A cancer history is important in any patient presenting with atraumatic bone pain. A history of breast or prostate cancer, no matter how remote, may indicate disease recurrence with metastases.  Be wary of patients with bony pain plus features concerning for lung or renal carcinomas since these malignancies are often metastatic to bone at presentation.  Pain is often a less prominent complaint of those with blastic mets, in contrast to lytic lesions, which tend to be more painful.

     The physical exam focuses on localizing tenderness to guide the subsequent radiologic evaluation. Breast or prostate exams may reveal the primary malignancy. A thorough neurologic examination of the lower extremities including a rectal exam should be performed to exclude cauda equina syndrome in patients with back pain and findings consistent with metastases to the spine. Any concern in physical exam for cord impingement warrants an MRI of the lumbar spine and possible neurosurgical consultation.