Arnold Goldberg
Polymyalgia or diffuse painful muscles (myalgia) does not always imply muscular disease. Chronic aches, pains, or stiffness in multiple areas of the body are increasingly common complaints among patients.
Differential diagnosis is best approached by dividing the various causes of polymyalgia into those with muscular weakness and those without (Table 12.10).
Is the onset insidious or acute? What body areas are involved? Is there associated joint pain? Does the patient complain of weakness? Is fever or prominent fatigue present (Chapters 2.5 and 2.6)? Is the patient’s sleep disturbed? Is depression an overriding symptom? Look for precipitating events. Is there domestic abuse? Could there be any potential emotional or financial gain from the symptoms? Are there any symptoms suggestive of the diseases mentioned in Table 12.10? Take a careful medication, travel, occupational, and family history.
A. Musculoskeletal. Inspect for muscle atrophy. Palpate for muscle tenderness. Is any tenderness diffuse or focal in nature? Evaluate joint range of motion and gait.
B. Neurologic. Assess muscle strength and cranial nerve function.
C. Other. Palpate for scalp tenderness and tender areas or nodules localized to the temporal or occipital arteries. Look for rash.
For the workup, costs are increasingly relevant. Initial testing can be divided into pathways.
A. With objective muscle weakness. Electromyography (EMG), a complete blood count (CBC), erythrocyte sedimentation rate (ESR), creatine phosphokinase (CPK), potassium, calcium, phosphorous, magnesium, and thyroid-stimulating hormone (TSH) are warranted. If CPK is elevated or a myopathic picture appears on EMG, consider a muscle biopsy in cases of moderately weak, but not atrophic, muscle and no history of recent muscle trauma.
B. Without objective muscle weakness. Obtain a CBC, electrolytes, TSH, CPK, and ESR. If normal, evaluate, as needed, for other disorders listed in Table 12.10.
A. Polymalgia rheumatica (PMR). Typical onset is from age 50 years to more than 90 years. Symptoms can begin abruptly or insidiously. Fatigue, anorexia, weight loss, and low grade fever are common. Patients with PMR complain of aching and stiffness in the morning. “Jelling” of the joints after inactivity, in two of the three proximal (hips, shoulders, neck) areas of the extremities and torso for 1 month or longer is diagnostic of PMR. On examination will be found diffuse, proximal muscle tenderness without weakness. Temporal arteritis (TA) is associated with PMR in 16% to 20% of cases. In TA, scalp tenderness and diffuse or focal tender areas or nodules are localized to the temporal or occipital arteries. Headache is present in two-thirds of patients (Chapter 2.7). Visual symptoms and claudication of the jaw, tongue, or entire swallowing mechanism are common. The visual deficit is usually permanent.
B. Fibromyalgia is a chronic, widespread pain syndrome without overt muscular pathology. The pain typically waxes and wanes in intensity. The core symptom is widespread musculoskeletal pain with multiple tender points on both sides of the body, above and below the waist. Classically, tenderness is found in more than 11 of 18 trigger point sites with the application of 4 kg of palpation pressure (1,2). Other point areas can be tender and fibromyalgia can still be diagnosed in patients with fewer than 11 classic trigger points. Other symptoms are stiffness, skin tenderness, postexertion pain, poor sleep pattern, and, at times, fatigue. Patients are more sensitive to pain throughout their body leading to many associated symptoms including headache, crampy abdominal pain, vertigo, vulvodynia, nondermatomal paresthesias, and premenstrual syndrome symptoms as well as other somatic complaints (1). Fibromyalgia patients have a higher incidence of psychiatric illnesses such as depression, but the debate continues to whether this is the cause or effect of the chronic pain and ensuing disability. Chronic fatigue syndrome (CFS) has characteristics similar to fibromyalgia. Persisting, debilitating fatigue and postexertion malaise are the paramount symptoms. Myalgias, low grade fevers, pharyngitis, adenopathy, and cognitive impairment are common occurrences (3). At least 25% to 40% of patients with misdiagnosed Lyme disease have fibromyalgia or CFS (Chapter 2.5).
C. Psychogenic rheumatism, typically, has a histrionic presentation where the fatigue symptom is very prominent (4). Neurologic and musculoskeletal examination are often inconsistent on repetition.
D. Rheumatic disorders. Soft tissue pain can be secondary to well-established rheumatoid arthritis or systemic lupus erythematosus. Sjögren’s syndrome may be the exception, as myalgia symptoms can antecede the full presentation of the syndrome.
E. Inflammatory disorders. Causes of polymyalgia symptoms and muscle weakness include polymyositis, dermatomyositis, and inclusion body myositis (IBM). Proximal limb or neck weakness is the most prominent symptom. Fewer than 50% of patients have associated muscle pain. Other symptoms include difficulty climbing stairs, getting into or out of a car, rising from a chair, combing hair, and lifting objects (4). There may be a history of falls (4). On examination, muscle atrophy is more typical of myositis. Muscle weakness is symmetric and diffuse. Unlike PMR, the hip, shoulder, and neck are infrequently tender to palpation. Gait is slow and waddling. Joint contractures may be present. Facial and ocular weakness almost never occur, which separates myositis from myasthenia gravis and some inherited myopathies. In IBM, more distal muscle involvement is seen. Weakness is usually bilateral and greater in the legs. In dermatomyositis, cutaneous manifestations can precede, follow, or develop together with muscle weakness. Cutaneous findings include Grotton’s papules, a heliotropic rash on the upper eyelids, and rash on the neck (V sign), shoulders, and upper back (shawl sign) (4).
F. Other. The other illnesses mentioned in Table 12.10 have polymyalgia as a finding that is secondary to their underlying illness; however, myalgia may be the first symptom described.
References
1. Clauw DJ. Fibromyalgia. More than just a musculoskeletal disease. Am Fam Physician 1995;52:843–851.
2. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 1990;33:160–172.
3. Meenan RF. The evaluation of arthralgia. American Academy of Family Physicians 46th Annual Scientific Assembly, 1994.
4. Olsen NJ, Wortmann RL. Inflammatory and metabolic diseases of muscle. In: Schumacher HR Jr, ed. Primer on rheumatic diseases, 11th ed. Atlanta: Arthritis Foundation, 1997.
Review other book chapters online related to Temporal arteritis:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X 
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