The symptoms: Pathology and Assessment

  1. Muscle Involvement
    1. Tenderness
    2. Tender Points
    3. Trigger Points
    4. Aching
    5. Stiffness (Gelling)
    6. Shortening
    7. Nodules (not part of fibromyalgia syndrome)
  2. Tendon Involvement (Tendon Attached muscle to bone)
    1. The part of the tendon that attaches to the bone is called the enthesis.
      Inflammation, like acute “tennis elbow” is called “inflammatory enthesopathy” (this is not related to firbomyalgia).
    2. Pain and tenderness over the tendon without signs of inflammation is called “non-inflammatory enthesopathy” or “pseudo-tendonitis” (This is very common in firbomyalgia).
    3. It is especially common around the joints in the upper and lower extremities.
    4. Pseudotendinitis / Enthesopathy
    5. Sharp Pain at Insertion
    6. Tendon vs Joint Pain
  3. Upper Extremity Symptoms and Misdiagnoses.
    1. Paresthesias – Tingling, Burning
      1. In the fingers, any combination and location.
      2. Glove distribution.
      3. Circumscribed areas, in the thumb and fingers.
      4. In odd circular pattern in the upper extremities. It can be misdiagnosed as carpal tunnel syndrome, thoracic outlet syndrome, or ulnar nerve entrapment at the elbow.
    2. Swelling – subjective, objective, circumscribed
      1. Subjective swelling in the hands, i.e. They feel swollen, but do not look swollen. This is a characteristic feature of fibromyalgia and is typically bilateral. It appears to reflect the sensation of stiffness patients experience. It can be mistaken for osteoarthritis.
      2. Diffuse bilateral swelling throughout the hands – the hands appear puffy. The swelling can be constant, diurnal, or appear and disappear in hours. It may coincide with swelling in the face and feet. It can occur in women not on medication. The influence of medications that cause fluid retention or weight gain is not clear. It may cause carpal tunnel syndrome similar to that seen with weight gain in pregnancy.
      3. Odd circular areas of swelling may occur anywhere on the upper extremity. For example, this may appear as a 2 inch wide area of swelling over the extensor muscles in the forearm or over the wrist. This phenomenon is frequently misdiagnosed as a tendonitis or tennis elbow or attributed to inflammation of the underlying structure. There is no warmth or redness and it does not respond to NSAIDS.
    3. Stiffness – Muscle vs Joint Fibromyalgia vs Osteoarthritis
      1. Stiffness throughout the hands – this may or may not correlate with objective swelling. This is often very hard to distinguish for osteoarthritis. Patients may think their joints are stiff, when in fact it is the muscles and tendons that are stiff. Patients with very mild, normally asymptomatic osteoarthritis may perceive pain from affected joints when their pain threshold is lowered secondary to fibromyalgia syndrome
      2. Muscle tenderness – the muscle bellies (not tender points) are frequently tender to palpation. This finding is generally diffuse and inclusive of the intrinsic hand muscles. Tender points are generally tender if there is diffuse tenderness. Muscle tenderness is characteristic of fibromyalgia and is helpful in differentiating this condition from osteoarthritis.
    4. Non-inflammatory enthesopathy: Wrist, MCP (intrinsic)
      1. Noninflammatory enthesopathy is indicated by pain and tenderness in tendon insertions without signs of inflammation. Frequently misdiagnosed as tendonitis. Most common in the wrist tendon insertions on the back of the wrist, but it can occur in all estheses. It can also occur in the insertions of the interossei muscles in the palm of the hand, resulting in pain around the metacarpal heads (large knuckles). This may be misinterpreted as metacarpal joint involvement. Pain in an enthesis is generally related to shortening of the muscle. If this is the case then specific gentle stretching, NOT rest, is the indicated treatment.
    5. Pain Referred to: Deltoid Insertion, Mid-Forearm, Thenar Area
      1. When pain in these areas is not related to underlying anatomical involvement, it is most likely referred pain from the neck and shoulder. Depending on the location, this can be mistaken for tendonitis, radial nerve entrapment, CMC OA, overuse, or DeQuervain’s Tenosynovitis.
    6. Raynaud’s Phenomenon – A vascular disorder that causes instability in the blood vessels causing the hands to turn red, white or blue.
      1. Raynaud’s phenomenon is reported in about one-third of patients with fibromyalgia compared to 10% of the total population. In addition, most patients have dysfunction in thermal regulation, typically an intolerance to cold. Some are also intolerant to heat. Hypersensitivity to cold may contribute to muscle stiffness. Sometimes this contributes to a misdiagnosis of SLE.
  4. Neurological Involvement
    1. Headaches: tension, migraine, global
    2. Hypersensitivity to sound, light, color, taste, touch
    3. Paresthesias (tingling, odd sensations)
    4. Muscular weakness / paralysis (temporary inability to do a repetitive motion)
    5. Balance problems
    6. Clumsiness (slow motor planning)
  5. Skin – Circulatory Involvement
    1. Hypersensitivity
    2. Burning
    3. Rashes (not common)
    4. Raynaud’s Phenomenon
    5. Livedo Reticularis
  6. Cardiovascular – Pulmonary
    1. Heart palpitations, skips
    2. Difficulty breathing to intercostal and diaphragm FM
    3. Allergies
    4. Sinus congestion
  7. Gastrointestinal Symptoms
    1. Indigestion
    2. Gastric reflux
    3. Functional Bowel Disorder – Irritable Bowel Syndrome
      gas, bloating, cramping, loose movements, constipation
  8. Gynecological and Urinary Involvement
    1. Premenstrual Syndrome (PMS) makes fibromyalgia syndrome worse
    2. Urinary frequency (irritable bladder syndrome)
  9. Systemic / Immune Symptoms
    1. Fatigue
    2. “Flu-like” feeling
    3. Malaise (not feeling well)
  10. Thermal Dis-regulation
    1. Intolerance to heat/cold
    2. Night sweats
    3. Increased sweating
    4. Altered body temperature
  11. Sleep Dysfunction
    1. Alpha non-REM sleep disorder (non-restorative sleep with episodes of alpha (light sleep) during deep sleep)
    2. Waking in early morning
    3. Multiple awakenings throughout the night
    4. Difficulty falling asleep
    5. Sleep through – waking refreshed
    6. Waking exhausted, depressed, angry
  12. Visual and Auditory Changes
    1. Decreased range of duction (eye mobility)
    2. Latency in accommodation (blurring when adjusting to near or far)
    3. Abnormal auditory brainstem response on hearing tests
  13. Psychological / Behavioral Manifestations
    1. Irritable mood
    2. Increased anxiety
    3. Increased depression
    4. Decreased motivation
    5. Decreased self confidence
    6. Lack of enjoyment in things and activities
    7. Social withdrawal or avoidance
    8. Sadness
  14. Cognitive (thinking) Impairment
    1. Short term memory
    2. Concentration and focus
    3. Remembering what you read
    4. Processing information
    5. Organization and planning skills
    6. Difficulty finding words and thoughts
    7. Foggy thinking in the morning (Fibro-fog)
    8. Analyzing and problem-solving