Diagnostic Imaging Pathways - Bone Pain

{tab=Pathway Home}

Population Covered By The Guidance

This pathway provides guidance for imaging patients with bone pain. There are links to other pathways for imaging patients with suspected bony metastases, myeloma, soft tissue masses, low back pain or joint pain in various joints.

Date reviewed: August 2013

Date of next review: 2017/2018

Published: October 2013

Quick User Guide

Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.

No radiation None 0
Minimal radiation Minimal < 1 millisieverts
Low radiation Low 1-5 mSv
Medium radiation Medium 5-10 mSv
High radiation High >10 mSv


Pathway Diagram


Image Gallery

Pending clarification of consent

{tab=Teaching Points}

Teaching Points


Red Flags: Clinical Assessment in Bone Pain


Plain Radiography


Magnetic Resonance Imaging (MRI)


Computed Tomography (CT)


Bone Scintigraphy

Positron Emission Tomography (PET)



Date of literature search: June 2013

The search methodology is available on request. Email

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

  1. National Institute for Health and Care Excellence (NICE). NICE Clinical Guideline 27: Referral guidelines for suspected cancer. 2005 [updated 2011 April; cited 2013 June 25th]. (Evidence based guidelines). View the guidelines
  2. Expert Panel on Musculoskeletal Imaging:, Morrison W, Zoga A, Daffner RH, Weissman BN, Bancroft L, et al. ACR Appropriateness Criteria: Primary bone tumours. American College of Radiology; 2009 [cited 2013 April 1]. (Evidence based guideline). View the guideline
  3. Ludwig H, Kumpan W, Sinzinger H. Radiography and bone scintigraphy in multiple myeloma: a comparative analysis. Br J Radiol. 1982;55(651):173-81. (Level III evidence)
  4. Dimopoulos M, Terpos E, Comenzo RL, Tosi P, Beksac M, Sezer O, et al. International myeloma working group consensus statement and guidelines regarding the current role of imaging techniques in the diagnosis and monitoring of multiple Myeloma. Leukemia. 2009;23(9):1545-56. (Evidence based guidelines)
  5. Frank JA, Ling A, Patronas NJ, Carrasquillo JA, Horvath K, Hickey AM, et al. Detection of malignant bone tumors: MR imaging vs scintigraphy. AJR Am J Roentgenol. 1990;155(5):1043-8. (Level III evidence)
  6. Hogeboom WR, Hoekstra HJ, Mooyaart EL, Freling NJ, Veth RP, Postma A, et al. MRI or CT in the preoperative diagnosis of bone tumours. Eur J Surg Oncol. 1992;18(1):67-72. (Level II evidence)
  7. Bloem JL, Taminiau AH, Eulderink F, Hermans J, Pauwels EK. Radiologic staging of primary bone sarcoma: MR imaging, scintigraphy, angiography, and CT correlated with pathologic examination. Radiology. 1988;169(3):805-10. (Level II evidence)
  8. Yu HHM, Tsai Y-Y, Hoffe S. Overview of diagnosis and management of metastatic disease to bone. Cancer Control. 2012;19(2):84-91. (Review article)
  9. Ilaslan H, Schils J, Nageotte W, Lietman SA, Sundaram M. Clinical presentation and imaging of bone and soft-tissue sarcomas. Cleve Clin J Med. 2010;77 Suppl 1:S2-7. (Review article)
  10. Pettersson H, Gillespy T, 3rd, Hamlin DJ, Enneking WF, Springfield DS, Andrew ER, et al. Primary musculoskeletal tumors: examination with MR imaging compared with conventional modalities. Radiology. 1987;164(1):237-41. (Level III evidence)
  11. Collins MS, Koyama T, Swee RG, Inwards CY. Clear cell chondrosarcoma: radiographic, computed tomographic, and magnetic resonance findings in 34 patients with pathologic correlation. Skeletal Radiol. 2003;32(12):687-94. (Level II evidence)
  12. Murphey MD, Jelinek JS, Temple HT, Flemming DJ, Gannon FH. Imaging of periosteal osteosarcoma: radiologic-pathologic comparison. Radiology. 2004;233(1):129-38. (Level II/III evidence)
  13. Littrell LA, Wenger DE, Wold LE, Bertoni F, Unni KK, White LM, et al. Radiographic, CT, and MR imaging features of dedifferentiated chondrosarcomas: a retrospective review of 174 de novo cases. Radiographics. 2004;24(5):1397-409. (Level II/III evidence)
  14. Murphey MD, wan Jaovisidha S, Temple HT, Gannon FH, Jelinek JS, Malawer MM. Telangiectatic osteosarcoma: radiologic-pathologic comparison. Radiology. 2003;229(2):545-53. (Level III evidence)
  15. Assoun J, Richardi G, Railhac JJ, Baunin C, Fajadet P, Giron J, et al. Osteoid osteoma: MR imaging versus CT. Radiology. 1994;191(1):217-23. (Level III evidence)
  16. Davies M, Cassar-Pullicino VN, Davies AM, McCall IW, Tyrrell PN. The diagnostic accuracy of MR imaging in osteoid osteoma. Skeletal Radiol. 2002;31(10):559-69. (Level III evidence)
  17. Zampa V, Bargellini I, Ortori S, Faggioni L, Cioni R, Bartolozzi C. Osteoid osteoma in atypical locations: the added value of dynamic gadolinium-enhanced MR imaging. Eur J Radiol. 2009;71(3):527-35. (Level III evidence)
  18. Liu PT, Chivers FS, Roberts CC, Schultz CJ, Beauchamp CP. Imaging of osteoid osteoma with dynamic gadolinium-enhanced MR imaging. Radiology. 2003;227(3):691-700. (Level III evidence)
  19. Niitsu M, Takeda T. Solitary hot spots in the ribs on bone scan: value of thin-section reformatted computed tomography to exclude radiography-negative fractures. J Comput Assist Tomogr. 2003;27(4):469-74. (Level II/III evidence)
  20. Levine BD, Motamedi K, Chow K, Gold RH, Seeger LL. CT of rib lesions. AJR Am J Roentgenol. 2009;193(1):5-13. (Review article)
  21. Dalbeth N, Choi HK. Dual-energy computed tomography for gout diagnosis and management. Curr Rheumatol Rep. 2013;15(1):301. (Review article)
  22. The Royal College of Radiologists. iRefer 7.0.1: Making the best use of clinical radiology. 2012 [updated 2012 Jan; cited 2013 May 5]; 7. (Evidence based guideline). View the guideline
  23. Schaffer DL, Pendergrass HP. Comparison of enzyme, clinical, radiographic, and radionuclide methods of detecting bone metastases from carcinoma of the prostate. Radiology. 1976;121(2):431-4. (Level III evidence)
  24. Du Y, Cullum I, Illidge T, Ell P. Fusion of metabolic function and morphology: sequential [18F]fluorodeoxyglucose positron-emission tomography/computed tomography studies yield new insights into the natural history of bone metastases in breast cancer. J Clin Oncol. 2007;25(23):3440-7. (Level II evidence)
  25. Treglia G, Salsano M, Stefanelli A, Mattoli MV, Giordano A, Bonomo L. Diagnostic accuracy of (1)(8)F-FDG-PET and PET/CT in patients with Ewing sarcoma family tumours: a systematic review and a meta-analysis. Skeletal Radiol. 2012;41(3):249-56. (Level I/II evidence)

{tab=Information for Consumers}

Information for Consumers

Information from this website

Information from the Royal Australian and New Zealand College of Radiologists’ website

Consent to Procedure or Treatment

Radiation Risks of X-rays and Scans

Bone Scan

Computed Tomography (CT)

Magnetic Resonance Imaging (MRI)

Plain Radiography (X-ray)

Computed Tomography (CT)

Contrast Medium (Gadolinium versus Iodine)

Gadolinium Contrast Medium

Iodine-Containing Contrast Medium

Magnetic Resonance Imaging (MRI)

Plain Radiography/X-rays

Radiation Risk of Medical Imaging During Pregnancy

Radiation Risk of Medical Imaging for Adults and Children



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