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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]


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.


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


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



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
Contributor Information and Disclosures

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.


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

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

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

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

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

Disclosure: Nothing to disclose.

Chief Editor

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

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

Disclosure: Nothing to disclose.

Additional Contributors

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

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

Disclosure: Nothing to disclose.

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The spectrum of nonarticular myofascial pain syndromes.
Possible factors that lead to myofascial pain syndromes.
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