About This Page
This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Chronic widespread pain with fatigue, sleep disturbance, cognitive symptoms, and somatic symptoms
- Positive clinical diagnosis, not purely diagnosis of exclusion
- Inflammatory markers, CK, neurologic exam, and joint exam are usually normal
- First-line treatment is education, graded exercise, sleep optimization, and CBT
- Duloxetine, milnacipran, and pregabalin are medication options; opioids are not recommended
Overview
Fibromyalgia is a centralized pain syndrome with altered pain processing rather than inflammatory tissue damage. It causes widespread pain, fatigue, nonrestorative sleep, cognitive symptoms, and tenderness without synovitis.
Epidemiology
Common, more often diagnosed in women, and frequently coexists with migraine, IBS, interstitial cystitis, depression, anxiety, PTSD, and inflammatory arthritis.
Clinical Features
Symptoms
Chronic widespread pain above and below the waist
Fatigue and nonrestorative sleep
Brain fog and concentration difficulty
Headache, IBS, paresthesias, sensory sensitivity
Weight loss, fever, objective weakness, or synovitis are red flags
Signs
Diffuse tenderness without synovitis
Normal objective strength
Normal reflexes and sensation
No rash, effusion, or focal inflammation
Objective swelling or weakness suggests another diagnosis
Investigations
First-line
Focused clinical assessmentPattern recognition, red flags, functional impact, and targeted examination
Basic labs when indicatedCBC, CMP, ESR/CRP, CK, urinalysis, or disease-specific testing depending on suspected condition
Initial imaging when indicatedPlain radiographs or MRI/ultrasound based on suspected structural, inflammatory, infectious, or neurologic disease
Second-line
Disease-specific confirmatory testingAutoantibodies, HLA-B27, synovial fluid, nerve conduction studies, DEXA, or cultures as appropriate
MRI/ultrasound/CTUsed for early inflammatory disease, occult fracture, tendon tear, infection, or surgical planning
Screening before immunosuppressionTB, hepatitis, vaccination review, and baseline labs when biologic or high-risk therapy is planned
Specialist
Specialist referralRheumatology, orthopedics, infectious disease, ophthalmology, neurology, or spine surgery depending on red flags and disease severity
1
Initial management
- Address red flags and emergencies first
- Use guideline-directed first-line therapy matched to disease severity
- Educate the patient and set functional goals
- Use analgesia and rehabilitation when appropriate
2
Escalation
- Escalate to specialist-directed therapy if severe, refractory, progressive, or organ-threatening disease
- Use imaging, procedures, immunosuppression, antibiotics, or surgery according to diagnosis
- Monitor response objectively and revise diagnosis if response is atypical
3
Prevention and follow-up
- Manage comorbidities and medication toxicity
- Vaccinate and screen when immunosuppression is used
- Prevent disability, falls, fracture, infection, and functional decline
Complications
- Functional impairment: Pain, weakness, stiffness, deformity, or disability depending on disease
- Diagnostic delay: Missed infection, fracture, inflammatory disease, neurologic compromise, or organ-threatening complication
- Medication toxicity: NSAID, steroid, antibiotic, anticoagulation, opioid, or immunosuppressive adverse effects
- Chronic disease burden: Reduced quality of life, work impairment, deconditioning, and mental health impact
USMLE Step 2 CK Exam Tips
- 1Widespread pain + fatigue + poor sleep + normal exam = fibromyalgia
- 2Tenderness without synovitis
- 3High CK/true weakness points to myositis
- 4Older patient with high ESR shoulder/hip stiffness = PMR
- 5First-line therapy is graded exercise and education
- 6Avoid opioids and broad autoantibody panels
practicetest your knowledge on fibromyalgiaApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — musculoskeletal and beyond.
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