Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Nonarticular Rheumatism/Regional Pain Syndrome Treatment & Management

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

Medical Care

Patients with fibromyalgia and multiple bursitis-tendonitis syndrome are most likely to benefit from a multicomponent program.[19] The European League Against Rheumatism (EULAR) recently published an evidence-based review of treatment modalities, as follows[20] :

  • 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

For acute exacerbations (first 24-48 h) of regional and local bursitis and tendonitis, the following treatments are used:

  • 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.

Goode et al (2010) estimated the prevalence of chronic neck pain to be 2.2% in North Carolina in 2006. The authors found an overuse of diagnostic testing, narcotics, and unproven modalities in these individuals, as well as an underuse of effective treatments such as therapeutic exercise.[21]

A meta-analysis of the use of corticosteroid injection for tendinopathy showed good short-term outcomes. However, intermediate and long-term outcomes may be better with prolotherapy, botulinum toxin, or platelet-rich injection therapies. Most of these latter studies have been small; studies that are more comprehensive are needed before any firm recommendations can be made.[22]

A 2011 article demonstrates the possibility of using leech therapy for lateral epicondylitis. Such therapy may be helpful, but there will likely be barriers to overcome before patients and practitioners accept this mode of therapy.[23]

Next

Surgical Care

See the list below:

  • 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.
Previous
Next

Consultations

See the list below:

  • 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
Previous
Next

Diet

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

Previous
Next

Activity

See the list below:

  • 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.[24]
    • 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
Previous
 
 
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.

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. 2007 Jun. 22(6):818-21. [Medline].

  2. Makol A, Wright K, Matteson EL. Safe use of antirheumatic agents in patients with comorbidities. Rheum Dis Clin North Am. 2012 Nov. 38(4):771-93. [Medline].

  3. Król P, Franek A, Durmała J, Błaszczak E, Ficek K, Król B, et al. Focused and Radial Shock Wave Therapy in the Treatment of Tennis Elbow: A Pilot Randomised Controlled Study. J Hum Kinet. 2015 Sep 29. 47:127-35. [Medline].

  4. Sheikh Taha AM, Feldman DS. Painful Flexible Flatfoot. Foot Ankle Clin. 2015 Dec. 20 (4):693-704. [Medline].

  5. Gómez Robledo J. Associated lateral process and posteromedial tubercle talus fractures with entrapment of the medial neurovascular bundle: A case report. Foot (Edinb). 2013 Aug 13. [Medline].

  6. De-la-Llave-Rincon AI, Ortega-Santiago R, Ambite-Quesada S, Gil-Crujera A, Puentedura EJ, Valenza MC, et al. Response of pain intensity to soft tissue mobilization and neurodynamic technique: a series of 18 patients with chronic carpal tunnel syndrome. J Manipulative Physiol Ther. 2012 Jul. 35(6):420-7. [Medline].

  7. Possover M, Forman A. Pelvic Neuralgias by Neuro-Vascular Entrapment: Anatomical Findings in a Series of 97 Consecutive Patients Treated by Laparoscopic Nerve Decompression. Pain Physician. 2015 Nov. 18 (6):E1139-43. [Medline].

  8. Chammas M. Carpal tunnel syndrome. Chir Main. 2014 Apr. 33 (2):75-94. [Medline].

  9. Breslin FC, Ibrahim S, Smith P, Mustard C, Amick B, Shankardass K. The demographic and contextual correlates of work-related repetitive strain injuries among canadian men and women. Am J Ind Med. 2013 Oct. 56(10):1180-9. [Medline].

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

  11. 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. 1995 Jul. 38(7):926-38. [Medline].

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

  13. 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. 2009 Oct. 10(10):1099-112. [Medline]. [Full Text].

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

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

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

  17. 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. 1990 Feb. 33(2):160-72. [Medline].

  18. 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. 2009 Oct 8. [Medline]. [Full Text].

  19. 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. 2009 Feb 15. 61(2):216-24. [Medline].

  20. [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. 2008 Apr. 67(4):536-41. [Medline].

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

  22. 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. 2010 Nov 20. 376(9754):1751-67. [Medline].

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

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

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

  26. 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. 1996 Nov. 39(11):1852-9. [Medline].

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

  28. 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. 2004 Sep. 50(9):2974-84. [Medline].

  29. 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. 2007 Apr. 56(4):1336-44. [Medline].

  30. 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. 2005 Apr. 52(4):1264-73. [Medline].

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

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

  33. 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. 2009 Jan. 60(1):299-309. [Medline].

  34. 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].

  35. 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. 2001 Feb. 45(1):42-7. [Medline].

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

  37. 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. 1996 Feb. 2(1):18-22. [Medline].

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

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

  40. 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.

  41. 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. 2003 Apr. 71(2):330-8. [Medline].

  42. 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. 2002 Aug. 32(1):38-50. [Medline].

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

  44. 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.

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

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

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

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

  49. 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. 1995 May. 22(5):953-8. [Medline].

  50. 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. 2007 Mar-Apr. 25(2):182-8. [Medline].

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

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

  53. 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 © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.