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Possible multiple myeloma presenting as non-mechanical groin pain — MSRA MCQ

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HardHip and GroinPossible multiple myeloma presenting as non-mechanical groin painMSRA

A 68-year-old man presents with 9 weeks of progressive right groin pain. It is now present at night and when resting, and he has started using a stick because of an unexplained limp. There has been no trauma. He has lost 4 kg unintentionally. Hip flexion, internal rotation and external rotation are full and do not reproduce the pain. There is no greater-trochanteric tenderness, radicular pain or neurological deficit. An anteroposterior pelvis radiograph shows mild bilateral hip osteoarthritis only. Blood tests requested because of his weight loss show haemoglobin 108 g/L and corrected calcium 2.71 mmol/L. eGFR and liver blood tests are normal. What is the most appropriate next step in primary care?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Arrange serum protein electrophoresis, serum free light chains, and plasma viscosity or erythrocyte sedimentation rate, then make a suspected-cancer-pathway referral if results suggest myeloma

Explanation lettering: B = shown as A · D = shown as B · E = shown as C · A = shown as D · C = shown as E

This presentation should not be attributed to the mild radiographic hip osteoarthritis. The pain is persistent, non-mechanical and occurs at rest/night; examination does not localise pathology to the hip joint; and he has systemic and biochemical warning features, specifically weight loss, anaemia and hypercalcaemia. In a person aged 60 years or over with persistent bone pain, NICE recommends assessment for myeloma with full blood count, calcium, plasma viscosity or ESR, serum protein electrophoresis and serum free light chains. He already has anaemia and hypercalcaemia, so the remaining myeloma investigations should be arranged promptly; suspected-cancer-pathway referral follows if these results suggest myeloma. A is initially attractive because normal plain radiography does not exclude some bony pathology, but occult femoral-neck fracture is less likely without trauma or inability to weight-bear and does not address the myeloma pattern. C wrongly delays investigation of a potentially malignant cause. D may be appropriate if the clinical picture primarily suggested prostate cancer, but it omits the NICE-recommended first-line myeloma tests indicated here. E is inappropriate because the clinical phenotype is atypical for hip osteoarthritis and oral NSAID treatment would delay investigation.

Reference: NICE NG12: Suspected cancer: recognition and referral — Myeloma, recommendation 1.10.4 (Updated 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE NG226: Osteoarthritis in over 16s — Diagnosis, recommendation 1.1.2 (19 October 2022) — https://www.nice.org.uk/guidance/ng226/chapter/Recommendations