What is the pragmatic physician to do with all this ? Here’s another way I can offer. When you get down to concretely examining patients with seemingly “widespread” soft-tissue pain (which for many has a troublesome pattern of fluctuating persistency), you find a selection of very rational ailments. The most common are trapezio-cervical strain, rotator cuff syndromes, epicondylitis, iliac crest strain, and trochanteric pain disorder (a form of gluteus medius tendinopathy). It takes about 3 focal sources of pain to flood a person’s reportage to the point where terms such as “pain all over” start to be heard. Of 30 more-or-less common soft-tissue ailments of the human body, all occur in the setting of everyday auto-traumatic myo-tendinous resiliency disorders. There is nothing mysterious or neuro-interpretive about them — in fact they are biomechanically explainable and even inevitable for our locomotor structure and its weak links. They are not “muscular” specifically but are the result of powerful normal muscles transmitting forces through weaker myo-tendinous and tendo-osseous transition structures to cause pathology. Rheumatology has done a poor job of educating the medical world about myotendinous disorders. The published investigators have gone so far off the rails that they literally speak another language and have created para-scientifc factoids which seem to justify their hypothesis. For instance, all the findings of abnormal fMRI’s and altered pain thresholds are the result of comparisons with pain-free control cases — if you used other pain populations as comparators you’d find that the “abnormalities” are simply the body’s way of handling any persistent pain. Further, the tender point exam is a useless exercise searching for abstract signals that the patient is too sensitive.

Why not instead do an anatomically-informed exam searching for rational pathology? The human locomotor system has stereotypical themes which are easily enumerated and clarified … even in the most neurotic individuals. In fact, finding and explaining those themes makes the patient a lot less neurotic.

Most rheumatologists, rightly, would rather chew tinfoil than see a patient for whom they expect to use the “fibromyalgia” paradigm. It’s a painful exercise in disinformation, it’s misogynistic, and produces emotional and cognitive dissonance in all parties.

Contrarily, it is a surprisingly satisfying medical experience to deconstruct “widespread” pain into its components and find that the individual features are anatomically rational (and frequently very treatable). No mysteries involved and no matrix of non-locomotor symptoms is attached (all that irritable bowel, fatigue, cognitive defects, bladder stuff is common in the general population).

The fibromyalgia hypothesis has been very damaging to medical reasoning and is one of the most egregious intellectual misadventures of our time.

For anyone further interested in this and who’d like an option to the fibromyalgia theory of Smythe, Yunus, Wallace, Clauw, Russell, Crofford and others … I can provide a powerpoint presentation as well as a link to a grand rounds presentation detailing myotendinous pain disorders and developing a critique of fibromyalgia.

I still think of fibro as a diagnosis of exclusion.

Most of the rheums in my neighborhood won’t take “fibro” consults.

Your comments were very funny, there is always someone more sensitive than yourself to try to make you feel bad.

Fibromyalgia is a work in progress. As with any pain syndrome, we don’t yet have objective measures of pain, and so everyone (doctors, nurses, other patients) are always concerned that they are missing the ‘real problem (depression, anxiety, other sources of pain, malingering). It could be perceived as dishonest to just label something as ‘Fibromyalgia’ and prescribe drug x, instead of looking deeper into the issue.

Maybe you can educate us so I can stop wasting my time researching JAK-STAT pathways and treating autoimmune illnesses with TNF alpha inhibitors.

I believe the reason fibromyalgia has such a bad reputation and it’s been hard to convince some doctors it’s real is because for every 1 organic patient without psychiatric overtones you have 1000 with so much noise from the psychiatric overtones and snake oil salesmen you can’t weed out the signal.