Fibrositis or fibrositic nodules are two of the many names that back mice have received. Reynolds presented this extensive review in 1983 (Personal note: The term back mice, which was made popular by Peter Curtis’s papers, was not still popularized).
Reynolds presents a GREAT REVIEW about the history of the term fibrositis and its related terms that have been used to describe the painful points and nodules with referred pain syndromes. Despite it was a very complicated task, he managed to make it quite clear that there seem to be a complete CHAOS about the studies of this clinical entity. Many terms have been used, many with similar but different explanations at the same time.
On page 32, he mentions very briefly Copeman and Ackerman’s study about the “fibrositis of the back”, where they presented the theory that the lesions lay in the FIBRO-FATTY TISSUE. He mentions the term EPISACROILIAC LIPOMA between brackets, and does not mention any of the many other authors that studied them.
At the last pages, he also mentions very briefly the French term CELULLITE or PANNICULITE that has also been used to describe the painful nodules.
He also mentions briefly some authors that relate the term fibrositis to certain syndrome that was also described as “Psychogenic rheumatism” (Personal note: Later, it became fibromyalgia).
Reynolds concludes that these nodules and painful points had a lot of interest in medicine between 1850 and 1950, somehow later they received much less attention, and even the TERM FIBROSITIS (so used during some years) passed into oblivion.
Reynolds hypothesized many reasons, one of the reasons was the INADEQUATE terms that authors used. For example, the fact that STOCKMAN’S “INFLAMMATION” COULD NOT BE PROVED (PERSONAL NOTE: Stockman used inflammation as synonym of hyperplasic swelling and serous exudation, that is clear when one reads the original work, but I wonder how many people read Stockman’s original work). And also, the fact that other terms are now used more commonly, as tendinitis or bursitis.
Reynolds also expressed that the “loss of interests” in the points and nodules is also due to the POPULARITY of the concept of degeneration and prolapse of vertebral disks of the last years (Personal note: What I call the “discopathy fever”). He states that DISK DISEASE is by then used to give explanation of many symptoms that previously would have been attributed to fibrositis.
(Personal note: The result of what Reynolds exposed in this long review in 1983 is still valid nowadays. The physician is not taught to explore the patients to find these nodules and trigger points -as it happens in my case, I was never taught at the university during my studies-. And many “fibrositic pains” are labelled as mysterious tendinitis or bursitis or believed to be of emotional origin).
Notes on the article:
The Development of the Concept of Fibrositis
(And Fibrositic Nodules)
Michael D. Reynolds
College of Medicine
“FIBROSITIS or MUSCULAR RHEUMATISM has been one of the MOST controversial subjects in medicine”.
The very existence of this condition has been questioned. There have also been doubts about the validity of the patient’s symptoms and the signs observed by the physicians.
The theories about the physiopathology have been very diverse and, as a consequence, a large number of TERMS have been created to identify the illness.
Reynolds is ASTONISHED to compare the interest about this entity at the beginning of the century and the little interest by his contemporary colleagues.
The term fibrositis has usually been used to describe certain “rheumatic pains” or certain NON-ARTICULAR rheumatism (tendinitis, bursitis, neuralgia, and so on).
Reynolds mentions that the old authors related the TERM “INFLAMMATION” to SEROUS EXUDATION, which did not mean cellular exudation of leucocytes but just a kind of “painful swallowing”. (Personal note: It has led to many controversies).
In the eighteenth century
In the eighteenth century, they tried to differentiate what they called ARTICULAR RHEUMATISM from MUSCULAR RHEUMATISM.
Reynolds mentions that the GERMAN and SCANDINAVIAN described the muscular rheumatism as an EXUDATIVE and PROLIFERATIVE process of muscle itself. WHEREAS the French and the British thought it was an “inflammation of the connective tissue” (Personal note: Inflammation in the sense of “exudative painful swelling”).
ROBERT FRORIEP and the history of fibrositis
In 1843, ROBERT FRORIEP described the treatment of several “rheumatic cases” (upper limb pain, fascial neuralgia, lumbago and weakness or atrophy of limbs) that he cured with ELECTRICITY.
Froriep described the presence of PALPABLE EXUDATIONS or CALLUS in the affected parts.
Most of the times the exudations or callus were located in the subcutaneous tissue, the skin, muscles, and periosteum.
But, according to REYNOLDS, the fact that MASSAGE was used to treat “rheumatic pains” more and more led to the discovery, not just by Froriep but also by other authors, of the presence of PALPATING CHANGES in the soft tissues.
Froriep had the theory that the exudations were related to the diminished activity of the nerves of the affected part, which would result in vascular atony and dilatation of the blood vessels that would lead to EXUDATION OF PLASMA. Then it would be like HYPEREMIA with EXUDATION.
If the fibrinous exudates would persist, then they could become clinically detectable as callus.
JOHANN MEZGER and the history of fibrositis
Reynolds mentions that in 1850 the Dutch physician Mezger published that he succeeded in treating a variety of diseases by massage. And many physicians in Europe got intrigued by that.
HELLEDAY and the history of fibrositis
One of the students intrigued by MEZEGER was HELLEDAY, from Stockholm, who was interested in the finding of the nodules. In 1876 he published under the term CHRONIC RHEUMATIC MYITIS a myalgic condition with the presence of nodules in the muscles. He found that the nodules were found more frequently near the “origin of the muscles”. He insisted that a proper technique of palpation was necessary.
Despite he used the term myitis and myositis he meant SEROUS EXUDATION and not cellular exudation or the presence of leucocytes.
He also noted that the seat of the pain of muscular rheumatism need not coincide with the location of the palpable abnormalities. He also reported that the HETEROTOPIC PAIN could be precipitated by pressure upon the muscular nodules.
They explained the “phenomenon” of neuralgic pains” SPREADING from nodules in rheumatic muscles due to the presumed “inflammation”.
VIRSHOW and the history of fibrositis
In 1852, Rudolph Virshow thought that the process would be related to a balance between EXUDATION and REABSORTION that would be disrupted. And that would be related to an act of “altered nutrition”, which would lead to an atrophy of the muscle fibers and a consequent replacement by PROLIFERATED CONNECTIVE TISSUE.
BALFOUR and the history of fibrositis
William Balfour from Edinburgh has two publications (1816 and 1824) where he also described the presence of the rheumatic nodules that he treated. He related the acute and the chronic rheumatism pain to a disorder in the cellular membrane that bounds everywhere in the human body (Personal note: What we know now as fascia). “The proximate cause of the disease consists in a languid, or obstructed circulation in the parts affected”.
In 1826 he described the “presence of tender points” in soft tissues of several persons with rheumatism.
He also described the SPREAD OF PAIN from points in affected muscles.
Scudamore and the history of fibrositis
This British author also states that the rheumatism was related to the white fibrous textures.
Xavier Bichat and the history of fibrositis
In 1825 Bichat regarded what it was later called areolar connective tissue named “cellular tissue” different from the tissue of the tendons and ligaments “fibrous system”.
He also stated that muscular rheumatism was not established in the muscular or tendinous fibers.
Sir William Gowers and the history of fibrositis
In 1904, Gowers reasserted the idea that the connective tissue was the seat of rheumatism and introduced the term FIBROSITIS. In certain points, he built the concept that the seat of rheumatism was the fibrous tissue of the aponeurosis or the nerves sheets. He proposed the term “fibrositis” by analogy with cellulitis. The term “Fibrositis” then was specially proposed to designate the MUSCULAR RHEUMATISM.
Ralph Stockman from the University of Glasgow and the history of fibrositis
In 1904, after Gowers, Stockman published his study where he described the chronic rheumatism as:
Stockman was the first one to provide the histological appearance of the nodule of the nonarticular rheumatism. It revealed “inflammatory hyperplasia of the connective tissue in patches”, “confined in the white fibrous tissue” and with “increased and edematous fibrous tissue” (but NO leukocytic infiltrate). From then, the BRITISH view was established that the connective tissue rather than the muscular parenchyma was the seat of the disease. After Stockman’s work, there was little histological studies done and with the contribution of Gowers the term of “fibrositis” settled.
After him some authors thought that the presence of FIBROSITIC NODULES was a requirement to diagnose muscular rheumatism.
Stockman also explained the referred pain, he stated that “a branch of a nerve may be pressed upon by a nodule, or may even pass through it, hence the pain often radiates over a wide area perhaps far from the nodule” (Personal note: What we now know as cluneal neuropathy).
Stockman reported the curation of a “sciatic neuralgia” by excision of a nodule from the gluteus medius. (Personal note: Reynolds mentions again the fact that the sciatic nerves have not such an upper origin, so they could not be a “sciatic neuralgia”. Nowadays, we have the term PSEUDOSCIATICA to explain cluneal neuropathic referred pain).
François Valleix and the study of the painful points
Some authors did not focus on the nodules, but more on the painful points related with the pressure of the tissue. In 1841, in his treatise on neuralgia, he described the phenomenon of tender points as follows:
Valleix, writing about “sciatic pain”, described POINTS DOULOUREUX in the lumbar region (almost always bilateral), above the posterior, superior iliac spine; over the middle of the iliac crest (at the attachment of the gluteus medius); in the buttock at the upper part of the sciatic notch; and on the posterior part of the greater trochanter. (Personal note: As it happens with the cluneal neuropathies and pseudociatic pains).
He noted that pressure on those points produced RADIATING PAIN. And he regarded the muscular rheumatism to a type of neuralgia.
In 1848 he wrote:
(Personal note: Reynolds mentions that he does NOT understand how those lumbar points can be related to the sciatic trunk, he does not seem to know that the cluneal neuralgia can give REFERRED PAIN down to the leg, now known as pseudo sciatic pain).
Alfons Cornelius and the study of the painful points
In the 1900s Alfons Cornelius, from Germany, published about the tender points. He described areas of tenderness in persons with muscular rheumatism under the name “nerve points” or “nervenpunkte”. He emphasized the necessity of careful palpation to find such points.
The tender points were SPONTANEOUSLY painful under the influence of physical activity, weather, emotions, and other factors.
Sometimes the “nervenpunkten” could feel slightly indurated.
Then he described that the local muscles could be under spasm, as a reflex spasm.
He noticed that pressure on the painful point could cause RADIATION PAIN to another area.
He gave a different etiopathological explanation: he believed that all nerves conducted impulses both centrifugally and centripetally, and that the movement of nervous impulses constituted a circulation. Each locus in the nervous system, therefore, was in communication with each other. He could explain by this theory the “reactions” after a massage like referred pain or other local or systemic symptoms. He considered the nerve points sites “of purely mechanical hindrance”. He considered it a point of obstruction by scar tissue, cell necrosis or proliferated fibrous tissue.
He described the exciting influences related to production of symptoms as: overexertion, emotions, changes of temperature and weather, dietary and digestive disturbances, menstruation and pregnancy. He also described that there could be a “heightened excitability” state of the entire nervous system (influenced by heredity, intemperate modes of life and illness).
He also mentions that the “nerve points” produced radiating pain that would not follow any nerve trunk and that it seems not bound to “any anatomical law”. He attributed the radiation to connection among all the nerve points, so when one was excited, the others too”.
He was also one of the first to state that the “nerve points” were connected with “motor, vasomotor and secretory reflexes”. He cited the pupillary dilatation and flushing when a nerve point in the epigastrium was pressed, and sneezing and rhinorrhea in response to pressure on an occipital point. He did not think that the connection was in the central nervous system.
Konrad Pott, an orthopedic surgeon, and the fibrositis nodules
In 1913, Konrad Pott, an othopaedic surgeon, published a paper comparing Cornelius’s teachings with those of the Swedish massage therapist. The Swedes also used the term “nerve knots”. So the nodules of the rheumatism were similar to the Cornelius’ nerve points.
The nodules and the tender points are thought to be situated in the muscles, the skin, fascia or other tissues. They tend to be located in the origins and insertions of the muscles.
The headache can be produced by pressure on the nodules in cervical muscles.
Like the nodules, some tender points are found in some asymptomatic persons. And then they are said to be in a latent state.
Dr. GOOD or GUTSTEIN from Poland and the fibrositic nodules
Dr. Good was a native of Poland whose original name was Gutstain, and he published numerous articles during a period of twenty years of the well-defined “myalgic spots” in muscles or tendons that produced LOCAL or HETEROTOPIC PAIN. He provided diagrams with many of these pain patterns.
Lindstedt from Sweden
In 1920, Folke Lindstedt developed a reflex theory of sciatica among hospitalized patients. He noticed a high prevalence of deformities of knees and feet, injuries to the lower limbs and arthritis of the spine and the lower limb joints. He postulated that the symptoms were caused by the NEURALGIA. The sciatica would occur at the same site of the other unilateral disorders. He postulated a theory of a “neuralgic alteration” that could be due to the family history of nervousness, neurosis or psychosis.
While doing the “Lasègue’s test”, he noticed that people with sciatica complained of pain in the UPPER GLUTEAL AND LUMBAR REGIONS, which are not innervated by the sciatic nerve. (Personal note: Now maybe we know this is due to cluneal nerve neuropathy, the patient refers pain down the leg as a PSEUDOSCIATICA).
He also theorized that some treatments could work as “counterirritation”.
Lindstedt. “Uber die aetiologie und pathogenese der Ischias” Acta med, Scand. 1920. 53, 318-380.
Reichart in 1938 and the reflex pain
Reichart, a Czechoslovakian physician, published the diagram and stated that “when the examiner pressed on such points, one may think that has hit a nerve stem, but the radiating pain that is felt does not coincide with the nerve trunks territory, then the direct stimulation can be excluded”. The radiation then may be explained by a REFLEX through the GRAY MATTER of the SPINAL CORD. Then he considered the PAIN as a reflex sensation.
A.Reichart “Reflexschmerzen auf Grund von Myogelosen. “ Dt. Med. Wschr. 1938,64, 823-824.
Michael Good in 1938 and the spinal segmental pattern
In 1938, Michael Good believed that the heterotopic pain sometimes exhibited a SPINAL SEGMENT PATTERN but he did not formulate any theory about it. He also said that it could be one or several dermatomes. He developed the theory of local hypoxia or decreased blood flow. And that sometimes sympathetic and vasomotor axon reflexes could also be present. Good noted that the elimination of tender points by procaine injection was explicable as the interruption of a vicious circle of reflex impulses by local anesthesia.
M.G.Good. “Rheumatic myalgias” Practioner, 1941, 146, 167-174.
M.G. Good “The role of skeletal muscle in the pathogenesis of diseases” Acta med. scand. 1950 138, 285-292.
Michael Kelly, from Australia, about pain
Michael Kelly was influenced by the works of Thomas Lewis and Jonas Kellgren on pain, especially about the somatic tissues.
In 1941, Kelly published the first of a series of papers in which fibrositis and a number of “visceral pain syndromes” were related to tender sites causing referred pain.
He also described certain nodules or tender areas located at the muscle sites.
He described the role of these tender points in the genesis of pain in the low back, shoulder, head, chest, knee, forearm, and hand.
He insisted on the frequency of SOMATOVISCERAL reflexes in association with muscular tender points. He had a reflex theory. He had a theory that explained that the muscular areas could become myalgic lesions by an alteration of nerves impulses. Kelly suggested that it had to do with the spindle receptors of the MUSCULOTENDINOUS JUNCTIONS.
THE DETRACTORS OF the fibrositis’s authors stated the tissue lesion was located in the muscle rather than fibrous tissue
During the first half of the twentieth century some investigators failed in finding any pathological anatomical abnormalities. Negative results of histological studies were reported by some authors that believed that FUNCTIONAL rather than ANATOMICAL changes in the muscles caused the nodules.
- 1918 A. Schmidt. Der muskelrheumatismus (myalgie) auf grund eigner beobachtungen und untersuchngen gemeinverständlich dargestelt [Muscular rheumatism understood on the basis of own observations and examinations]. Bonn
- 1931 M.Lange. Die Muskelhärten (myogelosen). Munich
- 1950 J.M. Strong. “Fibroistis and segmental neuralgia”
- In 1850, Thomas Inman advocated that LOCAL hypertonus (contraction, spasm) was responsible for it.
- Some authors thought that a neuralgia was causing the nodulation by irritation of the muscles. (Schmidt)
- Some authors suggested that spasm of muscle produced sensory stimuli that, by reflex mechanisms, provoked further contraction (Buchthal and Clemmesen).
- In 1893, in Boston, Graham suggested that the pathological basis could be related to “probably coagulation of the semi-fluid contractile muscular substance and adhesion of muscular fibrils”.
- Two German physicians did some experiments and concluded that the tissue changes could not just be done by contraction since they observed that the nodules persisted after death. They suggested that the nodules represent a change in the colloidal state of the muscle cytoplasm and proposed the name of MYOGELOSES and muscle hardenings.
- Some other authors claimed that the nodules disclosed degenerative changes in muscle fibers and with proliferation of interstitial elements.
Arthur Steindler’s views
He described the relief of “sciatica” by procaine injection of tender points in the lumbar and gluteal areas. He also used the term “trigger points”.
He wrote about the fact that the injection of the lumbogluteal tender points resulted in the disappearance of the sciatic pain, and since the nerve has nothing to do with that anatomical site of origin, the sciatic pain had to be a kind of “reflex phenomenon” (Personal note: It was a heterotopic pain by cluneal neuropathy).
Steindler. “The Interpretation of Sciatic Radiation and the Syndrome of Low-backpain”. J. Bone jt surg. 1940, 22, 28-34.
Janet Travell and coworkers, the creation of the term “myofascial pain syndrome”
In 1942, Janet Travel and coworkers published a work about pain arising from muscles. They referred to the works of Arthur Steindler and took the term “trigger point” from him. The initial papers focused on the treatment of chronic pain in the shoulder accompanied by pain and paresthesisas in the upper limb. And she introduced the popular name of “myofascial pain syndromes”.
They used the technique of the local anesthetic injection with procaine to treat the painful points.
They reflected the theory that the heterotopic pain was the result of the pressure on the peripheral nerves.
They explained that the LOCAL ANESTHETIC injection of the trigger points worked because it could somehow break the vicious cycle of REFLEX PAIN.
The palpation technique of the fibrositic nodules
Some authors believed that a SPECIAL TECHNIQUE was required to palpate nodules and that such a technique was not easily acquired. Details from one writer to another varied in some way. MANY, but not all, physicians found that use of LUBRICANTS on the skin made it easier to feel nodules and that the complete relaxation of the muscles being palpated was essential.
Nevertheless, even physicians who regarded nodules as the essential lesion in muscular rheumatism or fibrositis admitted that sometimes only tender points could be found, but not nodules. They assumed that the nodules were present, but were too small or too deeply situated to be palpated.
The topographical and anatomical sites of the fibrositic nodules
Many authors described the sites of the fibrositic nodules, especially they were located in the ORIGINS or INSERTIONS of the muscles (suggesting the tendinous rather than muscle tissue).
Some authors noticed that the nodules were found located in certain sites with respect to ANATOMICAL LANDMARKS.
The size and the shape of the fibrositic nodules
The descriptions ranged from less than one millimeter to five centimeters. Nodules were compared in size to millet seeds, wheat grains, lentils, peas, beans, coffee beans, date seeds, plum seeds, almonds, olives, hazelnuts, walnuts, plums, eggs, and apples. Spherical or elliptical shape, or also elongated and present as a band or ropelike. Such elongated nodules were orientated in the direction of the muscle fibers among which they lay.
The behavior of the fibrositic nodules and pain manifestations
The authors described that the nodules could form by exudation and fibrosis. And they could progress from a simple swelling to an increasing degree of hardness, which would be a final state of induration. Others believed that, with the passing of time, nodules became larger.
The nodules could be found in ASYMPTOMATIC people. And in some cases, the nodules of certain people persist during remission of rheumatism. Also some people that did not present rheumatic pains had pain while pressing the nodules.
Some physicians could NOT find any nodules in certain rheumatic patients, and even questioned the existence of the nodules at all.
Some authors asserted that the physicians who could not feel the nodules had a lack in proper technique or sensitivity to detect them.
Some claimed that the presence of nodules was not essential, but the presence of FOCAL TENDER AREAS was.
Many noticed that while pressing the nodules, referred or heterotopic pain by pressure on the local nerves could be caused. This ability of the tender points or nodules to produce heterotopic pain at a distance led to the introduction in the late 1930s of the terms TRIGGER ZONES, AREAS, POINTS or SPOTS. The terms may be incorrectly used some times to designate just painful points.
Around the years 1938 and 1942, the authors published many DIAGRAMS to describe the heterotopic pain charts related to the fibrositic nodules.
Some authors did not agree with the idea that the heterotopic pain would arise from the local pressure from the nodules to the sensitive nerves.
The tender nodules or points have been described to produce other symptoms such as paresthesia, cutaneous hyperalgesia, vasoconstriction, visceral symptoms such as nausea, bloating, vomiting, diarrhea, abdominal cramps, dizziness, visual disturbances, and GLANDULAR SECRETION.
Other theories about the referred pain by massage therapist: perineuritis or neurofibrositis
According to the theories of Gowers, some massage therapists also published certain works where they explained the pain by presence of PERINEURITIS or NEUROFIBROSITIS of the connective tissue around or within the nerves.
The theories about the effect of treatment
T. O. Ward “on acupuncture”. Br. Med. J. 1858, 728-729. The relief of rheumatic pain in the muscles by acupuncture could be explained by “the reflex action induced by COUNTERIRRITATION”, a mechanism that was also used to explain some effects of the cautery.
THE CHAOS OF NAMES according to Reynolds
Reynolds refers to a chronological list of the many names that have been used to describe the pain of the fibrositic nodules.
(Personal note: Reynolds clearly states in two paragraphs THE CHAOS that exists regarding all this subject, and we should even include the term BACK MICE, that in 1983 was still not known).
The final conclusions
Reynolds concludes that, for several reasons, the entity known as fibrositis received much less attention in medical textbooks and journals around the 80s than what it did in the period between 1850-1950.
This neglecting was due to several reasons but one clear reason was the consequence that this clinical syndrome had received many inappropriate names and the lack of an adequate nosological focus.
Another reason is that in the last years there has been a remarkable popularity of the concept of the degeneration and prolapse of intervertebral disks (disk disease was used in the 80s to explain many symptoms that previously would have been attributed to fibrositis).
Published in April 2019 by Marta Cañis Parera
Reynolds MD. The Development of the Concept of Fibrositis. Journal of the History of Medicine and Allied Sciences. 1983. 38 (1) p 5-35. ISSN: 0022-5045.