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  • Fibromyalgia syndrome (FM, FMS)

  • Chronic fatigue syndrome


  • 729.1 Myalgia and myositis unspecified


  • M79.7 Fibromyalgia


  • 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Localized Inflammation1

  • 5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury2


A 44-year-old female began complaining of pain in multiple areas including upper back, mid back, low back, and knees for the last 3 months. X-rays and MRI were negative. Laboratory tests including CBC, C-reactive protein, rheumatoid factor, and thyroid profile were also negative. Recently, patient had to stop working as a social worker due to the severity of pain and stiffness, fatigue, difficulty concentrating, and sleep disturbances. She reported difficulty with daily activities mainly due to pain and fatigue. Patient revealed an unremarkable PMH, except for a recent flu virus with no major symptoms. Upon examination, patient was found with multiple tender points with pain radiating to vicinity areas only with palpation. Patient presented with limited ROM in the cervical spine, lumbar spine, and bilateral knee extension. Patient presented with a normal gait pattern, and her 6MWT was abnormal for her age.



  • Widespread musculoskeletal pain and fatigue for at least 3 months

  • Commonly involves mood disturbances

  • Preliminary new criteria from American College of Rheumatology in 2010 include Widespread Pain Index and Symptom Severity Score instead of tender points

  • Current criteria: Tender points in at least 11 of 18 areas

    • Arms, chest, buttocks, knees, low back, neck, rib cage, thighs, shoulders

FIGURE 223-1

The tender points of fibromyalgia. There should be tenderness in at least 11 of the 18 points to diagnose fibromyalgia. (From LeBlond RF, DeGowin RL, Brown DD. DeGowin’s Diagnostic Examination. 9th ed. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)

FIGURE 223-2

Typical pain diagram by a patient with fibromyalgia. (From Lalwani AK. Current Diagnosis & Treatment in Otolaryngology—Head and Neck Surgery. 3rd ed. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)

FIGURE 223-3

Symptoms in fibromyalgia in addition to “pain all over” and tender points. ENT, ear, nose, and throat. (From Imboden J, Hellmann DB, Stone JH. Current Rheumatology Diagnosis & Treatment. 2nd ed. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)

Essentials of Diagnosis

  • Diagnosis based primarily on symptoms of widespread pain

  • Fatigue, typically begins on rising from sleep

  • Morning stiffness, typically ...

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