eMedicine Specialties > Rheumatology > Soft Tissue and Regional Rheumatic Disease

Nonarticular Rheumatism/Regional Pain Syndrome

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

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.

Differential Diagnoses

Other Problems to Be Considered

Multiple Sclerosis
Hyperparathyroidism
Sleep apnea syndrome
Cervical spondylosis
Psychogenic rheumatism
Depression

Workup

Laboratory Studies

• Obtain the following studies to screen for systemic disease. All should yield results within the reference range.
  • CBC count
  • Erythrocyte sedimentation rate (ESR)
  • Thyroid-stimulating hormone (TSH)
  • Electrolytes, calcium, alanine aminotransferase (ALT), creatinine
• If indicated by history findings or abnormalities found on physical examination, the following studies may be obtained. All should yield results within the reference range unless the patients has a coexistent systemic illness.
  • Antinuclear antibody (ANA) for systemic autoimmune disease (Many false-positive tests have been reported.)
  • Rheumatoid factor (RF) for rheumatoid arthritis or immune complex disease
  • Creatine kinase (CK) for myositis
  • HIV serology
  • Lyme serology for Lyme disease (enzyme-linked immunosorbent assay [ELISA] screen and, if positive, Western blot to confirm)
  • Prolactin for panhypopituitarism
  • Urinalysis for renal disease
  • Hepatitis C antibody

Imaging Studies

• Plain radiographs may show calcific tendonitis. However, these may or may not correlate with clinical symptoms.
• MRI can be used to delineate rotator cuff disruption at the shoulder and to distinguish tendinitis from intra-articular synovitis. Otherwise, imaging is not necessary unless indicated by history findings or abnormalities found on physical examination.

Other Tests

• No other tests are necessary unless indicated by history findings or abnormalities found on physical examination.
• True muscle weakness may prompt electromyography (EMG) and nerve conduction velocity (NCV) studies. Compression neuropathies can be diagnosed using NCV studies.
• History of loud snoring, respiratory pauses, and excessive daytime sleepiness requires a sleep study to exclude sleep apnea syndrome.

Procedures

• No procedures are necessary unless indicated by history findings or abnormalities found on physical examination.
• Swollen bursae or tendon sheaths should be aspirated if infection or gout is suspected.

Histologic Findings

In most cases, characteristic histologic changes do not warrant biopsy.

Treatment

Medical Care

• Fibromyalgia and multiple bursitis-tendonitis syndrome
  • Sedating antidepressant (tricyclic) at night
  • Activating antidepressant in the morning
  • Low-level aerobic exercise and physical therapy, including heat or ice
  • Meditation training (Mindfulness meditation is recommended.)
  • Subcutaneous tender-point injections
  • EMG biofeedback and hypnotherapy
  • Psychotherapy and stress management
  • Cognitive behavior therapy program
• Regional and local bursitis and tendonitis
  • Acute exacerbations, first 24-48 hours
    • Rest
    • Immobilization
    • Ice
    • Nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Physical therapy
    • Antibiotics for infection
    • Chronic pain treatment
    • Local heat
    • NSAIDs
    • Tennis elbow strap for lateral epicondylitis
    • Padding for bursa and Achilles tendon
    • Local injection of bursa or tendon with lidocaine and long-acting steroids for cases resistant to conservative therapy: Infection must be ruled out prior to the use of steroids, especially in patients with olecranon and prepatellar bursitis. Never inject into the Achilles tendon because of the risk of rupture.
    • Bursal aspiration and sometimes sclerosis with tetracycline
    • Assessment of home and workplace habits such as posture and repetitive motion
• Alterations in sleep position may benefit persons with neurovascular entrapment such as thoracic outlet syndrome (ie, avoiding arm hyperabduction) and carpal tunnel syndromes (avoiding wrist flexion). Women with heavy pendulous breasts may need brassieres with proper support. Exercises to correct postural deficits are necessary. Night wrist splints may be curative in carpal tunnel syndrome. Postural therapies such as Alexander or Feldenkrais might be beneficial.
• Proper foot support and orthotics can benefit persons with tarsal tunnel syndrome. NSAIDS can be tried for carpal and tarsal tunnel syndromes. Local long-acting steroid injection can be helpful in carpal and tarsal tunnel syndromes.

Surgical Care

• No surgical care is necessary for fibromyalgia or multiple bursitis-tendonitis syndrome.
• Chronic local bursitis and tendonitis occasionally require bursectomy or excision of the inflamed tissue around the tendon, respectively, if conservative measures fail.
• Carpal and tarsal tunnel syndromes may require surgical decompression. Aggressively treat coexisting carpal tunnel syndrome before surgical therapy for thoracic outlet syndrome.

Consultations

• Fibromyalgia or multiple bursitis-tendonitis syndrome - Rheumatologist, psychologist, physical therapist, acupuncturist
• Local bursitis and tendonitis - Rheumatologist, general/orthopedic surgeon, podiatrist, acupuncturist
• Long-term management of fibromyalgia – Usually, primary care physician

Diet

No known benefits or worsening of symptoms are associated with dietary manipulations. No special diet requirements exist.

Activity

• Fibromyalgia and multiple bursitis-tendonitis syndrome
  • Often, patients must have periods of rest alternating with mild-to-moderate aerobic activity to optimize function. Hoffman recently published a detailed program of graded exercise for fibromyalgia.⁵  
  • Moderate activity over baseline often results in increased pain and fatigue.
• Local bursitis and tendonitis
  • Rest or immobilization for acute exacerbations
  • Moderate muscle strengthening and stretching for chronic syndromes

Medication

Fibromyalgia and multiple bursitis-tendonitis syndrome

Nonrestorative sleep is a significant problem for patients with fibromyalgia. Initial drug therapy consists of a low-dose sedating tricyclic antidepressant (TCA), usually amitriptyline (5-10 mg) 1 hour prior to bedtime.⁶ The dose is titrated upward every 5-14 days as tolerated, using the minimal dose to achieve restorative sleep. TCAs can cause excessive sedation; therefore, sertraline 25 mg in the morning or another of the more activating antidepressants (eg, fluoxetine) can be added. Other less-sedating TCAs can be substituted for amitriptyline in the evening (eg, nortriptyline) if necessary because of sedation. Dual-action serotonin and norepinephrine reuptake inhibitors, such as milnacipran (not yet on the market) and duloxetine (Cymbalta), have shown to be helpful in fibromyalgia.^7,8

Gabapentin has been used off-label for fibromyalgia syndrome because of its salutary effects on chronic pain. A recent clinical trial has shown benefit in fibromyalgia.⁹ Pregabalin, a similar drug, has been shown to be modestly beneficial in patients with fibromyalgia syndrome at a dose of 450 mg/day.¹⁰  

Trazodone can also be particularly helpful for sedation at night and may cause fewer adverse effects than amitriptyline. Doxepin, a non-TCA antidepressant, can be useful in liquid form to titrate at low doses (2-5 mg) for sedation at night. Cyclobenzaprine can relax muscles and can be used as a single dose at night (2.5-10 mg) or, commonly, at 10 mg tid.

Analgesic effects of NSAIDs may be helpful. One controlled trial showed benefits with tramadol (50-400 mg in divided doses)¹¹ ; however, tramadol used in combination with antidepressants can cause serotonin syndrome and increased sedation. Tramadol may play a role by allowing a 4-week drug holiday from antidepressant therapy to reset neural receptors and, in intermittent therapy, for exacerbations. Avoid long-term use of benzodiazepines and narcotics.

Regional and local bursitis and tendonitis

NSAIDs can decrease inflammation. Corticosteroid infiltrations may provide short-term and, occasionally, long-term benefit.  The Achilles tendon sheath must not be injected with corticosteroids because of the risk of tendon rupture. Patients with septic bursitis or tendonitis and systemic symptoms should be admitted for intravenous antibiotic therapy. 

See Temporomandibular Joint Syndrome, Carpal Tunnel Syndrome, Thoracic Outlet Syndrome, Tendonitis, and Bursitis.

Antidepressants

Some antidepressants provide sedation and relieve chronic pain. They may have a moderate-to-marked sedative effect.

Amitriptyline (Elavil)

Analgesic for certain chronic and neuropathic pain.

Dosing

Adult

5-100 mg PO qhs

Pediatric

Children: 0.1 mg/kg PO qhs, increase as tolerated over 2-3 wk to 0.5-2 mg PO qhs
Adolescents: 25-50 mg/d PO in divided doses, increase as tolerated to 100 mg/d PO in divided doses

Interactions

Increased sedation with CNS depressants (eg, alcohol, hypnotics, sedatives); effect decreased by carbamazepine, phenobarbital, and rifampin; inhibits antihypertensive response to bethanidine, clonidine, debrisoquin, guanadrel, guanethidine, and guanfacine; increases risk of malignant arrhythmias; enhances hypertensive crisis due to abrupt discontinuation of clonidine; use with altretamine may cause orthostatic hypertension; use with MAOI may induce hyperpyrexia, hypertension, tachycardia, confusion, seizures, and death; increased PT with warfarin; metabolism decreased by SSRIs, cimetidine, and methylphenidate; additive anticholinergic effects with other anticholinergics; lithium increases risk of nephrotoxicity; phenothiazines increase concentration of some TCAs; TCAs may increase concentration of phenothiazines
Enhances hypoglycemic effects of tolazamide, chlorpropamide, and insulin; absorption is reduced by cholestyramine and colestipol; enhances effects of amphetamines; diltiazem and verapamil appear to decrease metabolism of imipramine and potentially other TCAs; enhances pressor response to epinephrine, norepinephrine, and phenylephrine; indinavir and ritonavir may inhibit metabolism of clomipramine and potentially other TCAs; beta agonists predispose patient to cardiac arrhythmias

Contraindications

Documented hypersensitivity; administration within 14 d of MAOI use; narrow-angle glaucoma; pregnancy; lactation

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Anticholinergic adverse effects include dry mouth, flushing, diaphoresis, blurred vision, constipation, tachycardia, and hypotension; avoid abrupt discontinuation of long-term high-dose therapy; caution in hyperthyroidism and renal/hepatic impairment

Sertraline (Zoloft)

SSRI, less sedating than TCAs but appears to improve pain symptoms.

Dosing

Adult

25-100 mg PO qam

Pediatric

Not established

Interactions

All SSRIs are capable of inhibiting metabolism of desipramine, dextromethorphan, encainide, haloperidol, imipramine, metoprolol, perphenazine, propafenone, and thioridazine; increased toxicity with MAOI, sumatriptan, lithium, and TCAs; decreases metabolism/plasma clearance of some drugs (diazepam, tolbutamide), increasing their duration and effect; displaces highly bound protein drugs (eg, warfarin), resulting in increased effect

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in preexisting seizure disorders and in patients who have experienced a recent myocardial infarction, have unstable heart disease, and have hepatic or renal impairment; caution in agitated and/or hyperactive patients because the drug may induce active mania/hypomania; risk of suicide is inherent in depression

Doxepin (Sinequan)

Inhibits histamine and acetylcholine activity and has proven useful in treatment of various forms of depression associated with chronic and neuropathic pain. Prominent sedative effect. Useful in oral concentrate, 10 mg/mL, to titrate small doses.

Dosing

Adult

2-100 mg PO qhs

Pediatric

<12 years: Not recommended
>12 years: 25-50 mg/d PO in single or divided doses

Interactions

Decreases effect of bretylium, guanethidine, clonidine, and levodopa; effect decreased by ascorbic acid and cholestyramine; increases effect/toxicity of carbamazepine, amphetamines, thyroid preparations, and sympathomimetics; increased toxicity with coadministration of fluoxetine (seizures), thyroid preparations, MAOIs, albuterol, CNS depressants (eg, benzodiazepines, opiate analgesics, phenothiazines, alcohol), anticholinergics, and cimetidine

Contraindications

Documented hypersensitivity; urinary retention; acute recovery phase following myocardial infarction; glaucoma

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, and hyperthyroidism; pregnancy and lactation; avoid discontinuation of long-term high-dose therapy

Trazodone (Desyrel)

5-HT2–receptor antagonist that inhibits reuptake of 5-HT. Negligible affinity for cholinergic, adrenergic, dopaminergic, or histaminic receptors. Intermediate sedation activity.

Dosing

Adult

50-150 mg PO qhs

Pediatric

Children: 1.5-2 mg/kg/d PO in divided doses, gradually increase q3-4d prn; not to exceed 6 mg/kg/d PO in 3 divided doses
Adolescents: 25-50 mg/d PO, increase to 100-150 mg/d PO in divided doses

Interactions

Additive serotonergic effects with other serotonergic agents (eg, buspirone, MAOIs); additive hypotensive effective with other psychotropics (eg, low-potency antipsychotics); additive sedation and impaired motor skills with ethanol

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Infrequent anticholinergic or cardiac adverse effects; safety/efficacy in children <18 y not established; caution in cardiac disease and/or arrhythmias; very sedating; therapeutic effects may take as long as 4 wk

Fluoxetine (Prozac)

SSRI, less sedating than TCAs but appears to improve symptoms of pain.

Dosing

Adult

10-40 mg PO qhs

Pediatric

Not established

Interactions

Increased effect with TCAs; increased/decreased effect of lithium (increased and decreased levels reported); increased toxicity of diazepam and trazodone; displaces highly protein bound drugs (warfarin); coadministration with sumatriptan causes increased weakness, hyperreflexia, and incoordination

Contraindications

Documented hypersensitivity; current MAOI use or administration within past 14 d

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Anxiety, insomnia, and significant anorexia and weight loss; caution in hepatic impairment and seizures; add/initiate other antidepressant therapy with caution as long as 5 wk after discontinuing drug

Duloxetine (Cymbalta)

Potent neuronal serotonin inhibitor and norepinephrine reuptake inhibitor. Antidepressive action is theorized to be due to serotonergic and noradrenergic potentiation in CNS.

Dosing

Adult

20 mg PO bid; may increase to 60 mg/d administered qd or divided as 30 mg PO bid

Pediatric

Not established

Interactions

Metabolized by CYP1A2 and CYP2D6; coadministration with drugs that inhibit CYP1A2 (eg, fluvoxamine, cimetidine, ciprofloxacin, enoxacin) may increase duloxetine blood levels and toxicity; coadministration with drugs that inhibit CYP2D6 (eg, paroxetine, fluoxetine, quinidine) may increase duloxetine blood levels and toxicity; duloxetine moderately inhibits CYP2D6 and may decrease elimination of CYP2D6 substrates (eg, TCAs, phenothiazines [eg, thioridazine], type 1C antiarrhythmics [eg, propafenone, flecainide]); coadministration with MAOIs may cause serious, sometimes fatal, reactions that include hyperthermia, rigidity, myoclonus, autonomic instability, and mental status changes including extreme agitation, delirium, and coma (see contraindications)

Contraindications

Documented hypersensitivity; uncontrolled narrow-angle glaucoma; do not administer within 14 d after cessation of MAOIs or initiation of MAOIs within 5 d after cessation of duloxetine

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Observe closely for clinical worsening and suicidality when initiating treatment or following dosage change; gradually decrease dose when discontinuing (do not abruptly discontinue); caution in hepatic impairment or end-stage renal disease; recommended not to prescribe to patients with substantial alcohol use or evidence of chronic liver disease; may cause slight blood pressure increase; may activate mania or hypomania; common adverse effects include nausea, dry mouth, constipation, decreased appetite, fatigue, somnolence, and increased sweating

Nonsteroidal anti-inflammatory agents (NSAIDS)

Although most NSAIDs are used primarily for their anti-inflammatory effects, they are effective analgesics and are useful for the relief of mild-to-moderate pain.

Ibuprofen (Ibuprin, Advil, Motrin)

DOC for mild-to-moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

200-800 mg PO tid

Pediatric

<6 months: Not established
>6 months: 30-70 mg/kg/d PO in divided doses q6-8h; not to exceed 400 mg/d if <20 kg, 600 mg/d if 20-30 kg, 800 mg/d if 30-40 kg, adult dose if >40 kg

Interactions

May decrease effects of loop diuretics with coadministration; coadministration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity of NSAIDs

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Nausea, heartburn, and GI bleeding; caution in CHF, hypertension, renal/hepatic impairment, and anticoagulant therapy; elderly people have increased risk for developing adverse effects (as many as 60% can develop peptic ulceration); compromises existing renal function, especially when CrCl <30 mL/min; CNS adverse effects (eg, confusion, agitation, hallucination) are generally observed in overdose or high-dose situations (elderly people can experience these effects at lower doses)

Centrally acting analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties.

Tramadol (Ultram)

Binds to mu opioid receptors and slightly inhibits reuptake of norepinephrine and serotonin.

Dosing

Adult

50-100 mg PO q4-6h, titrate in 50-mg increments q3d to effective dose; not to exceed 400 mg qd

Pediatric

Not established

Interactions

Decreases carbamazepine effects significantly; cimetidine increases toxicity; risk of serotonin syndrome with coadministration of antidepressants

Contraindications

Documented hypersensitivity; opioid dependency; concurrent use of MAOI or administration within 14 d; use of SSRIs, TCAs, and opioids; acute alcohol intoxication

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Less respiratory depression than opioids; can cause dizziness, nausea, constipation, sweating, and pruritus; additive sedation with alcohol and TCAs; abrupt discontinuation can precipitate opioid withdrawal symptoms; adjust dose in liver disease, myxedema, hypothyroidism, and hypoadrenalism; pregnancy and breastfeeding; seizure; development of tolerance or dependency occurs with extended use

Muscle relaxants

These agents are thought to work centrally by suppressing conduction in the vestibular cerebellar pathways. They may have an inhibitory effect on the parasympathetic nervous system.

Cyclobenzaprine (Flexeril)

Structurally similar to TCAs. Has anticholinergic and sedative adverse effects.

Dosing

Adult

2.5-40 mg PO; 10 mg tid usually effective

Pediatric

Not established

Interactions

Coadministration with MAOIs and TCAs may increase toxicity; cyclobenzaprine may have additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced with cyclobenzaprine

Contraindications

Documented hypersensitivity; current MAOI use or administration within 14 d; hyperthyroidism; CHF; arrhythmias

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Usual precautions of TCA therapy should be observed; caution in urinary hesitancy and angle-closure glaucoma

Anticonvulsants

These agents may alleviate chronic pain.

Gabapentin (Neurontin)

Membrane stabilizer, a structural analogue of inhibitory neurotransmitter gamma-aminobutyric acid (GABA), which paradoxically is thought not to exert effect on GABA receptors. Appears to exert action via the alpha(2)delta1 and alpha(2)delta2 auxiliary subunits of voltage-gaited calcium channels. Used to manage pain and provide sedation in neuropathic pain.

Dosing

Adult

100-1200 mg PO tid

Pediatric

<12 years: Not recommended
>12 years: Administer as in adults

Interactions

Antacids may significantly reduce bioavailability of gabapentin (administer at least 2 h following antacids); may significantly increase norethindrone levels; cimetidine, hydrocodone, and morphine may increase gabapentin AUC; naproxen may increase gabapentin absorption

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Common adverse effects include drowsiness, dizziness, somnolence, and unwanted eye movements; children may experience emotional ability hostility, thought disorder, and hyperkinesia; caution in elderly patients and patients with severe renal impairment; abrupt withdrawal may precipitate seizures

Pregabalin (Lyrica)

Structural derivative of GABA. Mechanism of action unknown. Binds with high affinity to alpha2-delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. Indicated for neuropathic pain associated with diabetic peripheral neuropathy, postherpetic neuralgia, or fibromyalgia. It is also indicated for adjunctive therapy in partial-onset seizures.

Dosing

Adult

75 mg PO bid initially; increase to 150 mg PO bid within 1 wk based on efficacy and tolerability; may further increase dose to 225 mg bid if needed

Pediatric

Not established

Interactions

May cause additive effects on cognitive and gross motor functioning when coadministered with drugs that cause dizziness or somnolence

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue gradually (over a minimum of 1 wk) to minimize increased seizure frequency in patients with seizure disorders; may cause insomnia, nausea, headache, or diarrhea upon abrupt withdrawal; common adverse effects include dizziness, somnolence, blurred vision, weight gain, and peripheral edema; may elevate creatinine kinase level, decrease platelet count, and increase PR interval; doses >300 mg/d associated with higher rate of adverse effects and treatment discontinuation; decrease dose with renal impairment (ie, CrCl <60 mL/min); angioedema has been reported during postmarketing surveillance

Follow-up

Further Outpatient Care

• Aerobic exercise
  • Exercise helps decrease the symptoms of fibromyalgia syndrome; however, too much exercise results in increased symptoms that are often severe. This can lead to a cycle of muscle disuse.
  • In one study, 9 of 16 patients worsened or reported no change after a 14-week aerobic training intervention; however, 3 of the 16 patients were able to maintain a program of aerobic exercise; 4 years later, none of these patients fulfilled criteria for fibromyalgia.¹²
  • Aerobic therapy in a warm-water pool may be helpful, particularly for severe cases.¹³  
  • Hoffman recently published a detailed program of graded exercise for fibromyalgia.⁵  
• Physical therapy
  • Restoration of muscle balance, stretching, and local therapy with heat and cold can be helpful. In 1996, Sheon et al published an excellent discussion of physical treatment modalities for fibromyalgia syndrome, tendonitis, and bursitis.¹⁴
  • Transcutaneous electrical nerve stimulation (TENS) may provide symptomatic relief in some cases.¹⁵
• Subcutaneous tender-point injections of lidocaine may be mildly helpful, although dry needling or sodium chloride solution may also work. Corticosteroids should be avoided in fibromyalgia.
• EMG biofeedback and hypnotherapy have been helpful in controlled studies.^16,17
• Psychotherapy: Fibromyalgia and all chronic tendonitis-bursitis disorders (tension-myalgia syndromes) may be conditions in which patients substitute physical pain for emotional pain, as advocated in the book by John Sarno, MD, The Mindbody Prescription: Healing the Body, Healing the Pain. Nancy Selfridge, MD, and Franklynn Peterson wrote Freedom from Fibromyalgia: The 5-Week Program Proven to Conquer Pain, a book using Dr. Sarno's and other techniques that some patients have found helpful.
• Stress management: In one study, 10 of 15 patients responded to a 14-week cognitive-behavioral and relaxation-training intervention; however, none remained improved after a 4-year follow-up.¹²
• Eye movement desensitization and reprocessing (EMDR) has been found to be useful in patients with posttraumatic stress disorder (PTSD).¹⁸ Because the pathophysiology of fibromyalgia is similar to that of PTSD¹⁹ , some practitioners have been using EMDR with anecdotal success.
• Meditation has been shown to be helpful.²⁰ Recommended is a mindfulness meditation program developed by Jon Kabat-Zinn, PhD, Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness.²¹
• Complementary and alternative methods of treatment include the following:
  • Acupuncture has been shown to be helpful in some trials.²² However, a recent study found acupuncture to be no better than placebo.²³
  • Few controlled trials of herbal or homeopathic treatments have been performed.^24,25 Many anecdotal cases report short-term benefit that wanes with time.
  • A controversial placebo-controlled trial of a homeopathic treatment (Rhus toxicodendron 6c) decreased tender points.²⁵ A recent trial of individualized homeopathic treatment showed modest benefits.²⁴
  • A combination of malic acid (200 mg) and magnesium (50 mg) (Super Malic) in high doses did not have an effect in the controlled portion of the trial but was found to be useful in the subsequent open-label study.²⁶
  • A recent multicenter trial showed modest salutary effects of acetyl L-carnitine using a combination of daily oral (1000 mg/d) and intramuscular (500 mg/d) treatment for 2 weeks, followed by oral treatment (1500 mg/d) for 8 weeks.²⁷  
  • For further information on integrative treatment, see the chapter “Fibromyalgia Syndrome” by Muller and Selfridge in Integrative Medicine (2007).²⁸

Deterrence/Prevention

• Prevention of bursitis and tendonitis depends on proper body mechanics at work and at play. Avoiding overuse and gradual increases in exercise is the best means for prevention. Warm-up and cool-down exercises and stretching are recommended. Balancing aerobics with strength training and stretching, particularly yoga, can be helpful.
• No methods have been proven to prevent fibromyalgia. An overall program of stress reduction that combines mindfulness, meditation, and vigorous exercise, as well as avoiding injury, may offer the best chance for prevention.

Prognosis

• Fibromyalgia and multiple bursitis-tendonitis syndrome
  • In one study, 65% of patients improved with therapy. A similar percentage reported feeling poor or fair 3 years after diagnosis.
  • About 10-30% of patients are disabled because of fibromyalgia. Most patients function well but continue to report chronic pain.
  • Better response to treatment is observed in patients of younger age with continued employment, supportive families, an absence of affective disorders, and without involvement in litigation.²⁹
  • One study showed that the level of disease activity did not change significantly over an average of 6.4 years that patients were studied. These findings suggest that current conventional medical treatment is unsatisfactory and does not alter the prognosis in fibromyalgia.
  • Complete remissions are uncommon.
• Regional and local bursitis, tendonitis, neurovascular entrapment, and structural syndromes
  • Most patients do well with therapy.
  • Exacerbations are common but respond well to treatment.

Patient Education

• Internet resources
  • The Arthritis Foundation has patient education pamphlets, support group information, and physician referrals.
  • National Institutes of Arthritis and Musculoskeletal and Skin Diseases has questions and answers and information sources for patients.
  • Fibrohugs is an Internet support network.
  • Living with Fibromyalgia and Chronic Myofascial Pain Syndrome is an Internet support network.
• For excellent patient education resources, visit eMedicine's Muscle Disorders Center and Hand, Wrist, Elbow, and Shoulder Center. Also, see eMedicine's patient education articles Fibromyalgia, Chronic Pain, and Tennis Elbow.

Miscellaneous

Medicolegal Pitfalls

• Fibromyalgia, multiple bursitis-tendonitis syndrome
  • Failure to diagnose concomitant autoimmune, infectious, or neoplastic disease can result in medicolegal issues.
  • Disability can occur in 10-30% of cases, with few objective findings on physical examination or laboratory testing.  Disability is significantly related to measures of psychological well-being.³⁰  
  • Litigation may follow an injury at work or in a motor vehicle.
• Regional and local bursitis and tendonitis - Failure to diagnose septic bursitis or tendonitis

Multimedia

Media file 1: The spectrum of nonarticular myofascial pain syndromes.

Media file 2: Possible factors that lead to myofascial pain syndromes.

References

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Keywords

nonarticular rheumatism, regional pain syndrome, soft tissue rheumatic pain syndrome, myofascial pain syndrome, repetitive strain injury, cumulative movement disorders, tendonitis, bursitis, neurovascular entrapment, multiple tendonitis and bursitis syndrome, fibromyalgia, fibrositis, FMS, temporomandibular joint syndrome, flatfoot, hypermobility syndrome, lateral epicondylitis, tennis elbow, carpal tunnel syndrome, thoracic outlet syndrome, regional myofascial pain syndrome, temporomandibular joint syndrome, multiple bursitis-tendonitis syndrome, enthesitis, golfer's elbow, entrapment syndrome, meralgia paresthetica, tarsal tunnel syndrome

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.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

Alex J Mechaber, MD, FACP, 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: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; West Penn Allegheny Health System None Board membership

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