Laboratory Studies

Obtain the following studies to screen for systemic disease. All should yield results within the reference range.

Complete blood cell count (CBC)
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
Thyroid-stimulating hormone (TSH)
Electrolytes, calcium, transaminases, 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 patient has a coexistent systemic illness:

Antinuclear antibody (ANA) for systemic autoimmune disease (however, 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 kidney disease
Hepatitis C antibody

Imaging Studies

Plain radiographs are often unremarkable. They may show calcific tendonitis, but that or may not correlate with clinical symptoms.

Magnetic resonance imaging (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 the clinical evaluation, such as the following:

True muscle weakness may prompt electromyography (EMG) and nerve conduction velocity (NCV) studies. Compression neuropathies can be diagnosed using NCV studies.
Patients with a history of loud snoring, respiratory pauses, and excessive daytime sleepiness require a sleep study to exclude sleep apnea syndrome. Clinicians can consider a lower threshold to refer for sleep studies in those with otherwise unexplained fibromyalgia.

Procedures

No procedures are necessary unless indicated by history findings or abnormalities found on physical examination. Swollen bursae or tendon sheaths may be aspirated if infection or crystal disease such as gout is suspected.

Treatment & Management

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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Sheikh Taha AM, Feldman DS. Painful Flexible Flatfoot. Foot Ankle Clin. 2015 Dec. 20 (4):693-704. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Chammas M. Carpal tunnel syndrome. Chir Main. 2014 Apr. 33 (2):75-94. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Abeles AM, Pillinger MH, Solitar BM, Abeles M. Narrative review: the pathophysiology of fibromyalgia. Ann Intern Med. 2007 May 15. 146(10):726-34. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link]. [Full Text].
Panelli S, Lorusso L, Balestrieri A, Lupo G, Capelli E. XMRV and Public Health: The Retroviral Genome Is Not a Suitable Template for Diagnostic PCR, and Its Association with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Appears Unreliable. Front Public Health. 2017. 5:108. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010 May. 62 (5):600-10. [QxMD MEDLINE Link]. [Full Text].
Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Häuser W, Katz RL, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum. 2016 Dec. 46 (3):319-329. [QxMD MEDLINE Link].
Bair MJ, Krebs EE. Fibromyalgia. Ann Intern Med. 2020 Mar 3. 172 (5):ITC33-ITC48. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[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. [QxMD MEDLINE Link].
Sheon RP, Moskowitz RW, Goldberg VM. Soft Tissue Rheumatic Pain: Recognition, Management, and Prevention. 3rd ed. Baltimore, Md: Williams and Wilkins; 1996.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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.
Ferraccioli G, Ghirelli L, Scita F, et al. EMG-biofeedback training in fibromyalgia syndrome. J Rheumatol. 1987 Aug. 14(4):820-5. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Fagerlund AJ, Hansen OA, Aslaksen PM. Transcranial direct current stimulation as a treatment for patients with fibromyalgia: a randomized controlled trial. Pain. 2015 Jan. 156 (1):62-71. [QxMD MEDLINE Link].
Cummiford CM, Nascimento TD, Foerster BR, Clauw DJ, Zubieta JK, Harris RE, et al. Changes in resting state functional connectivity after repetitive transcranial direct current stimulation applied to motor cortex in fibromyalgia patients. Arthritis Res Ther. 2016 Feb 3. 18:40. [QxMD MEDLINE Link].
Castillo-Saavedra L, Gebodh N, Bikson M, Diaz-Cruz C, Brandao R, Coutinho L, et al. Clinically Effective Treatment of Fibromyalgia Pain With High-Definition Transcranial Direct Current Stimulation: Phase II Open-Label Dose Optimization. J Pain. 2016 Jan. 17 (1):14-26. [QxMD MEDLINE Link].
Deluze C, Bosia L, Zirbs A, et al. Electroacupuncture in fibromyalgia: results of a controlled trial. BMJ. 1992 Nov 21. 305(6864):1249-52. [QxMD MEDLINE Link].
Karatay S, Okur SC, Uzkeser H, Yildirim K, Akcay F. Effects of Acupuncture Treatment on Fibromyalgia Symptoms, Serotonin, and Substance P Levels: A Randomized Sham and Placebo-Controlled Clinical Trial. Pain Med. 2018 Mar 1. 19 (3):615-628. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Fisher P, Greenwood A, Huskisson EC, et al. Effect of homeopathic treatment on fibrositis (primary fibromyalgia). BMJ. 1989 Aug 5. 299(6695):365-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Muller D, Selfridge N. Fibromyalgia syndrome. Rakel D, ed. Integrative Medicine. 2nd ed. Philadelphia, PA: Saunders; 2007. 509-18.
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Hoffman JH. Guidelines for Beneficial Group Exercise for Fibromyalgia. Practical Pain Management. 2007/06. 7:50-57.
Wang C, Schmid CH, Fielding RA, Harvey WF, Reid KF, Price LL, et al. Effect of tai chi versus aerobic exercise for fibromyalgia: comparative effectiveness randomized controlled trial. BMJ. 2018 Mar 21. 360:k851. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Bidonde J, Busch AJ, Schachter CL, Webber SC, Musselman KE, Overend TJ, et al. Mixed exercise training for adults with fibromyalgia. Cochrane Database Syst Rev. 2019 May 24. 5:CD013340. [QxMD MEDLINE Link]. [Full Text].
Living with Fibromyalgia, Drugs Approved to Manage Pain. U.S. Food and Drug Administration. Available at http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm107802.htm#approved. January 31, 2014; Accessed: January 3, 2018.
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. [QxMD MEDLINE Link].
Gendreau R, Mease P, Rao S, et al. Milnacipran: A potential new treatment of fibromyalgia. Arthritis Rheum. 2003. 48:S616.
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. [QxMD MEDLINE Link].
Upadhyaya HP, Arnold LM, Alaka K, Qiao M, Williams D, Mehta R. Efficacy and safety of duloxetine versus placebo in adolescents with juvenile fibromyalgia: results from a randomized controlled trial. Pediatr Rheumatol Online J. 2019 May 28. 17 (1):27. [QxMD MEDLINE Link].
Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov 17. 292(19):2388-95. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Younger J, Mackey S. Fibromyalgia symptoms are reduced by low-dose naltrexone: a pilot study. Pain Med. 2009 May-Jun. 10(4):663-72. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].

Media Gallery

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

of 2

Author

Evan Dombrosky, MD Rheumatologist, Central Virginia VA Health System

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, Lewis Katz School of Medicine at Temple University

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

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.

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.

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.

T P Sudha Rao, MD Associate Professor of Medicine, Virginia Commonwealth University School of Medicine; Chief, Rheumatology Fellowship Coordinator, Department of Rheumatology, McGuire VA Medical Center

T P Sudha Rao, MD is a member of the following medical societies: American College of Rheumatology

Disclosure: Nothing to disclose.