Offering a unique case study approach, this author discusses various forms of regional rheumatic pain syndrome and provides key treatment insights.

Patients who report chronic pain to the primary care physician are often referred to rheumatologists or orthopedists for treatment once they have failed conservative care. One possible diagnosis for these patients may be regional rheumatic pain syndrome, a group of conditions that can cause chronic pain in defined regions of the body. The syndrome has four main categories: generalized pain syndromes, impingement syndromes, structural disorders or tendonitis/bursitis.



With this group of disorders, one will rarely see positive lab results. However, clinicians can often use X-rays or nerve conduction tests to help differentiate regional rheumatic pain syndrome from other diagnoses. Obtaining a detailed medical history and performing a carefully focused exam are also essential for the diagnosis and treatment of these four disorders.

Accordingly, let us take a closer look at a few patient case studies.

Case Study: When A Patient Complains Of Severe Fatigue And Muscle Ache
Jane, a 25-year-old female, presented to the rheumatology clinic after seeing multiple doctors. She feels tired every day, has tingling in her feet and hands, and has muscle aches that seem to be exacerbated by exercise. After taking her kids to Disneyland, she said she could not get out of bed for the next three days.

She has been reprimanded by her employer for calling in sick multiple times but feels her fatigue is so severe that she cannot keep her eyes open. Her primary care doctor checked her blood work and told her that her muscle enzymes and thyroid are normal. She was referred to neurology for the numbness in her hands and feet. The neurologist performed a nerve conduction test and it was normal. She was then told she was “probably depressed” and was referred to a psychiatrist, who started her on an antidepressant. However, three months later, the patient did not feel any better.

She returned to her primary care doctor, who noted muscle inflammation and subsequently referred her to a rheumatologist. While the clinical exam revealed that all of her joints were normal, she did have localized trigger points that were indicative of fibromyalgia.

Fibromyalgia is a clinical syndrome defined by chronic widespread muscular pain, fatigue and tenderness in defined areas called “trigger points.” The symptoms usually develop between the ages of 20 to 40. There is a 7 to 1 ratio of females to males who suffer from this syndrome. Many patients also have additional symptoms such as fatigue, depressive symptoms, headaches as well as cognitive and memory problems often called “fibro fog.” These symptoms can change daily and be aggravated by stress or lack of sleep.

The cause of fibromyalgia is unknown but there are studies that show a relationship between lack of quality sleep (stage III and IV) and the development of fibromyalgia.1 There are other studies that show that people with fibromyalgia may have abnormal levels of Substance P, a chemical that helps transmit and amplify pain signals to and from the brain.2 Current studies are underway to examine the role of Substance P.

In one case, a 25-year-old woman presented to the rheumatology clinic after seeing multiple doctors. She feels tired every day, has tingling in her feet and hands, and has muscle aches that are exacerbated by exercise.

Unfortunately, there is no clear-cut diagnostic test for fibromyalgia and clinicians often refer to fibromyalgia as a diagnosis of exclusion. Some patients have been told that they have fibromyalgia but subsequently find out they have a sleep disorder such as sleep apnea or restless leg syndrome. Clinicians should also distinguish fibromyalgia from other chronic pain disorders such has myositis, hepatitis C, depression, hypothyroidism or polymyalgia rheumatica.

Pertinent Pointers On Managing Fibromyalgia
When it comes to managing the chronic pain of fibromyalgia, one can utilize medications, exercise and some alternative treatments such as massage or acupuncture. There are doctors that practice a technique called myofascial release. This therapy gently stretches, softens, lengthens and realigns the connective tissue to ease discomfort. These doctors often combine this technique with direct trigger point injections of xylocaine into the muscle to relieve muscle spasms.3

Current studies indicate the best pharmacologic treatments for treating the arthralgias of fibromyalgia pain are Ultram and Tylenol.4 Muscle relaxants like Flexeril or Skelaxin can help with the muscle pain but frequently exacerbate fatigue.5 Low doses of Elavil or Ambien can help with a patient’s disrupted sleep cycle.5 There have also been good results with Cymbalta (Eli Lilly) and Lyrica (Pfizer), two relatively new medications on the market that help modulate the pain signal to the brain.

In treating fibromyalgia, clinicians should avoid the use of narcotics and non-steroidal antiinflammatory medications (NSAIDs). Using NSAIDS long term can lead to gastrointestinal (GI) complications such as ulcers. Narcotics are only indicated for short-term pain control. They lose their effectiveness over time and require higher and higher doses for the same level of pain control.

Most patients with fibromyalgia find it very difficult to exercise. They may report that after 30 minutes of exercise, the pain increases to a level where they cannot get out of bed for the next two to three days.
In order to counteract this, one should have these patients start doing five minutes of aerobic exercise three to five days a week. For each subsequent week, patients should increase their exercise sessions by two minutes until their sessions reach 15 minutes in duration. If the patient can tolerate 15 minutes without relapsing, then the patient should slowly increase activity until he or she achieves 30-minute exercise sessions.

Case Study: When A Secretary Notices Numbness In Her Hand
Margaret is a 45-year-old secretary who has noticed that the three fingers of her right hand have been going numb. She also feels that her grip strength has decreased and she can no longer open jars with her right hand. She often wakes up in the middle of the night with her hand completely numb. After using the computer all day, she says the pain shoots up her right arm from her wrist. She has tried Tylenol (J&J) and Motrin (McNeil Consumer Health) for the pain but says neither medication seems to help. She is referred to neurology for a nerve conduction test and is subsequently diagnosed with carpal tunnel syndrome.

Impingement syndromes occur when a nerve is compressed at certain anatomical locations. The most common complaints are radiating pain with numbness. Sometimes these patients also have muscle weakness or atrophy. Common impingement locations are the cervical spine, lumbar spine, shoulders, elbows and wrists. The most common form of impingement syndrome is carpal tunnel syndrome.

Impingement syndromes occur when a nerve is compressed at certain anatomical locations. The most common form of impingement syndrome is carpal tunnel syndrome.

Compression can occur when a nerve passes through an opening in the bone (foraminal stenosis) or fibrous tissue (carpal tunnel). Sciatica occurs when the nerves to the legs are compressed in the lumbar spine. Patients complain of shooting pain down the leg and usually note numbness in the legs or feet. Walking long distances can aggravate the symptoms.

By performing a thorough neurologic exam and/or nerve conduction studies (NCV), one may diagnose impingement syndrome. Muscle weakness, loss of bowel or bladder function, and severe numbness usually necessitate surgery.

Exploring The Treatment Options For Impingement Syndromes
In general, clinicians may treat impingement syndromes through conservative methods. One should first instruct patients to avoid the activity that aggravates the condition. Bracing, steroid injections and medications are possible options. The common treatments for impingement are short courses of NSAIDs or oral steroids such as prednisone. If the symptoms persist for more then one month, medications such as Neurontin (Pfizer) or Lyrica can decrease the pain and numbness. One should avoid using narcotics for long-term treatment of pain.

If the patient fails to get relief after trying conservative options and medications, one may need to consider surgical treatment options. There are many surgical approaches depending on the type of impingement. When it comes to carpal tunnel syndrome, the surgeon may cut the fibrous tissue to widen the carpal tunnel. Surgeons may also move the affected nerve when there is ulnar entrapment of the elbow. In the shoulder, one can shave the acromion bone if it is impinging the nerve. In the neck, the surgeon can cut bone via a laminectomy in order to widen the opening for the exiting nerve.

Case Study: When A Double-Jointed Woman Notices Joint Pain After Having A Baby
Jane is a 21-year-old female who says she has been double jointed her entire life. She can hyperextend her elbows and can bend her thumb all the way back to her arm. She first noticed joint pain three months after giving birth to her first child and says all her joints have started to ache in the past six months.

She says Motrin has helped to some degree with her pain but she would like to know why her body hurts every day. An X-ray of her elbows was normal. Her muscle enzymes, thyroid levels and CBC were also normal. She is diagnosed with hypermobility syndrome and is told that she will have chronic pain. She is given a 24-hour antiinflammatory medication to take when the pain flares.

Keys To Treating Pain From Structural Disorders
Structural disorders such as scoliosis or flatfoot are often causes of chronic pain. One must consider these disorders when evaluating people who present with pain in one localized area such as the foot or low back. Also keep in mind that there is a hypermobility syndrome that causes pain due to increased joint laxity in the face of muscle disuse.

People often refer to themselves as being “double jointed” and can often bend their fingers at angles that most people are not able to achieve. This genetically based condition hypermobility syndrome is a diagnosis that affects only a minority of double-jointed people. People who are double jointed will often have localized pain in the hips, knees and feet but the pain can affect all of the joints. Those who are double jointed are not at increased risk for the early onset of osteoarthritis.

Here is a classic view of adult-acquired flatfoot. Structural disorders such as flatfoot are often causes of chronic pain. (Photo courtesy of Douglas Richie, Jr., DPM)

When it comes to treating pain from structural disorders, clinicians commonly utilize short courses of NSAIDs or Tylenol. Flatfoot disorders respond well to orthotic shoe inserts or special shoes. One may refer the patient to a podiatrist who can provide customized orthotics, which offer significant pain relief. Some specialty shoe stores such as Just For Feet have shoes for people with flatfoot or high arches. When it comes to scoliosis, it is best to catch this during adolescence and it can be treated surgically. Hypermobility syndrome responds best to physiotherapy. Physiotherapists are currently training in specific exercises that can help a patient cope with chronic pain.

Case Study: When A Surfer Complains Of Elbow Pain
Brad is a 30-year-old surfer who has been noticing pain at his right elbow. It seems that pain gets worse after he has been surfing for more than two hours. The patient says the pain used to subside after a few hours of rest but the pain has now increased to the point where he has pain whenever he tries to lift with his right arm. He is afraid that he may no longer be able to surf if the pain does not improve. He had an X-ray of the elbow and the results were normal. The lab work was also normal. The provider had him supinate his arm and the pain increased. He was diagnosed with tennis elbow and the clinician opted for steroid injections and the elbow pain resolved. The patient was able to surf again after one week of rest.

Tendonitis presents as local pain with inflammation at the attachment points of the muscles. It is most commonly associated with overuse and a specific muscle. Professional athletes will commonly inflame the same tendon because they repeatedly do the same maneuvers. Common examples are tennis elbow, golfer’s elbow, De Quervain’s tendonitis of the thumbs and Achilles tendonitis in the ankles.

However, infection, systemic rheumatic disease or metabolic conditions that cause calcium deposits in the tendons can also cause tendonitis.

Trigger finger involves a nodule that forms on the tendons of the hands. This causes the finger to often become stuck in the flexed position and requires the patient to use the other hand to straighten out the finger. Fluoroquinolone antibiotics such as Levaquin (Ortho-McNeil) have some rare side effects that are associated with tendonitis and rarely tendon rupture.

Professional athletes commonly inflame the same tendon because they repeatedly do the same maneuvers. Common examples are tennis elbow, golfer’s elbow, De Quervain’s tendonitis of the thumbs and Achilles tendonitis in the ankles.

Bursitis presents as localized pain and inflammation of the synovium. Overuse of a specific joint is the most common cause. There are some conditions such as gout and pseudogout that cause crystals to accumulate in the joints. This can subsequently lead to bursitis in the knees or elbows. Checking the blood for high levels of uric acid can help diagnose gout. Obtaining X-rays of the joints can show the accumulation of crystals in the synovial fluid. One can then aspirate synovial fluid and send it to the lab to be evaluated for the presence of crystals or bacteria.

Treatment Tips For Tendonitis, Bursitis And Gout
Stretching, physical therapy and rest of the inflamed area are the conservative treatments for these conditions. Patients may also use ice after the activity to reduce inflammation. Clinicians often have these patients utilize braces or bands to reduce symptom recurrence and decrease pain. Both conditions respond well to localized injections of steroids. It is common to use short courses of NSAIDs to control pain. Surgery is rarely indicated unless there is a tear or tendon rupture. Gout and pseudogout respond well to NSAIDs, steroids and a medication called colchicine.