Bodyaches & Pains

Synonyms: “Hurts all over,” widespread pain.

Definition: The evaluation of patients with widespread arthralgias and/or myalgias can be a challenge because many disorders may manifest these protean symptoms. Widespread pain can be defined as pain that extends beyond joint margins to involve large areas or whole limbs. Alternatively, it is described as pain on both sides of the body, above and below the waist, and includes axial pain as well. The examiner should search for revealing historical features or evidence of articular or periarticular pathology (i.e., swelling, erythema, warmth) before considering the disorders mentioned herein.

ICD-9 Codes: Arthralgia, site unspecified, 719.40; myalgia/myositis, 729.1

Etiology: The most common cause of widespread arthralgias and myalgias is fibromyalgia and myofascial pain syndrome. It is also possible that widespread pains may be drug induced, infectious, endocrinologic/metabolic, autoimmune, neoplastic, or psychiatric in origin (Table 4).

Table 4
Differential Diagnosis of Arthralgias and Myalgias (“Hurts All Over”)
Drug-inducedAntiinfectives: quinolones, amphotericin, acyclovir

Biologic agents: interferon, IL-2, IL-6, immunotoxins

Supplements: excessive vitamin A, fluoride
Lipid-lowering agents: clofibrate, statins (e.g. lovastatin)

Cardiac: quinidine, propranolol, nicardipine

Infectious

Viral syndromes

Dengue fever

Vaccines

Endocrine/metabolic

Hypothyroidism/myxedema

Hyperparathyroidism

Hypercortisolism

Corticosteroid withdrawal

Adrenal insufficiency

Hypophosphatemia

Autoimmune

Systemic lupus erythematosus

Polymyalgia rheumatica

Inflammatory myositis

Neoplastic/hematologic

Leukemia

Lymphoma

Multiple myeloma

Metastases to bone
Sickle cell crisis

Psychiatric

Depression
Psychogenic rheumatism
Malingering
Somatization disorder

Other

Fibromyalgia

Chronic fatigue syndrome

Hypermobility syndrome
Silicone implant syndrome (most have fibromyalgia)

IL, interleukin.

Cardinal Findings: Many patients manifest moderate to severe fatigue and morning stiffness (lasting minutes to hours); thus, these features have little discriminant value. The patient should be questioned about fever (i.e., >100°F) or weight loss because these may suggest conditions with significant morbidity. Symptoms suggesting endocrinopathies should be sought (i.e., heat or cold intolerance). Symptomatic rashes, muscle weakness, myalgias, muscle cramping, depression, or sleep disturbance may also provide important clues. It is equally important to review the patient’s medication history, medical and surgical history, health maintenance, and social history when evaluating diffuse musculoskeletal complaints.

Efforts should be directed toward identifying the source and extent of joint or muscle pain; many patients in this group will have periarticular rather than articular pain. The clinician should carefully examine for the trigger point tender areas of fibromyalgia. Signs of ligamentous laxity may indicate hypermobility syndrome. Lymphadenopathy, masses, organomegaly, and stigmata of thyroid, adrenal, or muscle disease (see Myasthenia Gravis) should be sought.

Diagnostic Testing: Routine laboratory testing should include a complete blood count (CBC), chemistries, and an ESR. Extreme elevation of the ESR (>60 mm Hg) seldom occurs without evidence of serious illness. Conversely, normal or low- level elevations of the ESR are less diagnostic and should not be overinterpreted. Serologic testing for ANA or RF (or batteries of rheumatic screening tests) are unlikely to yield useful information. Similarly, thyroid function studies or CPK should only be done if symptoms and signs (beyond arthralgias) warrant.

Differential Diagnosis: Table 4 lists the many disorders that may manifest widespread arthralgias/myalgias. Although fibromyalgia is most common among these, the clinician should be careful to not confuse fibromyalgia with influenza and other viral infections, thyroid or adrenal disease, metabolic bone disease (e.g., osteomalacia/rickets, hyperparathyroidism), polymyalgia rheumatica, Still’s disease, the early onset of a connective tissue disease (lupus, RA, myositis), multiple myeloma, bony metastases, or depression with somatization.

Imaging: Imaging will seldom reveal diagnostic information not gleaned from the physical examination. Rarely, bony metastases are found by plain radiographs or scintigraphy. The predictive value of whole body scintigraphy has been advocated for the evaluation of widespread pain without supportive physical findings.

Therapy: Patients should be treated symptomatically, and narcotic analgesics should be avoided until a confident diagnosis is made. Thereafter, therapeutic choices are defined by the diagnostic entity rather than the general complaint. If the complaint is drug induced, then drug withdrawal usually results in rapid improvement. Treatment of the underlying condition may also improve the musculoskeletal complaint.

Adapted from: RheumaKnowledgy


Musings

Of Soreness & Stretches