Unifying Concepts

1990 Criteria of ACR for the Classification of Fibromyalgia

Fibromyalgia syndrome (FMS) is conceptualized as a chronic disorder characterized by widespread and persistent non-inflammatory musculoskeletal pain. Concomitant symptoms usually include fatigue, insomnia, morning stiffness, depression, anxiety, and cognitive problems (forgetfulness, concentration difficulties, mental slowness, memory and attention problems, etc.). Furthermore, the majority of FMS patients usually show predominantly negative affect, including neuroticism, alexithymia, and catastrophizing and impaired health-related quality of life.

1. History of widespread pain.

  • Definition. Pain is considered widespread when all of the following are present: pain in the left side of the body, pain in the right side of the body, pain above the waist, and pain below the waist. In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low back) must be present. In this definition, shoulder and buttock pain is considered as pain for each involved side. “Low back” pain is considered lower segment pain.

2. Pain in 11 of 18 tender point sites on digital palpation.

  • Definition. Pain, on digital palpation, must be present in at least 11 of the following 18 sites:

  • Occiput: Bilateral, at the suboccipital muscle insertions.

  • Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7.

  • Trapezius: bilateral, at the midpoint of the upper border.

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

  • Second rib: bilateral, at he second costochondral junctions, just lateral to the junctions on upper surfaces.

  • Lateral epicondyle: bilateral, 2 cm distal to the epicondyles.

  • Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.

  • Greater trochanter: bilateral, posterior to the trochanteric prominence.

  • Knee: bilateral, at the medial fat pad proximal to the joint line.

Digital palpation should be performed with an approximate force of 4 kg.

For a tender point to be considered “positive” the subject must state that the palpation was painful. “Tender is not to be considered “painful.”

* For classification purposes, patients will be said to have fibromyalgia if both criteria are satisfied. Widespread pain must have been present for at least 3 months. The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia.



  1. 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. [Medline]


Created: Oct 24, 2006

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