Nonarticular Rheumatism/Regional Pain Syndrome Clinical Presentation

  • Author: Daniel Muller, MD, PhD; Chief Editor: Herbert S Diamond, MD   more...
 
Updated: May 24, 2011
 

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%.[9]
  • 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.
Next

Physical

  • 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).
Previous
Next

Causes

  • The cause of fibromyalgia has not been elucidated. A recent study links a little-known infectious retrovirus to chronic fatigue syndrome.[10] 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.
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Daniel Muller, MD, PhD  Department of Internal Medicine, Section of Rheumatology, Associate Professor, University of Wisconsin at Madison

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

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert E Wolf, MD, PhD  Professor Emeritus, Department of Medicine, Louisiana State University Health Sciences Center at Shreveport; Chief, Rheumatology Section, Medical Service, Overton Brooks Veterans Administration Medical Center of Shreveport

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

Disclosure: Nothing to disclose.

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

Disclosure: eMedicine Salary Employment

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, and American College of Rheumatology

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD  Professor of Medicine, Temple University School of Medicine; 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, and Phi Beta Kappa

Disclosure: Merck Ownership interest Other; Smith Kline Ownership interest Other; Zimmer Ownership interest Other

References

  1. Schur EA, Afari N, Furberg H, Olarte M, Goldberg J, Sullivan PF. Feeling bad in more ways than one: comorbidity patterns of medically unexplained and psychiatric conditions. J Gen Intern Med. Jun 2007;22(6):818-21. [Medline].

  2. Abeles AM, Pillinger MH, Solitar BM, Abeles M. Narrative review: the pathophysiology of fibromyalgia. Ann Intern Med. May 15 2007;146(10):726-34. [Medline].

  3. Mountz JM, Bradley LA, Modell JG, et al. Fibromyalgia in women. Abnormalities of regional cerebral blood flow in the thalamus and the caudate nucleus are associated with low pain threshold levels. Arthritis Rheum. Jul 1995;38(7):926-38. [Medline].

  4. Wolfe F, Russell IJ, Vipraio G, et al. Serotonin levels, pain threshold, and fibromyalgia symptoms in the general population. J Rheumatol. Mar 1997;24(3):555-9. [Medline].

  5. Light AR, White AT, Hughen RW, Light KC. Moderate exercise increases expression for sensory, adrenergic, and immune genes in chronic fatigue syndrome patients but not in normal subjects. J Pain. Oct 2009;10(10):1099-112. [Medline].

  6. Wolfe F, Ross K, Anderson J, et al. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum. Jan 1995;38(1):19-28. [Medline].

  7. Wolfe F, Anderson J, Harkness D, et al. Health status and disease severity in fibromyalgia: results of a six-center longitudinal study. Arthritis Rheum. Sep 1997;40(9):1571-9. [Medline].

  8. Wolfe F, Ross K, Anderson J, Russell IJ. Aspects of fibromyalgia in the general population: sex, pain threshold, and fibromyalgia symptoms. J Rheumatol. Jan 1995;22(1):151-6. [Medline].

  9. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. Feb 1990;33(2):160-72. [Medline].

  10. Lombardi VC, Ruscetti FW, Das Gupta J, Pfost MA, Hagen KS, Peterson DL. Detection of an Infectious Retrovirus, XMRV, in Blood Cells of Patients with Chronic Fatigue Syndrome. Science. Oct 8 2009;[Medline]. [Full Text].

  11. Häuser W, Bernardy K, Arnold B, Offenbächer M, Schiltenwolf M. Efficacy of multicomponent treatment in fibromyalgia syndrome: a meta-analysis of randomized controlled clinical trials. Arthritis Rheum. Feb 15 2009;61(2):216-24. [Medline].

  12. [Guideline] Carville SF, Arendt-Nielsen S, Bliddal H, Blotman F, Branco JC, Buskila D, et al. EULAR evidence-based recommendations for the management of fibromyalgia syndrome. Ann Rheum Dis. Apr 2008;67(4):536-41. [Medline].

  13. Goode AP, Freburger J, Carey T. Prevalence, practice patterns, and evidence for chronic neck pain. Arthritis Care Res (Hoboken). Nov 2010;62(11):1594-601. [Medline]. [Full Text].

  14. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. Nov 20 2010;376(9754):1751-67. [Medline].

  15. Bäcker M, Lüdtke R, Afra D, et al. Effectiveness of leech therapy in chronic lateral epicondylitis: a randomized controlled trial. Clin J Pain. Jun 2011;27(5):442-7. [Medline].

  16. Hoffman JH. Guidelines for Beneficial Group Exercise for Fibromyalgia. Practical Pain Management. 2007/06;7:50-57.

  17. Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. Nov 17 2004;292(19):2388-95. [Medline].

  18. Goldenberg D, Mayskiy M, Mossey C, et al. A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia. Arthritis Rheum. Nov 1996;39(11):1852-9. [Medline].

  19. Gendreau R, Mease P, Rao S, et al. Milnacipran: A potential new treatment of fibromyalgia. Arthritis Rheum. 2003;48:S616.

  20. Arnold LM, Lu Y, Crofford LJ, et al. A double-blind, multicenter trial comparing duloxetine with placebo in the treatment of fibromyalgia patients with or without major depressive disorder. Arthritis Rheum. Sep 2004;50(9):2974-84. [Medline].

  21. Arnold LM, Goldenberg DL, Stanford SB, Lalonde JK, Sandhu HS, Keck PE Jr. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled, multicenter trial. Arthritis Rheum. Apr 2007;56(4):1336-44. [Medline].

  22. Crofford LJ, Rowbotham MC, Mease PJ, et al. Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. Apr 2005;52(4):1264-73. [Medline].

  23. Russell IJ, Kamin M, Bennett RM, Schnitzer TJ, Green JA, Katz WA. Efficacy of Tramadol in Treatment of Pain in Fibromyalgia. J Clin Rheumatol. Oct 2000;6(5):250-7. [Medline].

  24. Younger J, Mackey S. Fibromyalgia symptoms are reduced by low-dose naltrexone: a pilot study. Pain Med. May-Jun 2009;10(4):663-72. [Medline].

  25. Russell IJ, Perkins AT, Michalek JE,. Sodium oxybate relieves pain and improves function in fibromyalgia syndrome: a randomized, double-blind, placebo-controlled, multicenter clinical trial. Arthritis Rheum. Jan 2009;60(1):299-309. [Medline].

  26. Wigers SH, Stiles TC, Vogel PA. Effects of aerobic exercise versus stress management treatment in fibromyalgia. A 4.5 year prospective study. Scand J Rheumatol. 1996;25(2):77-86. [Medline].

  27. Jentoft ES, Kvalvik AG, Mengshoel AM. Effects of pool-based and land-based aerobic exercise on women with fibromyalgia/chronic widespread muscle pain. Arthritis Rheum. Feb 2001;45(1):42-7. [Medline].

  28. Sheon RP, Moskowitz RW, Goldberg VM. Soft Tissue Rheumatic Pain: Recognition, Management, and Prevention. 3rd ed. Baltimore, Md: Williams and Wilkins; 1996.

  29. Sunshine W, Field TM, Quintino O, Fierro K, Kuhn C, Burman I, et al. Fibromyalgia benefits from massage therapy and transcutaneous electrical stimulation. J Clin Rheumatol. Feb 1996;2(1):18-22. [Medline].

  30. Ferraccioli G, Ghirelli L, Scita F, et al. EMG-biofeedback training in fibromyalgia syndrome. J Rheumatol. Aug 1987;14(4):820-5. [Medline].

  31. Haanen HC, Hoenderdos HT, van Romunde LK, et al. Controlled trial of hypnotherapy in the treatment of refractory fibromyalgia. J Rheumatol. Jan 1991;18(1):72-5. [Medline].

  32. Goldenberg DL, Kaplan KH, Nadeau MG. A controlled study of a stress-reduction, cognitive-behavioral treatment program in fibromyalgia. J Musculoskel Pain. 1994;2:53-66.

  33. Taylor S, Thordarson DS, Maxfield L, et al. Comparative efficacy, speed, and adverse effects of three PTSD treatments: exposure therapy, EMDR, and relaxation training. J Consult Clin Psychol. Apr 2003;71(2):330-8. [Medline].

  34. Cohen H, Neumann L, Haiman Y, et al. Prevalence of post-traumatic stress disorder in fibromyalgia patients: overlapping syndromes or post-traumatic fibromyalgia syndrome?. Semin Arthritis Rheum. Aug 2002;32(1):38-50. [Medline].

  35. Kaplan KH, Goldenberg DL, Galvin-Nadeau M. The impact of a meditation-based stress reduction program on fibromyalgia. Gen Hosp Psychiatry. Sep 1993;15(5):284-9. [Medline].

  36. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Dell Publishing; 1990.

  37. Deluze C, Bosia L, Zirbs A, et al. Electroacupuncture in fibromyalgia: results of a controlled trial. BMJ. Nov 21 1992;305(6864):1249-52. [Medline].

  38. Assefi NP, Sherman KJ, Jacobsen C, et al. A randomized clinical trial of acupuncture compared with sham acupuncture in fibromyalgia. Ann Intern Med. Jul 5 2005;143(1):10-9. [Medline].

  39. Bell IR, Lewis DA, Brooks AJ, et al. Improved clinical status in fibromyalgia patients treated with individualized homeopathic remedies versus placebo. Rheumatology (Oxford). May 2004;43(5):577-82. [Medline].

  40. Fisher P, Greenwood A, Huskisson EC, et al. Effect of homeopathic treatment on fibrositis (primary fibromyalgia). BMJ. Aug 5 1989;299(6695):365-6. [Medline].

  41. Russell IJ, Michalek JE, Flechas JD, Abraham GE. Treatment of fibromyalgia syndrome with Super Malic: a randomized, double blind, placebo controlled, crossover pilot study. J Rheumatol. May 1995;22(5):953-8. [Medline].

  42. Rossini M, Di Munno O, Valentini G, Bianchi G, Biasi G, Cacace E. Double-blind, multicenter trial comparing acetyl l-carnitine with placebo in the treatment of fibromyalgia patients. Clin Exp Rheumatol. Mar-Apr 2007;25(2):182-8. [Medline].

  43. Muller D, Selfridge N. Fibromyalgia syndrome. In: Rakel D, ed. Integrative Medicine. 2nd ed. Philadelphia, PA: Saunders; 2007:509-18.

  44. Turk DC, Okifuji A, Sinclair JD, Starz TW. Pain, disability, and physical functioning in subgroups of patients with fibromyalgia. J Rheumatol. Jul 1996;23(7):1255-62. [Medline].

  45. Schleicher H, Alonso C, Shirtcliff EA, Muller D, Loevinger BL, Coe CL. In the face of pain: the relationship between psychological well-being and disability in women with fibromyalgia. Psychother Psychosom. 2005;74(4):231-9. [Medline].

 
Previous
Next
 
The spectrum of nonarticular myofascial pain syndromes.
Possible factors that lead to myofascial pain syndromes.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.