Osteosarcoma

Recognition

Presentation: Persistent, deep, aching bone pain that worsens at night and does not respond to rest. Progressive swelling or palpable mass near a joint (often the knee). Restricted ROM of the adjacent joint. Limping or refusal to bear weight in adolescents. Pathological fracture may be the presenting event
Critical red flag: Pain that wakes a child or adolescent from sleep, worsening progressively over weeks, not responsive to rest
Imaging findings: Sunburst pattern (radiating spicules of new bone), Codman triangle (periosteal elevation), destructive metaphyseal lesion
Metastasis: Hematogenous metastasis to the lungs occurs early (present in 15-20% at diagnosis)
Key pathology: Tumor cells produce disorganized osteoid. Rapid growth destroys normal bone architecture and extends through cortex into soft tissue. Periosteal reaction produces characteristic radiographic patterns

Absolute contraindication: Do not massage over the tumor site, surrounding tissues, or any area of known or suspected metastasis
During chemotherapy: Follow oncology massage guidelines — light pressure only, avoid port sites, be aware of thrombocytopenia and neutropenia
Post-surgical (limb salvage or amputation): Massage supports scar management, phantom limb pain, and surrounding soft tissue recovery with physician clearance
Palliative care: Gentle, comfort-focused massage with oncology training. Prioritize quality of life and emotional support

Immediate referral: Any adolescent presenting with persistent, worsening bone pain near a joint (especially the knee) with swelling and night pain must be referred for medical evaluation before any treatment
Do not treat the affected area — massage does not address malignancy and may increase discomfort or theoretically affect circulation to the tumor region
Differentiate from benign causes: Growing pains (bilateral, muscular, evening onset, no swelling), stress fractures (activity-related, no mass), Osgood-Schlatter (tibial tuberosity, not metaphyseal)

Osteosarcoma is the most common primary malignant bone tumor, with peak incidence in adolescents during rapid skeletal growth
Night pain in an adolescent that worsens over time and does not respond to rest is a critical red flag
The tumor site and areas of metastasis are absolute contraindications to massage. Systemic work requires oncology guidelines
Distal femur, proximal tibia, and proximal humerus are the most common sites (metaphyseal regions near growth plates)
Sunburst pattern, Codman triangle, and destructive metaphyseal lesion are characteristic imaging findings