Painful Tumours

Clinical Features

  • Many benign lesions are painless and incidental
  • Rest, night or progressive pain suggests an active, malignant or impending fracture process
  • Osteoid osteoma causes night pain relieved by NSAIDs, from nidus prostaglandins
  • Osteoid osteoma affects adolescents and young adults in femur and tibia
  • Spinal osteoid osteoma causes painful scoliosis, lesion on the concave side
  • Intra-articular osteoid osteoma mimics arthritis
  • Osteoblastoma pain is duller, less nocturnal and less NSAID responsive
  • Osteoblastoma exceeds 2 cm, often in posterior spinal elements
  • Chondroblastoma causes epiphyseal joint line pain, effusion and marrow oedema in adolescents
  • Malignant pain is constant, progressive and present at rest and night
  • Osteosarcoma and Ewing pain is often blamed on injury or growing pains
  • Ewing sarcoma may cause fever and raised inflammatory markers
  • Pain in an adult long bone cartilage lesion suggests chondrosarcoma
  • Functional pain on weightbearing predicts fracture and forms part of the Mirels score

Differential Diagnosis

  • Painful, aneurysmal bone cyst, LCH, Brodie abscess and GCTB
  • Painful, microfracture through fibrous dysplasia or unicameral bone cyst
  • Painful soft tissue lesions, ANGEL (angiolipoma, neuroma, glomus, eccrine spiradenoma, leiomyoma)
  • Glomus tumour causes cold sensitivity and pinpoint subungual tenderness
  • Painless, NOF, fibrous cortical defect, bone island, bone infarct and intraosseous lipoma
  • Painless, vertebral haemangioma and unicameral bone cyst until fracture
  • Painful enchondroma prompts a search for another cause or chondrosarcoma
  • Osteochondroma is painless unless mechanical or with stalk fracture

Management

  • Radiofrequency ablation is the usual osteoid osteoma treatment
  • Exclude referred pain, such as hip pathology presenting at the knee
  • Image for fracture
  • Refer atypical pain or aggressive features to a bone tumour service before intervention

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.