Ask a sports medicine doc: Recognizing bone tumors over other sports injuries
August 25, 2014
A 26-year-old friend of mine was having leg pain and thought it was a sports injury but he was diagnosed with a bone tumor. How do bone tumors commonly present?
Most tumors in bone are found in older patients who have cancer from a more distant source (i.e. breast or prostate) that then metastasizes or spreads to bone. However, primary bone cancer that actually starts in bone are seen mainly in young adults. Thus, it is easy to misdiagnose a bone tumor as a sports injury.
One of the hallmark signs of a possible bone tumor is pain that does not decrease with rest and there is pain at night that can wake someone from sleep. Less commonly, a patient may have fever and chills. One should also be suspicious if symptoms persist longer than one would expect from an injury or if symptoms are much greater in intensity than one would expect from a sports injury.
In the office, it is not uncommon to see incidental benign bone lesions in young people on radiographs taken for other purposes. With benign bone tumors, there is a clear border between the benign bone lesion and normal bone. In a more aggressive or malignant bone tumor, there is commonly erosion of the surrounding normal bone and there is no clear border between the tumor and normal bone. The bone may have multiple "holes" or lucencies in the bone where a tumor has seeded itself. However, if a tumor is in its early stages, radiographs may be unremarkable. Therefore if symptoms persist, I order an MRI.
If a football player takes a helmet to the thigh, they can develop a hematoma as a result of the muscle bleeding and causing a mass comprised of blood under the skin. Sometimes, tumors are mistakenly diagnosed as a hematoma. With hematomas, there is a distinct traumatic episode which caused the mass to occur. Moreover, with hematomas the skin over the mass has redness. With most bone or soft tissue tumors, the skin overlying the mass has no redness and the mass is firm and immobile.
Stress fractures can also mimic a bone tumor. Radiographs of an advanced stress fracture show areas of reactive bone. Stress fractures can usually be distinguished from a bone tumor in that symptoms from a stress fracture should decrease when the athlete rests and avoids sports. An MRI can also help distinguish between a stress fracture and a bone tumor.
I not uncommonly see benign Fibrous Cortical Defects (non-ossifying fibromas) in patients under the age of 20. In fact, up to 30 percent of people have had these and most never know it as they usually do not cause any symptoms. Most of these resolve by the age of 25.
Pigmented Villonodular Synovitis (PVNS) is another benign but aggressive process that I see. Patients typically present with knee pain and swelling. There is typically no injury and the swelling does not respond to rest. Patients complain of locking and catching similar to what one would feel with a meniscal tear. With PVNS, there is overgrowth of the synovium or lining tissue of the knee. An MRI can help diagnose it, but arthroscopy is often needed to confirm the diagnosis and to help control it. Unfortunately, it is difficult to eradicate PVNS.
An osteoid osteoma is a common benign bone tumor. Patients present with dull achy pain that is worse at night and is made much better after taking a non-steroidal anti-inflammatory medication such as ibuprofen. Most of these tumors occur in patients ages 5-20. These are usually clearly visible on radiographs. Osteoid osteomas can be successfully treated with surgery.
Giant Cell Tumors occur in patients 20-40 years of age and Chondroblastomas occur in patients 10-20 years of age. These typically occur around the knee or shoulder and cause pain in these areas. Radiographs typically show a large area devoid of bone and sometimes patients present with a fracture through these weak areas in the bone. Both of these types of benign tumors are treated with surgical removal, but unfortunately they can recur.
Osteosarcoma is the most common malignant bone tumor arising from bone. Most cases are seen in patients ages 10-20. These tumors usually present around the knee. Patients typically have night pain and pain may be worse after sports. These tumors can be treated with chemotherapy and surgery, but unfortunately, many patients may come to amputation to effectively treat and prevent spread of the cancer.
Ewings sarcoma is a malignant tumor found in patients ages 5-15. These often present in the femur or tibia, or pelvis. Patients may present with a palpable mass and have systemic symptoms such as fever and chills. This tumor is difficult to diagnose in the early stages. It can be effectively treated with chemo, radiation and/or surgery, but unfortunately many young patients die from this disease.
Fortunately, primary malignant bone tumors such as osteosarcomas are rare. For instance, in 11 years of orthopedic practice, I have diagnosed only one malignant bone tumor, but I do see several benign bone tumors each year.
Dr. Rick Cunningham is a Knee and Shoulder Sports Medicine Specialist with Vail-Summit Orthopaedics. He is a physician for the US Ski Team and chief of surgery at Vail Valley Medical Center. Do you have a sports medicine question you'd like him to answer in this column? Visit his website at http://www.vailknee.com to submit your topic idea. For more information about Vail-Summit Orthopaedics, visit http://www.vsortho.com.
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