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9.08 Fibromyalgia (Trigger Points)


Presentation

The patient, generally between 25 and 50 years old, will be troubled with the gradual onset of fibromuscular pain that at times can be immobilizing. There may be a previous history of acute strain, muscle spasm or nerve root irritation (e.g., whiplash injury of the neck or low back strain). The areas most commonly affected include the posterior muscles of the neck and scapula, the soft tissues lateral to the thoracic and lumbar spine, and the sacroiliac joints. The patient is often depressed or under emotional or physical stress and often has associated fatigue with disturbed sleep as well as sensations of numbness or swelling in the hands and feet. Cold weather may be one of the precipitating causes of pain. There should be no swelling, erythema or heat over the painful areas, but applying pressure over the site with an examining finger will cause the patient to wince with pain . This tender " trigger pont" is usually no larger than your finger tip and when pressed will cause local pain, referred pain, or both.

What to do:

What not to do:

Discussion

Although the pathophysiology of fibromyalgia is unknown it is a very real syndrome. Treatment may provide only partial symptomatic relief. True fibromyalgia syndrome is a chronic conditio requiring long term management that may include physical therapy, exercise, patient education and reassurance along with sleep-enhancing medications like low dose tricyclic antidepressants.

Emergency physicians often see trigger points associated with simple self-limiting regional myofascial pain syndromes which appear to arise from muscles, muscle-tendon junctions, or tendon-bone junctions. Myofascial disease can result in severe pain, but typically in a limited distribution and without the systemic feature of fatigue. When symptoms recur or persist after the basic therapy above, or are accompanied by generalized complaints, refer the patient to a rheumatologist or primary care physician.

When the quadratus lumborum muscle is involved there is often confusion as to whether or not the patient has a renal, abdominal, or pulmonary ailment. The reason for this is the muscle's proximity to the flank and abdomen as well as its attachment to the 12th rib, which when tender, can create pleuritic symptoms. A careful physical exam, with palpation, active contraction, and passive stretching of this muscle reproducing symptoms, can save this patient from a multitude of laboratory and x ray studies.


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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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