Nonarticular Rheumatism/Regional Pain Syndrome

Nonarticular Rheumatism/Regional Pain Syndrome

No Results

No Results


Nonarticular rheumatic pain syndromes can be classified into five general categories, as follows:

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 the image below. Comorbidity is common. [1, 2]


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. [3]

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. [4] 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). [5, 6, 7, 8]  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. [9]

Multiple bursitis and tendonitis syndrome presents 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 onset often follows 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. [10, 11, 12]

A study by Light and colleagues found that patients with chronic fatigue syndrome have an increased expression of sensory, adrenergic, and immune genes during moderate exercise. [13] Abnormalities of the neuroendocrine immune system are well documented, but none has yet been proven to be sensitive and specific enough to be used as a criterion for diagnosis.

Psychological, personality, and social factors may play important roles in many chronic cases of local and generalized pain syndromes. The image below depicts possible factors that contribute to the generation of these syndromes.

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. [14]


International incidence and prevalence are similar to those in the United States.

These syndromes are not life threatening but can be a cause of significant functional disability. [15, 16]

Racial differences in prevalence have not been reported.

Localized nonarticular rheumatism occurs with fairly equal distribution between males and females. In contrast, 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.

Nonarticular rheumatism is most common in persons aged 45-64 years, and less 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%. [14, 16]

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. [Medline].

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. [Medline].

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. [Medline].

Sheikh Taha AM, Feldman DS. Painful Flexible Flatfoot. Foot Ankle Clin. 2015 Dec. 20 (4):693-704. [Medline].

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. [Medline].

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. [Medline].

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. [Medline].

Chammas M. Carpal tunnel syndrome. Chir Main. 2014 Apr. 33 (2):75-94. [Medline].

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. [Medline].

Abeles AM, Pillinger MH, Solitar BM, Abeles M. Narrative review: the pathophysiology of fibromyalgia. Ann Intern Med. 2007 May 15. 146(10):726-34. [Medline].

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. [Medline].

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. [Medline].

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. [Medline]. [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. [Medline].

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. [Medline].

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. [Medline].

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. 1990 Feb. 33(2):160-72. [Medline].

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. [Medline]. [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. [Medline]. [Full Text].

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. [Medline].

[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. [Medline].

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. [Medline].

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. [Medline].

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. [Medline].

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. [Medline]. [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. [Medline].

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. [Medline].

Hoffman JH. Guidelines for Beneficial Group Exercise for Fibromyalgia. Practical Pain Management. 2007/06. 7:50-57.

Living with Fibromyalgia, Drugs Approved to Manage Pain. U.S. Food and Drug Administration. Available at 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. [Medline].

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. [Medline].

Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004 Nov 17. 292(19):2388-95. [Medline].

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. [Medline].

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. [Medline].

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. [Medline].

Younger J, Mackey S. Fibromyalgia symptoms are reduced by low-dose naltrexone: a pilot study. Pain Med. 2009 May-Jun. 10(4):663-72. [Medline].

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. [Medline].

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. [Medline]. [Full Text].

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].

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. [Medline].

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. [Medline].

Ferraccioli G, Ghirelli L, Scita F, et al. EMG-biofeedback training in fibromyalgia syndrome. J Rheumatol. 1987 Aug. 14(4):820-5. [Medline].

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. [Medline].

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. [Medline].

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. [Medline].

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. [Medline].

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.

Deluze C, Bosia L, Zirbs A, et al. Electroacupuncture in fibromyalgia: results of a controlled trial. BMJ. 1992 Nov 21. 305(6864):1249-52. [Medline].

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. [Medline].

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. [Medline].

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. [Medline].

Fisher P, Greenwood A, Huskisson EC, et al. Effect of homeopathic treatment on fibrositis (primary fibromyalgia). BMJ. 1989 Aug 5. 299(6695):365-6. [Medline].

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. [Medline].

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. [Medline].

Muller D, Selfridge N. Fibromyalgia syndrome. Rakel D, ed. Integrative Medicine. 2nd ed. Philadelphia, PA: Saunders; 2007. 509-18.

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. [Medline].

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.

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.

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.

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.

Nonarticular Rheumatism/Regional Pain Syndrome

Research & References of Nonarticular Rheumatism/Regional Pain Syndrome|A&C Accounting And Tax Services