of fibromyalgia is currently based on the
Classification Criteria developed by The American College of
Rheumatology in 1990. These diagnostic recommendations are
based on 2 features:
1. A history
of widespread pain of 3 months or more. Widespread is
defined as pain in an axial distribution plus pain of both left
and right sides of the body, and pain above and below the
Thus, a patient with axial pain, plus pain in 3 body
segments would qualify - as seen below.
2. The palpation of 18 specified locations of tenderness (so
called “tender points”). To make a diagnosis of fibromyalgia
there needs to be pain on digital palpation of 11 or more out of
the18 specified tender points. The recommendations specify that
the palpation be at a final force of 4 kg (the amount of
pressure required to blanch a thumbnail) starting at 1 kg and
incrementing by 1 kg at a rate of 1 kg per second.
Here are the approximate
9 paired tender point locations:
anatomical locations of the tender point locations are as
Cervical Region: (front neck area)
at anterior aspect of the interspaces
between the transverse processes of
Second Rib: (front chest area) at
second costochondral junctions.
Occiput: (back of the neck) at
suboccipital muscle insertions.
Trapezius Muscle: (back shoulder
area) at midpoint of the upper border.
Supraspinatus Muscle: (shoulder
blade area) above the medial border of
the scapular spine.
Lateral Epicondyle: (elbow area) 2
cm distal to the lateral epicondyle.
Gluteal: (rear end) at upper outer
quadrant of the buttocks.
Greater Trochanter: (rear hip)
posterior to the greater trochanteric
(knee area) at the medial fat pad
proximal to the joint line.
Other common problems
Symptoms such as sleep disturbance, fatigue, stiffness, skin
fold tenderness, and cold intolerance, are common in
fibromyalgia patients, but their inclusion did not improve
diagnostic accuracy. The recommended number of tender points --
i.e., 11 or greater -- was originally derived from a receiver
operating curve and relates to the number giving the best
sensitivity and specificity.
pain typically waxes and wanes in intensity; flares are
associated with unaccustomed exertion, soft tissue injuries,
lack of sleep, cold exposure, and psychological stressors.
Although most patients have widespread body pain, there are
typically one or two locations that are the major foci. These
pain foci often shift to other locations -- often in response to
new biomechanical stresses or trauma. Fibromyalgia is more than
a muscle pain syndrome, as most patients have an array of other
somatic complaints. Nearly all fibromyalgia patients have
severe fatigue, poor sleep, and post-exertional pain. Other
symptoms include: tension type headaches, cold intolerance, dry
mouth, unexplained bruising, poor memory and concentration,
fluid retention, chest pain, jaw pain, dyspnea, dizziness,
abdominal pain, paresthesiae, and low grade depression and
anxiety. Some symptoms relate to specific syndromes whose
prevalence appears to be increased; these include: irritable
bowel syndrome, irritable bladder syndrome migraine,
premenstrual syndrome, Raynaud’s and restless leg syndrome.
Do you need blood tests and imaging tests to diagnose
The 1990 ACR
recommendations state that "fibromyalgia is not a diagnosis of
exclusion". This means that you do not need special tests to
rule out other conditions. If a patient meets the historic
and exam findings of tender points they can be diagnosed as
having FM. This is an important concept, as some physicians only
consider a diagnosis of FM after they have done exhaustive
testing to rule out other conditions.
However, it is
equally important to understand that FM often accompanies
other conditions such as osteoarthritis, lupus (SLE), rheumatoid
arthritits and multiple sclerosis. Thus, depending on the
history and physical exam, further testing is often quite
appropriate. In fact a careful evaluation for all other
conditions that may be contributing to pain is an essential part
of an informed treatment plan. However, I stress that the
finding of another condition does not necessarily rule out a
diagnosis of FM.
Classification versus Diagnostic Criteria
speaking classification criteria are used in scientific and
epidemiologic studies, as they represent a high degree of
separation from other disorders (i.e. specificity). It is
generally appreciated that classification criteria are not
always optimally sensitive; in other words some patients who
have fibromyalgia may not meet the classification criteria
specifications. Bearing this in mind most clinicians favor a
more "relaxed" approach to diagnosis. A recent attempt at a set
of diagnostic guidelines that eliminate the need for a tender
point examination have been proposed
Care & Research, 62:600–610, 2010).
A review and critique of these criteria can be
Acceptance of Fibromyalgia as a valid Diagnosis
of the ACR criteria led to widespread interest and research into
this disorder. For instance, the US Government provided research
funding for fibromyalgia through the NIH, and both the Social
Security Administration and the Veterans Administration
recognized fibromyalgia as a potential cause for disability.
More recently, the American Boards of Internal Medicine have
included questions on fibromyalgia in their certifying
examinations. Interestingly many soldiers suffering from
“Gulf-War Syndrome” have been found to have fibromyalgia. Here are some
links to Government and other influential websites that
Security Administration recognizes fibromyalgia as a cause of
Boards of Internal Medicine requires that physicians taking
their recertification examination be familiar with fibromyalgia:
Administration recognizes fibromyalgia as a potential cause of
Clinic recognizes fibromyalgia as a common cause of pain:
Clinic contributes to the WebMD website on fibromyalgia:
Institutes of Health recognize fibromyalgia as a common problem
Institutes of Health supports research on fibromyalgia -