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Metastatic Bone Disease Presenting as Trochanteric Bursitis

A woman of 77 was referred acutely with left leg pain, focused on the shin but also affecting the lateral aspect of the hip, the groin and the knee. Her pain had been previously thought due to trochanteric bursitis, for which she had been injected locally with corticosteroid-with improvement after the first injection, but not the second. She had a 9-year history of inflammatory arthritis, diagnosed 4 years earlier as seropositive rheumatoid arthritis. On examination she had a good range of movement in her lumbar spine, with straight leg raising of 60° bilaterally. Internal and external rotation of her left hip was limited. She was tender over the left greater trochanter and she also had a tender spot over the tibia. There was no abnormality of the knee. She had no breast lumps. Systemic examination was normal. Haemoglobin was 13 g/dL, rheumatoid factor 50 iu/L, erythrocyte sedimentation rate 33 mm/h. Alkaline phosphatase was mildly raised at 129 iu/L. Chest X-ray was normal, as were films of the pelvis and hips taken six months earlier. X-ray of the tibia showed no abnormality. An isotope bone scan revealed increased uptake over the left greater trochanter (Figure 1). On plain X-rays there was a periosteal reaction around the greater trochanter, and underlying bone had abnormal cortex. Bone biopsy revealed poorly differentiated metastatic carcinoma, consistent with a breast or lung primary. A mammogram showed an ill defined mass suspicious of carcinoma (Figure 2). The final diagnosis was therefore leg pain due to metastatic carcinoma of the breast, for which she has been treated with radiotherapy and tamoxifen. Figure 1 Isotope bone scan showing uptake in the left femoral head (posterior view)