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Nonarticular Rheumatism/Regional Pain Syndrome Clinical Presentation

  • Author: David Rabago, MD; Chief Editor: Herbert S Diamond, MD  more...
 
Updated: Dec 06, 2015
 

History

Persons with inflammatory syndromes, such as tendonitis and bursitis, usually experience pain during movement and may have local signs of swelling and redness.

Persons with noninflammatory syndromes, such as Fibromyalgia, often experience increased pain after movement during periods of rest. The reported sensation of swelling is subjective and not present on physical examination.

  • Classification criteria for fibromyalgia require widespread pain and tenderness in at least 11 of 18 defined points. These criteria yield a sensitivity of 88.4% and a specificity of 81.1%.[17]
  • In clinical practice, chronic widespread muscular pain may be associated with fewer tender points but is often combined with other characteristic symptoms of fibromyalgia, including nonrestorative sleep, chronic fatigue, stiffness, headache, irritable bowel syndrome, and mood disorders.
  • Multiple bursitis-tendonitis syndrome involves pain and tender points associated with defined bursae and tendon insertions.
  • Regional and local bursitis and tendonitis are associated with repetitive motion and overuse, pain upon motion, decreased range of motion, and local swelling over surface tendons and bursae. Trigger finger is caused by flexor tendon nodules in the palmar aspect of the hand.
    • Bursitis commonly affects the subdeltoid, olecranon, trochanteric, iliopsoas, prepatellar, anserine, and Achilles.
    • Tendonitis commonly affects the rotator cuff, biceps, abductor pollicis longus/extensor pollicis brevis (de Quervain tenosynovitis), digital flexor tendons (trigger finger), and Achilles.
    • Other common sites of inflammation at the attachment of tendons or ligaments to bone (enthesitis) include the lateral (tennis elbow) and the medial (golfer's elbow) humeral epicondyles and plantar fascia.
    • Entrapment syndromes cause paresthesia with numbness and tingling more than pain. Common sites include the ulnar nerve at the elbow, the median nerve at the wrist (carpal tunnel syndrome), the lateral cutaneous nerve at the thigh (meralgia paresthetica), and the posterior tibial nerve at the ankle (tarsal tunnel syndrome).
  • Determine the location and pattern of pain and specific movements that exacerbate the pain. The history should include questions about work tasks, hobbies, sports, previous injuries, sleeping position, and a history of clenching the jaw or hands.
  • Inquire about social and psychological stress at work, home, and in other relationships. Inquire about the use of tobacco, alcohol, and recreational drugs.
  • The following articles provide additional information: Temporomandibular Joint Syndrome, Carpal Tunnel Syndrome, Thoracic Outlet Syndrome, Tendonitis, and Bursitis.
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Physical

See the list below:

  • Tender-point examinations for fibromyalgia are performed using digital thumb pressure, 4 kg/cm3 at 9 bilateral upper and lower extremity sites. Control points—middle of forehead, midanterior thigh, mid deltoid, thumb, and big toe—provide information regarding general hyperesthesia.
  • Multiple bursitis-tendonitis syndrome is associated with tender points that relate to defined bursae and tendon insertions, as well as the absence of cervical, trapezius, and scapular tender points. No objective signs of inflammation are present.
  • Hypermobility syndrome is associated with 3 or more of the following 5 areas of joint laxity in the presence of symmetrical joint pain and stiffness: (1) passive apposition of the thumb to the forearm, (2) passive hyperextension of the fingers, (3) active hyperextension of the elbow greater than 10°, (4) active hyperextension of the knee greater than 10°, and (5) flexion of the spine and placement of the palms on the floor without bending the knees.
  • Neurovascular entrapment syndromes are associated with reproduction of pain and paresthesia distal to the site of entrapment upon tapping over the involved nerve (Tinel sign; carpal or tarsal tunnel syndrome) or upon maneuvers compressing the neurovascular passage. Forced wrist flexion (Phalen test) commonly elicits paresthesiae in patients with carpal tunnel syndrome.
  • No criterion-standard physical examination test is used to assess thoracic outlet syndrome. Postural problems, pendulous breasts, and poor muscle tone may be evident. In the modified Adson test, the pulse is palpated at the wrist and the supraclavicular space is auscultated while the patient performs a Valsalva maneuver with the arm elevated and the head turned to the opposite side. A positive test result entails decreased pulse and an arterial bruit, along with report of pain and paresthesia.
  • Regional and local bursitis and tendonitis are associated with pain upon motion, decreased range of motion, and local swelling and redness over surface tendons and bursae. In patients with tendonitis, active motion is often more limited than passive motion. In some cases of tendonitis, stretching the tendon elicits pain (Finkelstein test for de Quervain tendonitis).
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Causes

See the list below:

  • The cause of fibromyalgia has not been elucidated. A recent study links a little-known infectious retrovirus to chronic fatigue syndrome.[18] Further research will be needed to determine if this retrovirus is also linked to fibromyalgia and if antiretroviral treatment can be helpful.
  • Associated conditions, but not necessarily etiologic factors for fibromyalgia, may include the following:
    • Severe flulike syndrome
    • Autoimmune diseases (eg, rheumatoid arthritis [RA], systemic lupus erythematosus [SLE])
    • A defined infection (eg, Lyme disease, Hepatitis C, HIV)
    • Trauma (eg, a motor vehicle accident)
    • Chronic disturbed sleep
    • Family history of fibromyalgia
    • Female sex
    • Psychological stress and depression
    • Emotional trauma
  • Many of the above associated factors may contribute to multiple bursitis-tendonitis syndrome, which may be a subset of fibromyalgia.
  • Regional and local bursitis and tendonitis are often associated with repetitive motion and localized trauma. Fluoroquinolones have been linked to tendonitis, as have systemic disorders such as rheumatoid arthritis and spondyloarthropathies. Carpal tunnel syndrome may be idiopathic or may be associated with pregnancy, endocrine disorders (eg, hypothyroidism, acromegaly), wrist synovitis (eg, rheumatoid arthritis, gout, pseudogout), and systemic illnesses such as amyloidosis (eg, primary, secondary to hemodialysis).
  • Hypermobility syndrome appears in familial clusters, indicating a genetic predisposition. Defined genetic disorders characterized by joint laxity include Ehlers-Danlos, Marfan, and pseudoxanthoma elasticum.
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Contributor Information and Disclosures
Author

David Rabago, MD Assistant Professor, Co-Director, Primary Care Research Fellowship, Associate Research Director, Department of Family Medicine, University of Wisconsin School of Medicine and Public Health

David Rabago, MD is a member of the following medical societies: American Academy of Family Physicians, North American Primary Care Research Group, Society of Teachers of Family Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Daniel Muller, MD, PhD Associate Professor of Medicine, Department of Medicine, Section of Rheumatology, University of Wisconsin School of Medicine and Public Health

Daniel Muller, MD, PhD is a member of the following medical societies: American Holistic Medical Association, American College of Physicians-American Society of Internal Medicine, American College of Rheumatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Elliot Goldberg, MD Dean of the Western Pennsylvania Clinical Campus, Professor, Department of Medicine, Temple University School of Medicine

Elliot Goldberg, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Robert E Wolf, MD, PhD Professor Emeritus, Department of Medicine, Louisiana State University School of Medicine in Shreveport; Chief, Rheumatology Section, Medical Service, Overton Brooks Veterans Affairs Medical Center

Robert E Wolf, MD, PhD is a member of the following medical societies: American College of Rheumatology, Arthritis Foundation, Society for Leukocyte Biology

Disclosure: Nothing to disclose.

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