The old 1990 diagnostic criteria for fibromyalgia required the presence of at least 11 out of 18 possible tender points located on both sides of the body and above and below the waist (Picture 1).
The new diagnostic criteria for fibromyalgia introduced in 2010 by American College of Rheumatology and reviewed in 2016 include [1,3,11]:
- Body pain in at least 4 of 5 body regions is present.
- Pain and other symptoms, such as fatigue and mood changes, have been present at a similar level for at least 3 months.
- Symptoms are of a certain severity (explained in detail here).
- A diagnosis of fibromyalgia does not exclude the possibility of other health conditions.
If you have fibromyalgia, you can have tender points but also trigger points . Trigger points, which are typically associated with muscle knots, are not a sign of fibromyalgia but a co-existing myofascial pain syndrome (Chart 1) .
Chart 1. Tender vs Trigger Points
|TENDER Points||TRIGGER Points|
|In fibromyalgia||In myofascial pain syndrome|
|No palpable lumps||Muscle knots|
|In the muscle tendons||In the muscle bellies|
|In most body regions||In one or few body regions|
|Applying pressure triggers pain only in the tender point||Applying pressure triggers pain in the trigger point and a distant area|
|Massage, dry needling and injections do not relieve pain||Deep massage, stretching, dry needling and injections can relieve pain|
Char 1 references: 4,5,6
Tests and Investigations
Fibromyalgia currently cannot be detected by any known test [7,8]. According to the U.S. Food and Drug Administration (FDA), the FM/a test based on the cytokine levels in the blood is not reliable.
Before making a diagnosis of fibromyalgia, a doctor will likely suggest some blood tests (red and white blood cell count, sedimentation rate, mineral, vitamin and glucose levels, rheumatoid factor, antinuclear antibodies) or imaging investigations (X-ray, CT, MRI) to check for similar conditions (Chart 2).
Chart 2. Conditions Similar to Fibromyalgia
|Adrenal dysfunction (Addison’s disease) ||Severe exhaustion, muscle weakness, loss of appetite, craving for salt|
|Anemia ||Shortness of breath after light exercise, paleness|
||Swollen and painful joints, rash, dry mouth and eyes|
|Chronic fatigue syndrome and myalgic encephalomyelitis (CFS/ME) ||Fatigue, insomnia, memory problems, sore throat, swollen lymph nodes|
|Diabetic neuropathy ||Burning in the hands and feet|
|Ehlers-Danlos syndrome ||Joint hypermobility and pain, loose skin, easy bruising|
|Hepatitis C [27,28]||Abdominal, muscle or joint pain, jaundice, dark urine|
|Hyperparathyroidism ||Excessive urination, nausea, bone and joint pains|
|Hypochondria||Many complaints but no observable abnormalities|
|Hypothyroidism ||Muscle weakness, sensitivity to cold, constipation, goiter, puffy face|
|Malingering||Tenderness in the areas not typical for fibromyalgia (fingers, forearm)|
|Systemic inflammation or infection (infectious mononucleosis, influenza, Lyme disease, sarcoidosis)||Fever or rash, sore throat, cough, fatigue, muscle pain, swollen lymph nodes|
|Vitamin B1, B6, B12, D or mineral (potassium, calcium) deficiency ||Muscle weakness, hair loss, brittle nails, scaly skin, cracked lips|
- Wolfe F et al, 2010, The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity Wiley Online Library
- Konder C, 2015, Common Questions About the Diagnosis and Management of Fibromyalgia American Family Physician
- Fibromyalgia – understanding the diagnosis process Mayo Clinic
- Alonso-Blanco C et al, 2011, Multiple active myofascial trigger points reproduce the overall spontaneous pain pattern in women with fibromyalgia and are related to widespread mechanical hypersensitivity PubMed
- Brezinschek HP, 2008, Mechanisms of muscle pain : significance of trigger points and tender points PubMed
- Mense S, 2011, Differences between myofascial trigger points and tender points PubMed
- Questions and answers about fibromyalgia National Institute of Arthritis and Musculoskeletal and Skin Diseases
- Clauw DJ, 2014, Fibromyalgia clinical review CiteSeerX
- Al-Allaf AW et al, 2002, The prevalence and significance of positive antinuclear antibodies in patients with fibromyalgia syndrome: 2-4 years’ follow-up PubMed
- Koroschec J et al, 2011, Fibromyalgia and neuropathic pain – differences and similarities. A comparison of 3057 patients with diabetic painful neuropathy and fibromyalgia PubMed Central
- Wolfe F et al, 2016, 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria Seminars in Arthritis and Rheumatism
- Caro XJ et al, 2008, A subset of fibromyalgia patients have findings suggestive of chronic inflammatory demyelinating polyneuropathy and appear to respond to IVIg PubMed
- Levine TD et al, Routine use of punch biopsy to diagnose small fiber neuropathy in fibromyalgia patients PubMed Central
- Ge HY et al, 2011, Reproduction of overall spontaneous pain pattern by manual stimulation of active myofascial trigger points in fibromyalgia patients PubMed Central
- Myalgic encephalomyelitis/chronic fatigue syndrome symptoms CDC
- What Are the Signs and Symptoms of Anemia? National Heart Lung and Blood Institute
- What are the Ehlers-Danlos Syndromes? The Ehlers-Danlos Society
- Adrenal Insufficiency & Addison’s Disease NIDDK
- Hypothyroidism (underactive thyroid) Mayo Clinic
- MS symptoms National Multiple Sclerosis Society
- What is myasthenia gravis (MG)? Myasthenia Gravis Foundation of America
- Polymyalgia rheumatica American College of Rheumatology
- Polymyositis The Myositis Association
- Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) National Institute of Neurological Disorders and Stroke
- Tavee J et al, 2009, Small fiber neuropathy: A burning problem MDedge
- Hyperparathyroidism symptoms and causes Mayo Clinic
- Fibromyalgia differential diagnosis BMJ Best Practice
- Hepatitis C WHO
- Brazier Y, 2017, Nutritional deficiency anemia: Causes, symptoms, and treatment MedicalNewsToday