Multiple Myeloma Presenting as Sacroiliac Joint Pain: A Case Report
Danielle Southerst, BScH, DC, John Dufton, DC, MSc, MD,
Paula Stern, BSc, DC, FCCS(C)
Canadian Memorial Chiropractic College,
Division of Graduate Studies,
6100 Leslie Street,
Toronto, ON, M2H 3J1,
(416) 482-2344 x 287;
Multiple Myeloma (MM) is the most common primary cancer of bone in adults. The clinical presentation of MM is varied and depends on the sites and extent of involvement. Most importantly for chiropractors, the leading clinical symptoms of MM are related to bone neoplasm and may mimic pain of musculoskeletal origin. The following is the case of a 56 year old male chiropractic patient presenting with a 6 month history of sacroiliac joint pain previously diagnosed and managed unsuccessfully as a hematoma by multiple providers. Physical examination, imaging, and laboratory investigations confirmed a diagnosis of MM. The case report describes relevant pathophysiology, clinical presentation, imaging, and management for MM, while illustrating key issues in patient management as they relate to chiropractic practice and the recognition of pathology in the context of musculoskeletal pain.
From the FULL TEXT Article
Multiple Myeloma (MM) is a primary malignancy of bone marrow characterized by clonal proliferation of plasma cells and production of monoclonal immunoglobulin. It is the most common primary bone cancer in adults [1,2] contributing to 1.3% of new cancer cases in Canada and 1.9% of cancer deaths.  In 2008, an estimated 6000 Canadians were living with the disease, including 2100 newly diagnosed.  Myeloma is slightly more prevalent in males [4-6] and blacks. [4,5,7] The median age at diagnosis is 66, with the majority diagnosed over the age of 60; [8,9] however in a review of 1027 patients diagnosed with MM, 30% were under the age of 60 and the age of diagnosis ranged from 20–92.  The most common symptoms reported are those related to bone neoplasm including unexplained backache that is often severe and precipitated by movement. [8,11] These symptoms may motivate a patient to seek conservative care for what is assumed to be a complaint of musculoskeletal origin. This case emphasizes key components of patient management as they relate to chiropractic practice and the recognition of pathology in the context of a patient presenting with pain of presumed musculoskeletal origin.
The pathophysiology of MM begins with cytogenetic changes that occur in the plasma cell lineage within the bone marrow.  Monoclonal expansion of myeloma plasma cells within the bone marrow interferes with the production of normal blood cells. Myeloma cells produce abnormal immunoglobulin (M protein), light chain proteins (κ and λ), and other factors, such as cytokines. Excessive M protein causes hyperviscosity of the blood, whereas excessive light chains cause end organ damage (for example renal failure). Lesions of bone are largely caused by the release of cytokines  that promote bone resorption via upregulation of osteoclast activity, differentiation, and maturation. [7,9] Unrestrained osteoclast activation leads to the release of mediators that stimulate further clonal proliferation of myeloma cells and subsequent tumour growth.  The result is a vicious cycle of bone destruction and tumour growth, leading to further bone destruction.