1990 Wolfe et al – 18 specific tender point sites

This article has been very important for the fibromyalgic syndrome. In 1990 a group of researchers and professionals interested in this entity decided to perform a blinded study to select which diagnosis criteria would be the best to make it easy to diagnose the fibromyalgia syndrome. It was also necessary to find a certain degree of consensus.

After a complete study, they proposed the selection of the TENDER POINTS and the diagnosis criteria for fibromyalgia: widespread pain + 11 tender points. Those criteria had 88% sensitivity and 81 specificity.

They also decided that the term “secondary or concomitant fibromyalgia” that was used in the presence of “other” RHEUMATIC disorders was not necessary anymore (they tried to prove it with the study).

They made it clear that they did not find “objective” abnormalities, so they had to use a BLINDED design for the examiners.

The article explains the study very well, especially the methodology.

Personal notes about this article:

While doing the phD centered in the lumbar back mice, we have found out that the patients diagnosed as presenting a “fibromialgic syndrome” ALSO present low back pain related to back mice. That pain can also improve (temporarily or not) with local anesthetic injection as the back mice patients. The lumbar NODULES can be present and tender on palpation. It seems to me that, somehow, the fibromialgic syndrome seems to be a “mice infestation”. The nodules can be very well palpated in the lumbar area and in some other spots. The lumbar pain of these patients can be relieved by the local anesthetic test as other patients that just present low back pain by back miceWhy isn’t there any mention of the nodules then? In early studies related to fibromyalgia (fibromyalgia/fibrositis) they mention that sometimes painful nodules and other just tender points could be palpated. Why is it that they DO NOT MENTION the presence of the NODULES in this report? Why did they just focus on the POINTS? Why did they decide to omit this important examination finding? The nodules can be further studied, they can be like a clue to follow, why omitting them?)

Wolfe et al. said:

The consensus of the committee was to adopt the term fibromyalgia, which was first suggested by Hench in 1976, rather than the older term fibrositis” (article by Hench)”.

Personal note: The committee was just centered in defining DIAGNOSTIC CRITERIA for FIBROMYALGIA. Not really in its etiology. In this article they comment nothing about the etiology. And, of course, nothing about all the theories about the etiology of “fibrositis”, an old name for fibromyalgia. At least, they could be mentioned, so that knowledge would NOT be lost by changing the name of certain studied entities, even if the name was not a proper one… The article FINALLY buried the term FIBROSITIS (undoubtedly a bad term, but by burying the term they also buried all the knowledge that was behind this name in many medical studies and articles).

The fibromyalgic syndrome comes with pain outbreaks that can last some days. A variable that asks the patient whether he/she was on a pain outbreak or not should be included in the study, since the number of tender points and the pain may also vary.

While reviewing the tender points they described, they already mentioned that in the knee the tender point is on the FAT PAD. WHY DIDN’T ANYBODY RECALL ON THAT? There could be a crucial CLUE for understanding the underlying cause of the FIBROMYALGIC syndrome. Related to the dysfunction of the deep subcutaneous fibro-fatty tissue LIKE THE DESCRIBED BACK MICE IN THE LUMBAR ZONE.

They also studied the “reactive hyperemia” (asses over the midpoint of the trapezius after tender point examination at this site). The appearance of erythema 2 minutes after palpation was considered a positive test result. I wonder if the reactive hyperemia is related to the pain crisis, more present if there is more pain?

The first author is Wolfe.

18 specific tender point sites


The 18 specific tender point sites

Report of the Multicenter Criteria Committee

Wolfe et al.

They studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients.

They studied the syndrome in 16 centers of the United States and Canada.

They proposed criteria for the fibromyalgia classification:

1-widespread pain in combination with

2-tenderness at 11 or more of the 18 specific tender point sites

18 specific tender point sites 

No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities.

They abandoned the term secondary-concomitant fibromyalgia and the term fibrositis.

-In 1977, Smythe and Moldosky’s “Two contributions to understanding of the “fibrositis” syndrome” began a cascade of “interest” of the neglected fibrositis syndrome to propose diagnostic criteria.

-In 1986, a consortium of centers began a study for the diagnostic criteria.

Nevertheless, there were not any proper previous studies, that’s why they developed this study.

Historical view of the “concept of fibromyalgia

Wolf et al. said that the concept of fibromyalgia /fibrositis had EVOLVED and differs significantly from the view of the 50s that tended to define the syndrome (references from Kelly (1946), Kraft et al. (1968), and Reynolds (1983)).

-Yunus et al. related to the irritable bowel syndrome.

-Rosenhall (1987) and Hadj Djilani (1984, Meniere’s disease) related fibromyalgia with psychogenic rheumatism.

-Simons (1988) related it to a local myofascial pain syndrome.

-Wolfe et al. considered that just the high counts of tender points were sufficient.

-Yunus et al. emphasized the combined importance of symptoms (sleep disturbances, fatigue, morning stiffness, external factors) and severe tender points.


Definition of the TENDER POINT EXAMINATION (by palpation with the pulp of the thumb or the first 2 or 3 fingers). They also used 6 “control” sites.

12 pairs of points:

  1. -occiput at the suboccipital muscle insertions
  2. -low cervical at the anterior aspects of the intertransverse spaces at c5-c7
  3. trapezius at the MIDPOINT of the upper border
  4. -supraespinatus at origins, above the scapula spine near the medial border
  5. -paraespinatus 3cm lateral to the midline at the level of the mid-scapula
  6. -second rib at the second costochondral junctions, just lateral to the junctions on the upper surfaces
  7. -lateral pectoral at the level of the fourth rib at the anterior axillary line
  8. -lateral epicondyle 2cm distal to the epicondyles
  9. -medial epicondyle at the epicondyles
  10. -gluteal at the upper outer quadrants of buttocks in anterior fold of muscle
  11. -greater trochanter just posterior to the trochanteric prominence
  12. -knee at the MEDIAL FAT PAD proximal to the joint line


  • 0= no pain
  • 1 mild= complaint of pain without grimace, flinch or withdrawal
  • 2 moderate= pain plus grimace or flinch
  • 3 severe= pain plus marked flinch or withdrawal
  • 4 unbearable= patient is untouchable, withdraws without palpation
  • grimace= a facial expression
  • flinch=an exaggerated body movement
  • withdrawal= moving the body part away from the examiner
  • tender= It was not interpreted as pain
  • skin fold tenderness= It was assessed by rolling the upper border of the trapezius between the thumb and the second and third fingers using moderate pressure.


  • sleep disturbances: never, seldom, often, always
  • fatigue
  • morning stiffness: duration near 15 minutes
  • anxiety
  • irritable bowel syndrome: periodically altered bowel habits, with lower abdominal pain or distension, usually relieved or aggravated by bowel movements; no blood
  • frequent headaches
  • Raynaud’s phenomenon
  • sicca symptoms: oral or ocular dryness
  • prior depression
  • paresthedias
  • “pain all over”: pain on the left side or the right side, pain above the waist, pain below the waist, plus the presence of axial skeletal pain (cervical, anterior chest or thoracic spine or low back had to be present). For example, pain in 3 sites (right shoulder, left buttock, and thoracic spine) was considered widespread pain.
  • noise
  • stress
  • activity
  • humidity
  • warmth
  • cold
  • poor sleep
  • weather change
  • Apart from the tender points they also include symptoms such as: urinary urgency, dysmenorrhea
  • Modulating factors: vacation, rest, working hours
  • Other physical examination variables apart from the tender points were:
    • skinfold tenderness
    • reactive hyperemia: asses over the midpoint of the trapezius after tender point examination at this site. The appearance of erythema 2 minutes after palpation was considered a positive test result.
    • reticular skin disturbance: “a fish net like” red, blue or purple mottled appearance to the skin, mostly along the inner aspects of the arm, thighs and low back.

The results and the discussion from Wolfe et al.: 11 from the 18 specific tender points are suficient

-Widespread pain turned out to have a very high sensitivity (97%), when combined with the presence of 11 tender points then the accuracy was higher.

-They said that it was evident that the fibromialgic syndrome occurs in association with other rheumatic disorders, but it was not necessary to differentiate between primary and secondary-concomitant fribromyalgia.

Palpation of tender points with the thumb was more discriminatory than the dolorimetry.

Published in March 2019 By Marta Cañis Parera   ORCID iD icon


Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, Tugwell P, Campbell SM, Abeles M, Clark P, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990 Feb;33(2):160-72. PubMed PMID: 2306288.