Soft tissue rheumatism is a term applied to inflammatory or painful conditions which are, in general, non-articular in origin. The process may be localized (e.g. bursitis), regional (e.g. myofascial pain syndrome) or generalized (i.e. fibromyalgia). In general, the tender points in localized and regional soft tissue rheumatism, are the same ones involved in fibromyalgia.

The tender points occurring at a frequency of 30% or less, are not included in the criteria for diagnosing fibromyalgia (more on the criteria later). However, they are areas that are frequently involved in the localized or regional forms of soft tissue rheumatism.

Localized Soft Tissue Rheumatism:

Symptoms:

As the name implies, the symptoms are generally well localized (e.g. "my shoulder hurts", "my elbow hurts", "my back hurts", etc.). Keep in mind the following:

• 90% of shoulder pain is non-articular (i.e. tendinitis, bursitis, or less commonly adhesive capsulitis).
• >90% of elbow pain is non-articular (usu. epicondylitis, though rarely olecrenon bursitis, which may be infectious in etiology).
• Heel pain is usu. associated with plantar fasciitis. The pain is greatest in the AM on arising out of bed. Plantar fasciitis may be associated with spondyloarthropathies, but often occurs as an overuse syndrome.
• Sacroileitis is a common cause of low back pain. Though it may be associated with several syndromes (e.g. IBD, Reiter's, Bechet's, Psoriatic arthritis (the spondyloarthropathic form)), the idiopathic variety is much more common.
• Trochanteric bursitis and tensor (lata) fasciitis are common causes of "hip pain".
• "Repetitive motion injury": term applied to many occupational injuries nowadays, is usu. a form of localized soft tissue inflammation. The most common "repetitive motion injury", which is generally not considered soft tissue rheumatism is Carpal Tunnel Syndrome.

Diagnosis:

• Usually done by defining the point of maximal tenderness and correlating this with the location and likely underlying structure.
• Since bursae have no form, only location is used. Tendinitis should demonstrate tenderness localized to the tendon (i.e. the palpable cord).
• Care should be taken to make sure that there is no articular involvement (usu. done with range of motion). If range of motion is normal, and without pain, one can be quite confident that they are not dealing with an articular problem.
• With respect to the shoulder, pain that is greater on active motion versus passive motion (i.e. with the examiner doing the moving) is typical of non-articular inflammation.
• With respect to the hip, internal and external rotation can be easily checked with the pt. recumbent, and gently rolling the lower extremity back and forth.
• Sacroileitis should have tenderness confined to the palpable crevice which is the SI jt. It is easiest to palpate firmly with one's thumbs, having one's fingers extending laterally. Follow the contour of the sacrum beginning at the posterior iliac crest.
• Inflammation of the inguinal ligaments where they insert into the ASIS can be a cause of "lower abdominal pain". This should be sought when the complaint is lower quadrant pain without other sx suggestive of lower GI tract disease.

Treatment:

• The mainstay of therapy are NSAIDs at anti-inflammatory doses. There are inexpensive, single daily dose agents such as Indocin-SR (e.g. 75 mg po qd). Other inexpensive generics are available twice daily (e.g. sulindac 150-200 mg po bid and naproxen 375-500mg po bid).
• Other measures which may be helpful are: icing (generally for 20-30 minutes, two-three times a day is necessary) and stretching. Stretching is most helpful for preventing recurrence, and may not be appropriate if significant inflammation exists at the time of diagnosis.
• Soft tissue injections of corticosteroids may be the only treatment to provide significant long term relief. When using corticosteroids, the following apply:
  1. The point of maximal tenderness needs to be clearly defined. If you cannot convince yourself that you can reproducibly define the point of maximal tenderness, then the likelihood that the soft tissue injection will be helpful is low.
  2. Generally 40-80 mg of methylprednisilone is used along with 1 ml of 2% Xylocaine or 0.5% Marcaine (preferred because it is longer acting than lidocaine).
  3. The point of maximal tenderness is marked with the back of a pen to cause an indentation to serve as the landmark. It is important to be clear in your mind the angle of pressure you applied in defining the point of maximal tenderness and the landmark. You will need to insert the needle at this same angle to effectively reach the point of maximal tenderness. The site is prepped with a sterile alcohol wipe, as with any injection.
  4. The medication is injected into the point of maximal tenderness after a small amount is used to anesthetize the skin. Depending on the site injected, you may inject 1/3 of the medication into the point of maximal tenderness, and 1/3 about 1/2 cm on each side of this point (you do not need to withdraw the needle through the skin to do this, but just pull back about 1-2 cm and redirect the needle slightly laterally).
  5. There are a couple areas which are often resistant to NSAIDs, and thus, one should have a low threshold for using a steroid injection. These include: sacroileitis, anserine bursitis and inflammation of the inguinal ligament.
  6. The other factor to consider when deciding on whether or not to use a soft tissue injection, is whether the patient is likely to tolerate a 10 day to 2 week course of anti-inflammatory doses of an NSAID.
  7. Finally, a patient should receive no more than 2 soft tissue injections of corticosteroids into the same area in a year. Beyond this, one increases the risk of weakening the soft tissue structures, which could lead to "spontaneous" rupture of a tendon or ligament.

Myofascial Pain Syndrome (MPS):

This is defined as a regional distribution of pain which can be reproduced by pressure over a trigger point. A trigger point (TP) is a tender area within the belly of a muscle. MPS is defined as TP with the following features:

• Pressure over a TP causes pain and/or tingling in a characteristic distribution.
• The muscle harboring the TP is shortened (i.e. in spasm) and results in reduced ROM. Either stretching or contracting the muscle causes pain.
• The muscle is taut in the area of the TP causing pain.
• Injection of the TP with local anesthetic abolishes both the local and referred pain.

An alternative hypothesis, generally applied in alternative medicine, is that there is a deficiency of high energy phosphates (which has been documented, also, in fibromyalgia). The literature does not allow one to distinguish whether this is cause or effect (i.e. does prolonged spasm from a primary sleep disorder lead to a deficiency of high energy phosphates).

In the case of post-traumatic MPS, the pain from the initial injury may be the cause of disordered sleep, which in time, accentuates the muscle spasm. A similar process may be invoked for overuse. However, a significant group of pt. suffering from MPS do not have histories of trauma or overuse, and thus would be presumed to have a "primary" sleep disorder. The cause of the sleep disorder in idiopathic MPS and fibromyalgia is unclear (at best), and often, our attempts to improve upon such a sleep disorder with medications is not wholly effective in relieving the Sx and Findings.

Treatment:

Generally the following modalities are used:

• If early in a post-traumatic process, NSAIDs may be used, with some success.
• If sleep is disturbed, attempts should be made to regulate it. The usual cast of characters is: Amytriptilline (25 mg HS), Flexeril (10-20 mg HS), Zanaflex (2-4 mg HS), Doxepin (10-20 mg HS) or Zolpidem (10 mg HS). Generally, one starts with amytryptilline or flexeril. It is important to define the hour the patient usually arises in the AM, so that the amytryptilline or flexeril can be given 10-12 hours prior to this time, to minimize medication "hangover".
• Physical therapy is often a useful adjunct. You need to be clear with respect to your diagnosis, and should request massage to be part of the therapy. It can be difficult, at times, to find a physical therapist who works well with your patient.
• In severe cases, it may be necessary to anesthetize the TP with marcaine prior to PT to permit adequate massage and manipulation of the area.
• You need to stay on top of it. Failure to do so can lead to permanent spasm, that can be significant enough to be refractory to boutulin toxin.
• Consider alternative therapies, such as acupuncture, myotherapy or even alternative medical therapies directed at restoring high energy phosphates (e.g. Mg and Coenzyme Q-10), especially if the above therapies are failing.

Fibromyalgia:

This is one of the most contested entities in modern medicine. Your belief system about personal health will surely impact upon your view of this entity. Try to be open minded, and remember that there are specific criteria for the Dx of fibromyalgia. In addition, people who do work in this area, have been able to use these criteria to prospectively define a cohort of patients, and show treatment success in placebo controlled, double-blind studies.

Diagnosis:

1. Widespread aching and pain (defined as pain in all four quadrants, with the waist and spine serving as the points of reference).
   • chronic, generalized aches, pains or stiffness (involving > 3 anatomic sites for > 3 months)
   • absence of other systemic conditions to account these sx
2. Eleven or more tender points out of a total of 18:
   • 2 cm below lateral epicondyle of elbow
   • insertion of nuchal muscles into occiput
   • intertransverse ligaments (C5-7)
   • upper border of trapezius (approx. midpoint)
   • supraspinatus, medial aspect just above scapular spine
   • upper gluteal area, just below iliac crest in outer quadrant
   • insertion of muscles into greater trochanter
   • medial condyle of femur about 2 cm below the joint

Tender points tend to be symmetric and bilateral in fibromyalgia. Other sx which are considered minor criteria are: disturbed sleep, generalized fatigue, subjective swelling or numbness, chronic headache, pain in neck and irritable bowel symptoms.

The laboratory evaluation for fibromyalgia includes a CBC to rule out anemia, a TSH to rule out hypothyroidism and an ESR or CRP to look for evidence of an underlying inflammatory disorder. If symptoms and findings warrant it, an ANA and RF may be indicated. As with most clinical medicine, your familiarity with the condition through experience will permit a diagnosis at the initial visit with a patient, with the labs tests being done perfunctorily .

With respect to chronic fatigue syndrome (CFS), many of the symptoms are similar. A comparison of sx and findings was published in the Sept. 1994 Archives of IM. 70% of the pt meeting fibromyalgia criteria met CDC working criteria for CFS. Essentially all sx and findings occurred at the same frequency in the two conditions. The important difference between the two is that tender points are associated with fibromyalgia, and not CFS (tender points are not in the CDC criteria for CFS).

Treatment

Treatment for fibromyalgia, is as discussed above for MPS. In addition to medical therapy, physical modalities which have been helpful include:

• Stretching and flexibility exercises (Yoga may be appropriate in this context).
• Muscle massage, stretching and deep ultrasound (as part of physical therapy).
• aerobic conditioning (exercise cannot be understated as an important ajunctive therapy in Fibromyalgia).

Patients should be reassured that though fibromyalgia tends to be a chronic condition, it is not a life-threatening illness. Medical therapy, when it is helpful, takes at least 4 weeks to show efficacy. Thus, patients need to be counseled of the slow process to heel. Generally, I use the sleep hypothesis in this context. When one achieves sound sleep, they will be able to recapture the deep sleep of which they have been deprived. Each night of sound sleep will permit a small amount of the excess muscle tension to be relieved. If symptoms are long standing, then it will generally take a long time to achieve resolution of their symptoms.

NSAID are generally unhelpful in fibromyalgia. Thus, chronic pain conditions unresponsive to NSAID, should raise this diagnosis in your mind. Narcotic analgesics are generally avoided. They are efficacious, but your end-point in treatment may be hard to define, and thus may foster long-term dependency.