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

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ModerateHip and GroinPossible myeloma presenting as persistent non-mechanical groin bone painMSRA

A 72-year-old man presents with a 3-month history of progressively worsening deep left groin pain. The pain is now present at rest and regularly wakes him at night. It is not consistently related to walking, and morning stiffness is absent. He has had no trauma, fever, weight loss, urinary symptoms or change in bowel habit. On examination, he has a mildly antalgic gait but full passive hip flexion, internal rotation and external rotation without reproduction of pain. There is no inguinal mass, abdominal tenderness or focal neurological deficit. What is the most appropriate initial investigation in primary care?

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Correct answer: E — Request a full blood count, adjusted calcium, erythrocyte sedimentation rate or plasma viscosity, serum protein electrophoresis and serum free light chains

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

This is persistent, non-mechanical bone-type pain in a person aged over 60 years, rather than typical hip osteoarthritis: the pain occurs at rest and overnight, is not activity-related, and passive hip movement does not reproduce it. NICE recommends assessment for myeloma in people aged 60 years and over with persistent bone pain by requesting a full blood count, calcium, plasma viscosity or erythrocyte sedimentation rate, serum protein electrophoresis and serum free light chains. A is an initially plausible inflammatory or infective screen, but it omits the monoclonal protein investigations required for myeloma assessment. B may detect hypercalcaemia or bone turnover but remains an incomplete myeloma screen. C is reasonable where prostate cancer is suggested by urinary symptoms, an abnormal prostate examination or a raised PSA, but does not address the NICE investigation pathway for persistent bone pain. D would be appropriate if occult fracture, avascular necrosis or a local structural hip lesion were the leading diagnosis; this presentation instead requires first-line investigation for myeloma.

Reference: Suspected cancer: recognition and referral (NG12) — Recommendations organised by site of cancer (Updated 2025) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer