eMedicine Specialties > Rheumatology > Soft Tissue and Regional Rheumatic Disease

Nonarticular Rheumatism/Regional Pain Syndrome

Author: Daniel Muller, MD, PhD, Department of Internal Medicine, Section of Rheumatology, Associate Professor, University of Wisconsin at Madison
Contributor Information and Disclosures

Updated: Nov 5, 2007

Introduction

Background

Nonarticular rheumatic pain syndromes can be classified into 5 general categories, as follows: (1) tendonitis and bursitis, such as the common lateral epicondylitis (tennis elbow) and trochanteric bursitis; (2) structural disorders, such as pain syndromes resulting from flatfoot and the hypermobility syndrome; (3) neurovascular entrapment, such as carpal tunnel syndrome and thoracic outlet syndrome; (4) regional myofascial pain syndromes, with trigger points similar to those of fibromyalgia but in a localized distribution, such as the temporomandibular joint syndrome; and (5) generalized pain syndromes, such as fibromyalgia (FMS) and multiple bursitis-tendonitis syndrome. The more generalized and chronic the syndrome, the more difficult it is to treat.

The spectrum of nonarticular pain syndromes and their interactions with mood disorders and chronic fatigue is depicted in Image 1. Comorbidity is common.¹

Pathophysiology

Tendonitis presents as local pain, inflammation, dysfunction, and degeneration. It can be associated with overuse, infection, systemic rheumatic disease, or metabolic disturbance such as calcium apatite or pyrophosphate deposition. Fluoroquinolone antibiotic use can be associated with tendonitis and rupture. Inflammation can cause "triggering," in which the digit locks and a snapping sensation is felt upon release.

Bursitis presents as local pain and inflammation of the synovial fluid filled saclike structures that protect soft tissues from underlying bone. Overuse, infection, systemic rheumatic disease, and metabolic disturbance such as calcium apatite and pyrophosphate deposition can also cause bursitis. Gout often causes olecranon bursitis and prepatellar bursitis.

Structural disorders such as scoliosis, lateral patellar subluxation, and flatfoot can cause local pain but are not always a source of pain or dysfunction. The hypermobility syndrome presents with arthralgias due to increased joint laxity in the face of muscle disuse.

Neurovascular entrapment can occur centrally (eg, in spinal stenosis), in deep tissues (eg, thoracic outlet syndrome), or peripherally (eg, carpal or tarsal tunnel syndromes). Bone enlargement due to osteophytes, muscular tension, and inflammation can contribute to narrowing of a neurovascular passage. Pain and paresthesia usually occur distal to the site of entrapment.

Regional myofascial pain syndromes, such as temporomandibular joint syndrome, may represent a pain-spasm pain cycle triggered by mechanical injury, such as strain or overuse.

Multiple bursitis and tendonitis syndrome present with anatomically localized areas of pain and dysfunction. Pain can be widespread, but the muscle tender points observed in fibromyalgia are absent. Usually, much less fatigue occurs, and responses to local therapies are better than in fibromyalgia.

Fibromyalgia, in many cases, presents as a form of allodynia, in which usually painless stimuli are perceived as painful, and hyperalgesia, in which normally painful stimuli is amplified. Cerebrospinal fluid levels of substance P are elevated, and additional abnormalities in the serotonin system and in the regulation of cortisol exist. Fibromyalgia can also coexist with various autoimmune diseases and often presents after a severe flulike syndrome, a defined infection (eg, Lyme disease), or trauma. Sleep is often disturbed, and nonrestorative sleep is associated with increased pain. The increased prevalence in females may point to a hormonal influence. Few abnormalities occur in the peripheral musculature. Studies that show abnormalities of cerebral blood flow in the thalamus and caudate nucleus help support the likelihood that pain processing in the central nervous system behaves abnormally.²

Psychological, personality, and social factors may play important roles in many chronic cases of local and generalized pain syndromes. Image 2 depicts possible factors that contribute to the generation of these syndromes.

Frequency

United States

The incidence of all types of soft tissue rheumatism has been estimated at about 4000 per 100,000 population. The prevalence rate of fibromyalgia is about 2% of the population.³

International

International incidence and prevalence are similar to those in the United States.

Mortality/Morbidity

These syndromes are not life threatening but can be a cause of significant functional disability.

Race

Racial differences in prevalence have not been reported.

Sex

• Localized nonarticular rheumatism occurs with fairly equal distribution between males and females.
• The female-to-male ratio of fibromyalgia is about 8:1, affecting about 3.5% of females and 0.5% of males in the United States.

Age

• Nonarticular rheumatism is most common in persons aged 45-64 years, and fewer than 0.2% of people with nonarticular rheumatism are younger than 14 years.
• Fibromyalgia is most common in women in their fifth decade of life and is rare in prepubescent girls. The prevalence of fibromyalgia in women aged 60-79 years is 7%.³

Clinical

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%.⁴
• 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.

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).

Causes

• The cause of fibromyalgia has not been elucidated.
• 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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