Fibromyalgia
Diagnostics, tender point exam
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There is a great deal made of what you will commonly see on most FM sites, which is the table for diagnostics image, which is like so

FM tender points

Now, there is something to understand about this image and all others like it, they exist for only one reason, to help give you an idea of what doctors are supposed to be looking for, when they attempt a diagnosis of FM. As the tender points seen in FM, are one of a kind to FM. News, possible new criteria for making a diagnosis, see the bottom of the page.

This does not mean however, that these are the only areas of pain with FM. This is unfortunately, a common belief, that is reinforced by such images. In 1990, the primary diagnostic criteria for FM was created, as up to that point, it was done by exclusion, meaning if you ruled out everything else, then .. it was assumed to be FM. This created a lot of problems for those of us with the disorder, for the simple fact that it created the idea of FM being a "waste basket" diagnosis. So the main line diagnostic criteria was created. The official wording is :

A. Widespread pain in all four quadrants of the body, for a minimum of three months ( this was challenged, as not being expansive enough )

B. At least 11 of the 18 specified tender points

Now, what this meant is, if you didn't have at least 11 of the 18, you didn't have FM according to the criteria. Which has been proved wrong, and was proved wrong less than six years after the criteria was created. 

The lack of 11 out of 18, is often seen in those who do indeed have FM. This is especially true in men. ( which is yet another reason why they may be under diagnosed ) Therefore, the criteria has been expanded to include the most common signs seen with FM, which are: Research

Fatigue
Irritable bowel
Sleep disorders
Chronic headaches
Jaw pain ( TMJ signs or dysfunction)
Cognitive or memory impairments
Post-exertional malaise ( exhaustion )
Muscle pain
Morning stiffness (waking up stiff and in pain)
Numbness and tingling sensations (Paresthesias)
Skin and/or chemical sensitivities
Myofascial pain or CMP
Costochondritis
and others...

Mind you, these things are not FM. However, they are so commonly seen in persons with FM, that if the person has several of these things going on and is positive for the tender points, and has had widespread pain for more than 3 mts ...  then the doctor can reasonably assume a possible diagnosis of FM, barring ruling out any other conditions, which mimic FM signs.

Now, it is important with a tender point exam, that the doctor knows how to do it correctly. As if they do not, what can happen is they can press on CMP pain points instead, which can be anywhere ! This has caused more than one doctor to assume the person is malingering, as with CMP trigger points on site link, you could have them body wide. ( meaning it can hurt for them to poke you almost anywhere on your body )

So the problem lies, in the fact, that far too many doctors, still do not know how to do a tender point exam, properly. The problem is so large, to where there are those who are suggesting that doctors have to pass a test, to prove they know how to do it right, as part of their medical training. Article

I would whole heartedly agree, as this skill, like any other diagnostic skill requires understanding and practice to do so, correctly. There is very little pressure ( 4 gm ) is needed to do a proper tender point exam, and some very specific areas to press, those and NO others, are to be used for diagnostic purposes. 

They are:

- Occiput: bilateral, at the suboccipital muscle insertions ( back of your head, just under your hair line ) 

- Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7 ( just about directly under the frist ones, where your head meets your shoulders ) 

- Trapezius: bilateral, at the midpoint of the upper border ( about at the top of the deltoid muscles ) 

- Supraspinatus: bilateral, at origins above the scapular spine near the medial border ( where your shoulder blade is ) 

- Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces. ( under your collar bones, about half way to your breasts ) 

- Lateral epicondyle: bilateral, 2 cm distal to the epicondyles ( outer edge of your elbow ) 

- Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle ( outer top edge of your hip ) 

- Greater trochanter: bilateral, posterior to the trochanteric prominence ( close to the hip joint in the back ) 

- Knees: bilateral, at the medial fat pad proximal to the joint line ( mind you it is the fat pad of the knee, not the knee joint )

A bit of copy and paste to any search engine, will give you lots of diagrams of exactly where these points are, so you have a good understanding, for yourself, this is important. 

Notice, all of them are very specific as to where, and tender points, as rule, are not that large, so they have to know and understand, exactly where to press, or they are getting the wrong information.

So if your doctor is pressing anywhere else, and is supposed to be doing an tender point exam and they cannot tell you, exactly where they are supposed to be looking, it's likely you have the one of many, who does not know how to do it correctly. My personal suggestion is, stop them and ask them, what they think they are supposed to be doing, and where, and if they cannot answer you, in detail, then it's likely you need a different doctor. 


News: A new set of Criteria, is being proposed Research  that is much more comprehensive and detailed. That uses the above tender point exam only as a means to help determine severity, as it uses another set of exams, mostly questionnaires, to identify FM. 

It is called the Symptom Intensity Scale. "The Symptom Intensity Scale is an accurate surrogate measure for general health, depression, disability, and death. Fibromyalgia syndrome diagnosed with this instrument implies that this illness carries increased medical risk." It is the first of its kind that combines a variety of studies done over the years, that focuses on fatigue and pain, at its core. A thing that is the mainstay of anyone with FM that up to now ... has been largely ignored.

"The Regional Pain Scale " for example, a score, which is the number of anatomic areas—out of a possible 19—in which the patient feels pain. A fatigue visual analogue scale score, in which the patient makes a mark somewhere along a 10‑cm line to indicate how tired he or she feels."

Former scales used, such as the "Disease Activity Score" did not go far enough, as they are limited to one disease in particular. Now, as we all know, most of us have several things going on at once, so this limited scope did not help us very much.

"Not surprisingly, distress‑related Fibromyalgia syndrome is more common in patients with chronic rheumatic or arthritic diseases, with a frequency ranging from 5% in osteoarthritisto 47% in Sjögren syndrome. When present, Fibromyalgia syndrome changes the features of the other disease."


Therefore the new scale also gives the doctor a good indicator of our over all health and any co-commitant diseases we have going. As well as, by knowing the FM is part of the picture, fewer mistakes on other issues, maybe made.

"Fibromyalgia syndrome also has the potential to confound the diagnosis of concomitant diseases. Wolfe et al35, found that 22.1% of 458 patients with SLE ( Lupus ) also had Fibromyalgia syndrome, using the Symptom Intensity Scale criteria.... The authors warned that Fibromyalgia syndrome could intrude into the precision of the diagnosis if only a positive antinuclear antibody test and “soft” SLE criteria were used for diagnosis. If we are unaware of Fibromyalgia syndrome, spurious diagnoses may ensue."

This has not yet been "approved" as a testing means... yet, however the signs are very good, that it is very likely to be in the near future
.

Update, thanks to a forum member for bringing it to my attention, this testing means, has provisional approval:
"This criteria set has been approved by the American College of Rheumatology (ACR) Board of Directors as Provisional.
This signifies that the criteria set has been quantitatively validated using patient data, but it has not undergone validation
based on an external data set. All ACR-approved criteria sets are expected to undergo intermittent updates". Proposal. PDF file