AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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.

DIFFERENTIALS

Section 4 of 11  

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• Differentials
• Workup
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• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Multiple Sclerosis
Hyperparathyroidism
Sleep apnea syndrome
Cervical spondylosis
Psychogenic rheumatism
Depression

WORKUP

Section 5 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab 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

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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

Section 7 of 11  

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• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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.

Drug Category: Antidepressants

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

Drug Category: 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.

Drug Category: Centrally acting analgesics

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

Drug Category: 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.

Drug Category: Anticonvulsants

These agents may alleviate chronic pain.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal 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

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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

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

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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2. Abeles AM, Pillinger MH, Solitar BM, Abeles M. Narrative review: the pathophysiology of fibromyalgia. Ann Intern Med. May 15 2007;146(10):726-34. [Medline].
3. Wolfe F, Ross K, Anderson J, et al. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum. Jan 1995;38(1):19-28. [Medline].
4. 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. Feb 1990;33(2):160-72. [Medline].
5. Hoffman JH. Guidelines for Beneficial Group Exercise for Fibromyalgia. Practical Pain Management. 2007/06;7:50-57.
6. Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. Nov 17 2004;292(19):2388-95. [Medline].
7. Gendreau R, Mease P, Rao S, et al. Milnacipran: A potential new treatment of fibromyalgia. Arthritis Rheum. 2003;48:S616.
8. 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. Sep 2004;50(9):2974-84. [Medline].
9. 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. Apr 2007;56(4):1336-44. [Medline].
10. 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. Apr 2005;52(4):1264-73. [Medline].
11. Russell IJ, Kamin M, Bennett RM, et al. Efficacy of tramadol in treatment of pain in fibromyalgia. J Clin Rheumatol. 2000;6:250-257.
12. 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].
13. 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. Feb 2001;45(1):42-7. [Medline].
14. Sheon RP, Moskowitz RW, Goldberg VM. Soft Tissue Rheumatic Pain: Recognition, Management, and Prevention. 3^rd ed. Baltimore, Md: Williams and Wilkins; 1996.
15. Sunshine W, Field TM, Quintino O, et al. Fibromyalgia benefits from massage therapy and transcutaneous electrical stimulation. J Clin Rheumatol. 1996;2:18-22.
16. Ferraccioli G, Ghirelli L, Scita F, et al. EMG-biofeedback training in fibromyalgia syndrome. J Rheumatol. Aug 1987;14(4):820-5. [Medline].
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Article Last Updated: Nov 5, 2007