I hurt all over... what’s wrong with me?

Probably the most common cause of widespread aches and pains is a self-limited viral infection. Nonetheless, a specific diagnosis is necessary before effective treatment can be recommended.

In most cases, a list of possible causes can be established by history and physical examination and a few simple tests. The latter are recommended when symptoms are severe or have lasted longer than 1 or 2 weeks. Extensive testing should be reserved for situations when the clinical diagnosis is unclear.

 In an arthritis specialist’s office, the following conditions are what are generally encountered.

Fibromyalgia (FM) affects about two per cent of the population and can start at any age; it is more common in women than in men. By the time the diagnosis is made, patients have often had symptoms for many months to years. Patients with fibromyalgia complain of pain all over and, by definition, have pain on both sides of the body, above and below the waist, and in both the trunk and extremities.

Patients describe the pain in many different ways. Muscle stiffness is a very common complaint. Other features include non-restorative sleep, meaning the patient wakes up feeling as  if they haven’t slept, irritable bowel syndrome, irritable bladder, headaches, numbness and tingling in the hands and feet, a sensation of swelling of the hands and feet, and hypersensitivity to sensory stimuli such as smells, sounds, lights. Fibromyalgia is frequently associated with depression, memory and concentration difficulties, and anxiety, and it often accompanies other chronic painful disorders.

A diagnosis of fibromyalgia is made when there is widespread pain lasting for at least 3 months accompanied by tenderness at discrete locations. The exact location of these tender points forms the basis of the American College of Rheumatology diagnostic criteria for the diagnosis of FM. Patients with fibromyalgia are often tender all over; the presence of tenderness other than at the classic locations does not exclude the diagnosis.

A diagnosis of fibromyalgia does not mean that further tests are not required. The diagnosis of FM is a diagnosis of exclusion, meaning all other conditions that could be present need to be ruled out. A physician should make the diagnosis of FM with reluctance in an older patient without a long history of musculoskeletal symptoms. The cause of fibromyalgia is unknown, and its relation to preceding trauma, such as motor vehicle accidents, is controversial.

Current approaches to treatment include a comprehensive and integrated combination of the use of selective serotonin and nor-epinephrine uptake inhibitors (SSRIS, SSNIS), cognitive behavioral therapy, and non-impact aerobic exercise.

Inflammatory muscle diseases (myopathy) such as dermatomyositis and polymyositis, typically cause muscle weakness rather than pain, although pain is sometimes prominent, especially if there is associated joint inflammation. A careful history and examination will usually permit the physician to distinguish between true muscle weakness and weakness due to pain. Muscle pain may be significant in disorders due to toxins or drugs such as cholesterol-lowering agents or colchicine. Hypothyroidism sometimes presents as a myopathy, with muscle weakness and an elevated creatine phosphokinase (CPK) level, or as generalized muscle pains with normal muscle enzymes.

In the elderly, rheumatoid arthritis may start with typical generalized aches and pains accompanied by an elevation in the erythrocyte sedimentation rate (ESR). Symmetrical joint swelling, particularly involving the small joints of the hands, feet, and wrists may then appear weeks or months later.

Polymyalgia rheumatica (PMR) is a disorder affecting people over the age of 50 years. It is characterized by the presence of inflammation in joints.  Patients with PMR have widespread pain and stiffness, which is most severe in the neck, hips, thighs, and low back. Other symptoms such as fatigue, malaise (feeling lousy), fevers and weight loss are often prominent and may actually override the musculoskeletal complaints. Fatigue and malaise can lead to a mistaken diagnosis of depression. Physical findings include pain with movement of the shoulders, hips and knees; some patients cannot raise their arms over their head because of the pain. There may be joint swelling  involving the fingers, wrists and knees.

Laboratory tests will often show anemia, an elevated platelet count, an erythrocyte sedimentation rate (ESR) of over 40 mm/h, and elevated liver enzymes in up to one-third of patients. Results will be negative for rheumatoid factor and antinuclear antibodies. Although most patients will have a markedly elevated ESR,  roughly 20 per cent of patients can have a pretreatment ESR of 30 mm/h or lower.

Giant cell arteritis (GCA) is a disorder due to inflammation of medium and large blood vessels that typically involves arteries of the head and neck. GCA and PMR are closely related disorders that may develop together, or one may precede the other. In addition to the constitutional symptoms associated with PMR, symptoms of GCA include headache, swelling of the temporal artery, scalp tenderness, jaw cramping with chewing, tongue or throat pain and visual disturbances.

Physical findings are variable for this condition. When this diagnosis is suspected, the patient should be sent for a temporal artery biopsy and started on high doses of corticosteroids immediately because of the risk of sudden blindness associated with untreated GCA. A temporal artery biopsy should be done for all other patients with suspected GCA. It is sometimes necessary to do bilateral temporal artery biopsies to prove the diagnosis. A temporal artery biopsy can be performed within one to two weeks of starting treatment without compromising the biopsy findings.

Occasionally, a patient with mild symptoms of PMR may be successfully treated with non-steroidal anti-inflammatory drugs (NSAIDs). However in most cases, low dose prednisone is required. A usual course of therapy for PMR begins with prednisone, 10-20 mgs as a single morning dose. Patients with PMR usually require treatment with corticosteroids for extended periods, often for at least 18 months. Gradual tapering is required. Attempts to reduce prednisone doses more quickly may lead to a flare-up of symptoms; therefore, it is best to taper at a rate that will have patients off the drug in no less than 12-18 months. Alternate-day corticosteroids are usually poorly tolerated and should not be used.

The treatment of GCA usually requires higher initial doses of prednisone, usually 40–60 mg daily in divided doses, to reduce the risk of sudden blindness.

As with PMR, patient symptoms and changes in the ESR are used to guide tapering. The ESR often rises gradually as the prednisone dose is reduced. A sudden rise in the ESR should raise suspicions regarding  recurrence of disease, as well as alternative causes, such as infection. A rise in the ESR without associated symptoms is not an indication for increasing the dose of corticosteroid; however, it may delay further dose reductions. Evidence of disease flare-ups should lead to an increase in the prednisone dose to suppress symptoms and reduce the ESR. Corticosteroid treatment is usually continued for at least a year. Steroid-sparing agents such as azathioprine or methotrexate are occasionally helpful in patients who are unable to tolerate reductions in prednisone.

The prolonged use of corticosteroids is typically associated with multiple side effects, including osteoporosis, weight gain, hypertension and glaucoma.

Paget’s disease of bone is another condition that can cause aches and pains.  The diagnosis can often be suspected because of an elevation of blood alkaline phosphatase and confirmed by x-ray along with bone scan or magnetic resonance imaging.  Untreated Paget’s disease can lead to severe deformity and in rare cases, congestive heart failure. The treatment involves the use of bisphosphonate drugs.

Various malignancies, both primary as well as metastatic need to be considered in the list of potential causes of generalized aches and pains.  Any tumor that can metastasize to bone is suspect.  Also leukemia, lymphoma, and multiple myeloma need to be excluded.

In the final analysis, a patient who aches all over is a challenging problem for the clinician.  A careful history, physical examination, and further testing can usually lead to the diagnosis.