Nonarticular Rheumatism/Regional Pain Syndrome Clinical Presentation

Updated: Apr 04, 2018
  • Author: T P Sudha Rao, MD; Chief Editor: Herbert S Diamond, MD  more...
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Presentation

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%. [17]  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 the following:

  • Nonrestorative sleep
  • Chronic fatigue
  • Stiffness
  • Headache
  • Irritable bowel syndrome
  • 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. Features include the following:

  • 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 following:

  • Ulnar nerve at the elbow
  • Median nerve at the wrist (carpal tunnel syndrome)
  • Lateral cutaneous nerve at the thigh (meralgia paresthetica)
  • Posterior tibial nerve at the ankle (tarsal tunnel syndrome)

For the history, the following is recommended:

  • Determine the location and pattern of pain and specific movements that exacerbate the pain
  • Inquire 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:

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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°
  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 paresthesias 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).

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Causes

 

The cause of fibromyalgia has not been elucidated. A possible link between chronic fatigue syndrome and a little-known infectious retrovirus, xenotropic murine leukemia virus–related virus (XMRV) [18]  proved unreliable. [19]

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.

Possible etiologic factors for other conditions include the following:

  • 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 syndrome, Marfan syndrome, and pseudoxanthoma elasticum.
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