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Many of the muscle diseases described in the preceding pages are associated with aching and discomfort These are particularly prominent in conditions that are accompanied by cramp and biochemical contracture (phosphorylase and phosphofructokinase de ciency) Ischemia of muscle that is, intermittent claudication is also painful, as is dystonia in some cases Muscle weakness that imposes persistent abnormal postures on the limbs may cause stretch injury of muscles and tendons This is observed in a number of the congenital myopathies and dystrophies In all these conditions, clinical study will usually disclose the source or sources of the pain Diffuse muscle pain, which merges with malaise, is a frequent expression of a large variety of systemic infections eg, in uenza, brucellosis, dengue, Colorado tick fever, glanders, measles, malaria, relapsing fever, rheumatic fever ( growing pains ), salmonellosis, toxoplasmosis, trichinosis, tularemia, and Weil disease When the pain is intense, especially if it is localized to one side of the lower chest and abdomen, the most likely diagnostic possibility is epidemic myalgia (also designated as pleurodynia, devil s grip, and Bornholm disease, due to Coxsackie virus infection) Poliomyelitis may be accompanied by intense pain at the onset of neurologic involvement, and later the paralyzed muscles may ache This is true also of the Guillain-Barre syndrome, in which the pain may precede weakness by several days Little is known about the pathologic basis of the muscular pain in these diseases; it is not due to muscle in ammation Mild muscle pain is a frequent but not a necessary accompaniment of polymyositis and dermatomyositis Polymyalgia Rheumatica The major consideration in elderly and middle-aged patients with pain in proximal muscles of the limbs is polymyalgia rheumatica This subject is mentioned brie y in other sections of this book in relation to back and extremity pain (page 189) and to temporal arteritis, to which it is closely connected (page 159) The muscular soreness may be diffuse or asymmetrical, particularly in the proximal arms and shoulders Every movement is reported as stiff and painful The periarticular tissues and their muscular attachments are affected primarily and may be tender, but.

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how broad a de nition one allows for the widespread pain and painful trigger points, most or all patients in our experience manifest many of the same complaints as those with the chronic fatigue syndrome, which is discussed in Chap 24 Authorities on the subject, however, have claimed that in the majority of patients, formal assessment by modern criteria fails to con rm the presence of depression and that, when depression does coexist with the muscular complaints, the two are discordant temporally and in severity While we acknowledge that antidepressants often give disappointing results and that in our practice there have been several young women with bromyalgia who appeared to be psychologically stable and lacked depression, these are the exceptions The literature eschews the use of corticosteroids for treatment of the pain, but we have had occasion to see two patients whose symptoms were relieved when these medications were used for other purposes It can be said in conclusion that bromyalgia remains a problematic illness, de ned by a pattern of pain that justi es its name Despite attempts to objectify the physical symptoms, psychiatric factors should not be overlooked This condition is a favorite illness with physiotherapists, who claim that their physical measures are helpful, as they may well be Rarely, a similar syndrome is the forerunner of what proves, after some days, with the onset of neurologic signs, to be a radiculitis, brachial neuritis, or outbreak of herpes zoster (see Goldenberg) Other Myalgic States An impressive polymyalgia is the common one that follows excessive exercise Often the patient observes that aching pain occurs not at the time of activity but some hours or even a day or two later, resembling the discomfort following the excessive use of unconditioned muscles The muscles are sore and there is an intolerance of exercise and physical exertion This is a natural phenomenon and is self-limiting When such a state persists inde nitely and a program of conditioning exercises does not alleviate the pain, it represents a special category of disease In a few instances an increased sedimentation rate or other laboratory aids may clarify the diagnosis, and muscle biopsy may reveal a nonspeci c interstitial nodular myositis or the giant-cell arteritis associated with polymyalgia rheumatica A few individuals go on to have the features of the previously described bromyalgic syndrome However, this cluster of symptoms most often occurs without explanation, and one can only suspect an obscure infection or a subtle aberration of muscle metabolism, presently impossible to demonstrate Reference was made earlier to the nding of a myoadenylate deaminase de ciency in some of these cases Sometimes a rapid and excessive rise of creatine kinase (CK) after strenuous exercise will provide a clue (a slight to moderate elevation of CK is to be expected after heavy or prolonged exercise) There is also a group of patients who have idiopathic leg pain during rest after activity Some families af icted in this way are forced to live a sedentary existence The condition does not respond to analgesics In two cases, a de ciency of calcium-ATPase was found and reportedly alleviated by a calcium channel blocker such as verapamil, 120 mg qid (Walton; Taylor et al) It must be distinguished from Fabry disease (page 1159), from the syndromes of painful legs and moving toes, and from the restless leg syndrome (page 339) The problem of a muscular pain-fasciculation syndrome was discussed earlier In thin, asthenic adults who exhibit rather vague polymyalgia without other abnormalities, with or without cramps and fasciculations, the authors have found it dif cult to exclude hysteria or other neurosis and depression Before concluding that the condition has a psychiatric basis, it is important in every such.

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