The foremost complaint of patients with fibromyalgia is pain. The American College of Rheumatology states that fibromyalgia is diagnosed when there is widespread pain involving three out of four quadrants of the body for at least 3 months in duration. The criteria for the diagnosis of fibromyalgia includes widespread pain encompassing the axial system and involving both sides of the body above and below the waist, and also includes the presence of tender points. Axial skeletal pain must be also be present, such as pain involving cervical or thoracic spine, anterior chest, and lower back.

Tender points are considered positive when pain is elicited by digital palpation with an approximate force of 4 kg/cm2 and includes the presence of at least 11 out of 18 tender points located at nine pairs of specific sites, according to the definition of the American College of Rheumatology (Fig. 25.1). For a tender point to be considered "positive" the subject must state that the palpation was painful. Tender point sites include:

1. Low cervical, bilateral and anterior to C5-C7 interspaces.

2. Second rib, bilateral at the second costochondral junctions.

3. Lateral epicondyle, 2 cm distal to the epicondyles.

4. Knee, bilateral and proximal to the joint line at the medial fat pad.

5. Occiput, bilateral at the insertions of the subocciput muscles.

6. Trapezius, bilateral at the midpoint of the upper border of trapezius muscles.

7. Supraspinatus origins: bilateral, above the scapula spine near the medial border.

8. Gluteal: bilateral, in the anterior fold of the muscle in upper outer quandrant.

9. Greater trochanter: bilateral and posterior to the prominence of the trochanter.

Despite these guidelines, the diagnosis of fibromyalgia still can be challenging, since there are many other conditions that have overlapping signs and symptoms. These conditions include:

1. Rheumatologic disorders, such as systemic lupus erythematosus, Sjogren's syndrome, and ankylosing spondylitis.

2. Neurological disorders, such as myasthenia gravis and multiple sclerosis.

3. Peripheral neuropathic disorders.

4. Endocrine disorders, such as hypothyroidism and hyperthyroidism.

5. Myofascial pain syndrome.

6. Chronic fatigue syndrome.

7. Multiple chemical sensitivity syndrome.

It is important to remember that detailed medical evaluation and diagnosis by exclusion are important in order to distinguish fibromyalgia from these other conditions.

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