Generalised body aches

Generalised body aches are diffuse pains in muscles and often joints and bones, usually symmetrical and affecting several regions at once. The term covers myalgia (muscle pain), arthralgia (joint pain without swelling), bone pain and the widespread pain of central sensitisation. Acute generalised aches usually accompany infection or a drug reaction. Chronic widespread aching is commonly fibromyalgia, polymyalgia rheumatica, hypothyroidism or vitamin D deficiency.

Clinical relevance.

Related presentations to separate. Weakness is reduced power on testing. Stiffness is difficulty starting movement. Fatigue is reduced stamina. Joint swelling with heat suggests arthritis. Pain localised to a bone or a nerve root suggests structural disease.

Classification by tempo. Acute (under 2 weeks), subacute (2 weeks to 3 months), chronic (over 3 months).

Classification by source.

• Muscle (myalgia): infection, inflammation, drugs, metabolic and endocrine disorders, exertion.
• Bone: osteomalacia, osteoporotic fracture, metastases, myeloma, Paget disease, sickle cell crisis.
• Joint and periarticular: polyarthralgia from viral infection, polymyalgia rheumatica, inflammatory arthritis.
• Central sensitisation (nociplastic pain): fibromyalgia and chronic widespread pain.

Mechanisms. Pyrogenic cytokines (interleukin 1, interleukin 6, tumour necrosis factor) and prostaglandin E2 sensitise nociceptors in infection. Muscle injury releases creatine kinase and myoglobin. Impaired mineralisation causes bone pain in osteomalacia. Altered central pain processing, sleep disturbance and low mood sustain pain in fibromyalgia.

History.

• Onset and tempo, distribution (neck, shoulder and hip girdles in polymyalgia rheumatica; all four limbs and trunk in viral illness; widespread with tender points in fibromyalgia), constancy, morning stiffness and its duration (over 45 minutes suggests inflammatory disease), relation to exercise, nocturnal pain.
• Fever, rigors, sore throat, rash, red eyes, mouth ulcers, diarrhoea, jaundice, cough, headache, joint swelling, weight loss, night sweats.
• Weakness, difficulty rising from a chair or lifting arms, cramps, dark urine after exertion.
• Visual disturbance, jaw claudication, scalp tenderness (giant cell arteritis).
• Cold intolerance, constipation, weight gain; thirst, constipation and confusion (hypercalcaemia); bone pain and fractures.
• Sleep quality, unrefreshing sleep, cognitive complaints, low mood, anxiety, stress, trauma.
• Drugs: statins, fibrates, ezetimibe, colchicine, fluoroquinolones, aromatase inhibitors, bisphosphonates (acute phase reaction), checkpoint inhibitors, zidovudine, daptomycin, isotretinoin, proton pump inhibitors, corticosteroid withdrawal, alcohol.
• Exposures: travel (dengue, chikungunya, malaria, schistosomiasis), mosquito or tick bites, undercooked meat (trichinosis), animals (brucellosis, leptospirosis), vaccination, contacts, sexual history, injecting drug use.
• Diet and sun exposure (vitamin D), dark skin, covered dress, malabsorption, renal disease, menopause.
• Family history of rheumatic or muscle disease.

Examination.

• Temperature, pulse, blood pressure, hydration.
• Muscle power (neck flexors, shoulder abduction, hip flexion, sit to stand), tenderness, bulk, reflexes.
• Joints: swelling, warmth, range of movement. Temporal arteries (tenderness, absent pulse).
• Bone tenderness (sternum, ribs, tibia, spine, pelvis).
• Skin: heliotrope rash, Gottron papules, vasculitic rash, erythema migrans, eschar, petechiae.
• Thyroid, lymph nodes, spleen, liver, conjunctivae, mouth ulcers.
• Tender point count and widespread pain index in suspected fibromyalgia.
• Mental state, sleep, mood screen (PHQ-9).

Red flags.

• Fever with rigors, hypotension or confusion.
• Dark urine, severe muscle pain, marked weakness.
• Headache, jaw claudication, visual symptoms, scalp tenderness.
• Rash with fever, petechiae, eschar, jaundice.
• Bone pain with weight loss, night pain, hypercalcaemia, anaemia (malignancy, myeloma).
• Calf swelling or pain, recent travel to a malaria or dengue area.
• Progressive weakness, bulbar or respiratory symptoms.
• Immunosuppression, injecting drug use, pregnancy.

Infective (acute). Influenza and other viral respiratory infections, COVID-19, dengue, chikungunya, Zika, malaria, typhoid, leptospirosis, brucellosis, rickettsial infections, hepatitis A and B, HIV seroconversion, infectious mononucleosis, parvovirus B19, Ross River and other arbovirus infection, acute schistosomiasis (Katayama syndrome), trichinosis, toxoplasmosis, bacterial sepsis, pyomyositis, streptococcal infection, Lyme disease, post infective myalgia.

Rheumatological and inflammatory. Polymyalgia rheumatica, giant cell arteritis, rheumatoid arthritis, systemic lupus erythematosus, polymyositis and dermatomyositis, adult onset Still disease, vasculitis, Sjogren syndrome, spondyloarthritis, sarcoidosis, systemic sclerosis, mixed connective tissue disease.

Endocrine and metabolic. Hypothyroidism, hyperthyroidism, vitamin D deficiency and osteomalacia, primary hyperparathyroidism, hypercalcaemia, hypophosphataemia, hypokalaemia, hypomagnesaemia, adrenal insufficiency, Cushing syndrome, diabetes mellitus, chronic kidney disease (renal osteodystrophy), menopause, hypogonadism.

Drug and toxic. Statins and other lipid lowering drugs, colchicine, fluoroquinolones, aromatase inhibitors, bisphosphonates, corticosteroid withdrawal, checkpoint inhibitors, zidovudine, daptomycin, alcohol, cocaine and amphetamines (rhabdomyolysis), withdrawal syndromes.

Muscle-specific. Rhabdomyolysis, exertional myalgia, immune mediated necrotising myopathy, inclusion body myositis, metabolic myopathies (McArdle disease, carnitine palmitoyltransferase II deficiency), mitochondrial myopathy, hypothyroid myopathy, HIV myopathy.

Bone and neoplastic. Osteomalacia, osteoporotic vertebral fracture, bone metastases, multiple myeloma, leukaemia, lymphoma, Paget disease, sickle cell vaso-occlusive crisis, paraneoplastic syndromes.

Neurological and central. Fibromyalgia and chronic widespread pain, chronic fatigue syndrome, depression and anxiety, sleep disorders (obstructive sleep apnoea, restless legs), Parkinson disease, small fibre neuropathy, myofascial pain.

Others. Vitamin B12 deficiency, iron deficiency, deconditioning, hypermobility spectrum disorder, pregnancy related pain, overuse.

1. A short febrile illness with typical symptoms and a clear viral or drug cause needs no tests. Persistent or severe aches, weakness or red flags need a panel.
2. First line tests: full blood count with film, ESR and C reactive protein, creatine kinase, urea, creatinine and electrolytes, calcium (corrected), phosphate, alkaline phosphatase, liver function tests, thyroid stimulating hormone, glucose or HbA1c, 25 hydroxyvitamin D, urinalysis (blood on dipstick without red cells suggests myoglobinuria).
3. Infection directed: malaria rapid test and thick and thin films in anyone exposed within the past year, dengue NS1 antigen (days 1 to 5) and IgM, chikungunya polymerase chain reaction or IgM, blood cultures when febrile, HIV test, hepatitis serology, leptospirosis polymerase chain reaction and IgM, brucella and Epstein-Barr serology as exposures suggest.
4. Rheumatological: antinuclear antibody, rheumatoid factor, anti cyclic citrullinated peptide, extractable nuclear antigens, myositis antibody panel and HMGCR antibodies when weakness or elevated creatine kinase is present, complement, ANCA.
5. Metabolic and bone: parathyroid hormone, 25 hydroxyvitamin D (under 25 nmol/L is deficiency), serum protein electrophoresis and free light chains, plain radiographs of painful bones, bone scintigraphy or MRI, and bone density.
6. Polymyalgia rheumatica is likely when age is 50 or more with bilateral shoulder pain, raised ESR or C reactive protein, morning stiffness over 45 minutes, and a rapid response to prednisolone; shoulder or hip ultrasound shows bursitis and synovitis; exclude giant cell arteritis, rheumatoid arthritis and malignancy.
7. Fibromyalgia: widespread pain index 7 or more with symptom severity score 5 or more, or index 4 to 6 with severity score 9 or more, symptoms present at a similar level for at least 3 months, and no other disorder that explains the pain. Laboratory tests are normal.
8. Neurophysiology and muscle MRI or biopsy for weakness, a raised creatine kinase or abnormal myositis antibodies. Temporal artery ultrasound or biopsy for suspected giant cell arteritis.
9. Pregnancy test and sleep study as indicated.

Limits. ESR and C reactive protein are normal in a minority of polymyalgia rheumatica and giant cell arteritis. Creatine kinase is normal in inflammatory and endocrine causes in many patients. Malaria tests can miss low parasitaemia. Fibromyalgia can coexist with another disease.

Immediate. Exclude sepsis, malaria, dengue with warning signs, rhabdomyolysis and giant cell arteritis in anyone who is unwell. Hydrate, treat fever, and start empirical therapy when a dangerous cause is likely.

Symptom control. Paracetamol 1 g orally every 6 hours (maximum 4 g daily; 3 g in frail patients or under 50 kg). Ibuprofen 400 mg every 8 hours with food (maximum 2.4 g daily) or naproxen 500 mg orally twice daily (maximum 1 g daily) after excluding dengue, renal impairment, peptic ulcer and heart failure. Avoid aspirin in dengue and in children with viral illness. Heat, gentle activity and sleep.

Cause directed treatment.

• Viral illness: rest, fluids and analgesia. Influenza: oseltamivir 75 mg orally twice daily for 5 days in severe disease or risk groups, begun within 48 hours (reduce to 30 mg twice daily when creatinine clearance is 31 to 60 mL/min).
• Dengue: oral hydration, paracetamol only, close monitoring of warning signs.
• Chikungunya: paracetamol and, after dengue is excluded, naproxen 500 mg twice daily with food; persistent arthritis needs rheumatology and may respond to methotrexate.
• Malaria: artemether-lumefantrine 4 tablets (80 mg/480 mg total, for patients of 35 kg or more) at 0, 8, 24, 36, 48 and 60 hours with fatty food, or intravenous artesunate 2.4 mg/kg at 0, 12 and 24 hours then daily for severe disease.
• Polymyalgia rheumatica: prednisolone 15 mg orally daily for 3 weeks, then 12.5 mg for 3 weeks, then 10 mg for 4 to 6 weeks, then reduce by 1 mg every 4 to 8 weeks as long as symptoms stay controlled, over 12 to 24 months overall. Add calcium, vitamin D and bone protection, a proton pump inhibitor in at risk patients, and methotrexate 7.5 to 10 mg once weekly with folic acid 5 mg weekly as a steroid sparing option for relapse or high steroid risk.
• Giant cell arteritis: prednisolone 40 to 60 mg orally daily started at once, or methylprednisolone 500 mg to 1 g intravenously daily for 3 days for visual symptoms; tocilizumab 162 mg subcutaneously weekly is a steroid sparing option; aspirin 75 mg daily.
• Hypothyroidism: levothyroxine 1.6 micrograms/kg orally once daily on an empty stomach (start 25 micrograms daily in older adults or coronary disease and increase every 4 to 6 weeks).
• Vitamin D deficiency and osteomalacia: colecalciferol 50,000 units orally once weekly for 6 to 8 weeks (or 3,000 to 4,000 units daily), then 800 to 2,000 units daily, with calcium 1,000 mg daily from diet and supplements; treat the cause of phosphate wasting or malabsorption.
• Primary hyperparathyroidism and hypercalcaemia: hydration with 0.9% sodium chloride and endocrine or surgical review; zoledronic acid 4 mg intravenously over 15 minutes for severe hypercalcaemia (corrected calcium 3.0 mmol/L or more) with renal adjustment.
• Statin and drug myopathy: stop the drug, check creatine kinase and renal function, and rechallenge with a different agent only after resolution.
• Rhabdomyolysis: isotonic crystalloid 1 to 2 litres in the first hour then 200 to 300 mL/hour aiming for a urine output of 200 to 300 mL/hour until creatine kinase is under 1,000 units/L; monitor potassium, calcium, phosphate and creatinine.
• Inflammatory myopathy: prednisolone 1 mg/kg daily (maximum 60 to 80 mg) with methotrexate 15 to 25 mg weekly or azathioprine 2 to 3 mg/kg daily.
• Myeloma and bone metastases: urgent oncology and haematology care; hypercalcaemia and spinal cord compression precautions.
• Fibromyalgia and chronic widespread pain: explanation and reassurance, graded aerobic exercise (start 10 minutes, 3 times weekly, increasing by 10% each week to 150 minutes weekly), sleep management, cognitive behavioural therapy, and pacing. Drug options with modest benefit: amitriptyline 10 mg orally at night, increased to 25 to 50 mg; duloxetine 30 mg orally daily for 1 to 2 weeks, then 60 mg; pregabalin 75 mg orally twice daily, increased to 150 mg twice daily (maximum 300 mg twice daily, reduced in renal impairment). Opioids and long term NSAIDs are not advised.
• Chronic fatigue syndrome and depression: individualised pacing and treatment of the mood disorder with an antidepressant such as sertraline 50 mg orally daily.

Monitoring. Review at 2 weeks for acute illness and at 4 to 6 weeks for subacute or chronic aches. In polymyalgia rheumatica review symptoms and C reactive protein at 1, 3 and 6 weeks and then with each dose reduction. Repeat creatine kinase after stopping a statin.

Referral and escalation. Immediate: sepsis, severe malaria or dengue, rhabdomyolysis, suspected giant cell arteritis with visual symptoms. Urgent rheumatology for suspected polymyalgia rheumatica that is atypical, myositis or vasculitis. Endocrinology for hypercalcaemia or complex bone disease. Pain, rheumatology or psychology services for fibromyalgia.

Admission. Fever with haemodynamic instability, severe malaria or dengue with warning signs, rhabdomyolysis with acute kidney injury, giant cell arteritis with visual loss, hypercalcaemia with symptoms, or inability to cope at home.

Safety netting. Return for high fever, vomiting, drowsiness, dark urine, severe weakness, vision loss, jaw pain, bleeding, new rash, or breathlessness.

Special groups. Pregnancy: avoid NSAIDs in the third trimester, use paracetamol, and test for malaria and vitamin D deficiency. Children: viral myositis (influenza B), growing pains, leukaemia and juvenile arthritis. Older adults: polymyalgia rheumatica, giant cell arteritis, hypothyroidism, statin myopathy and osteomalacia are common; adjust doses for kidney function. Endemic regions: malaria, dengue, chikungunya, typhoid, brucellosis and schistosomiasis come first.