Finally, a stem cell transplant may be considered in the treatment of leukemia or multiple myeloma.

Sickle Cell Therapies

Sickle cell anemia requires life-long treatment. In addition to pain medications, patients often take antibiotics to prevent and treat infections and Hydrea (hydroxyurea) to help reduce the number of vaso-occlusive crises.

Radiation

Radiation is a key therapy for treating primary and metastatic bone cancer. Radiation kills the cancer cells, thereby alleviating pain and preventing further damage to the bone.

Physical Therapy

Physical therapy is often a key part of therapy once a fracture (especially a major one, like the hip) has healed. The purpose of physical therapy is to strengthen and improve the flexibility and mobility of surrounding muscles. Physical therapy is also useful for improving bone strength and health in people who have osteoporosis or osteomalacia.

In addition to various exercises, your physical therapist may utilize heat, ice, massage, or ultrasound and recommend an assistive device to ease your pain and prevent falls (e.g., a cane if a pelvic or leg bone is affected).

Surgery

Surgery may be utilized for various bone pain conditions, such as:

  • Repairing a bone fractureRemoving damaged bone and tissue from an infectionStabilizing bone from a cancer that has weakened or broken itRemoving part of a bone to improve blood flow in osteonecrosis

Prevention

Some bone pain diagnoses can be prevented, most notably bone fractures that occur as a result of osteoporosis.

Here are some strategies to optimize your bone health and strength:

  • Eat a diet rich in calcium.
  • Ensure proper vitamin D intake (a supplement may be required). The Institute of Medicine recommends 600 IU vitamin D daily for adults through the age of 70 and 800 IU daily for adults over the age of 70.
  • Engage in 30 minutes of daily weightbearing exercises (e.g., power walking, dancing, or lifting weights).
  • Avoid smoking.
  • Limit alcohol intake.

To prevent bone bruises, wear protective gear during contact sports (e.g., shin guards and knee or elbow pads) and seatbelts while riding in a vehicle.

A Word From Verywell

Getting to the root of your bone pain can be a bit of a tedious and intensive process. As you navigate your bone pain journey—from diagnosis to treatment—try to be patient, reach out for support, and remain resilient.