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WHAT: Tender points consistent with fibrositis. Tender Points Consistent with Fibrositis: localized areas of tenderness elicited by firm digital pressure on specific anatomic sites (see list in HOW section). WHY: The presence of typical tender points is a diagnostic sign seen in primary fibromyalgia (fibrositis). HOW: Ascertained by physical examination. Since these sites are normally somewhat tender, their location and the amount of pressure necessary to elicit normal degrees of tenderness can be determined on a normal subject (such as the examiner). In the patient being examined, the areas are palpated with digital pressure somewhat less firm, approximately 80% of that which would elicit tenderness in a normal subject. Physical withdrawal, vocalization of tenderness, or facial expression of pain are taken as evidence of exaggerated tenderness. The following list presents many of the consistently characteristic areas of tenderness noted in fibrositis, but is not exhaustive. Tender points on each side are counted individually: i.e., both trapezius muscles being tender counts as two tender points. 1) Insertion of nuchal muscles into occiput 2) Trapezius (R & L). The midpoint of the upper border of the trapezius in the firmer part of the muscle. 3) Second costochondral junction (R & L). On or just lateral to the junction, more marked on the superior surface than elsewhere on the rib. 4) Lateral epicondyle (R & L). Along the insertion of the finger extensor muscles, 1-2 cm distal to the lateral epicondyle. Best located by palpation of the area while the third finger is extended and relaxed. The medial epicondyle (R & L) may also be tender. 5) Buttocks (R & L). The mid-portion of the upper outer quadrant, in the anterior portion of the gluteus medius muscle. 6) Greater trochanter of the hip (R & L). The examiner must exclude trochanteric bursitis. 7) Medial fat pad of the knee (R & L). The subcutaneous tissues overlying the medial collateral ligament, just proximal to the joint line. 8) Gastrocnemius-Achilles tendon junction Control points (non-tender to equal pressure) include: 1) Middle of forehead 2. Volar aspect of mid-forearm 3) Thumb nail 4) Muscles of anterior thigh REFS: 1) Yunus, M, et al. Primary fibromyalgia (fibrositis): clinical study of 50 patients with matched normal controls. Semin Arthr Rheum, 11(1):151-71, 1981. 2) Smythe, H and Moldofsky, H: Two contributions to understanding of the \'Fibrositis\' syndrome. Bull Rheum Dis, 28(1):928-31, 1977. 3) Smythe, H: Nonarticular rheumatism and psychogenic musculo-skeletal syndromes. In McCarty: Arthritis and Allied Conditions. Lea and Febiger, 1979:881-91.
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