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How is Fibromyalgia Classified/Diagnosed Part 2 – TpT & ACR diagnostic criteria of 1990

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

How Fibromyalgia is diagnosed is often under the microscope and undergoing changes and in this part of ‘How is Fibromyalgia Diagnosed?’

I  originally shared some information from The American College of Rheumatology (ACR) regarding their Diagnostic criteria for Fibromyalgia, including The Tender-Point-Test (TpT) diagnostic tool but the links have gone due to TpT not being used as a diagnostic tool.

Please remember before reading this that I’m not a medical professional just a fellow fibromite/spoonie sharing some information and places to find info from reputable sources  🙂


The following is taken from the opening section of the ‘Fibromyalgia’ info pages on the ACR website and it explains it’s current view regarding diagnosing Fibromyalgia through taking into account an overall perspective of a patient’s symptoms as well as the TpT.  The ACR changed it’s criteria in 2010 after researchers found that the original diagnostic ACR criteria from 1990 did not cover enough area for diagnosis to be made properly.

Fast Facts

  1. Fibromyalgia affects two to four percent of people, mostly women.
  2. Doctors diagnose fibromyalgia based on all the patient’s relevant symptoms (what you feel), no longer just on the number of tender points.
  3. There is no test to detect this disease, but you may need lab tests or X-rays to rule out other health problems.
  4. Though there is no cure, medications can relieve symptoms.
  5. Patients also may feel better with proper self-care, such as exercise and getting enough sleep.

ACR Diseases & Conditions -I am a Patient-Caregiver > Fibromyalgia

  • Updated March 2017 by Suleman Bhana, MD and reviewed by the American College of Rheumatology Committee on Communications and Marketing.
  • This information is provided for general education only. Individuals should consult a qualified health care provider for professional medical advice, diagnosis and treatment of a medical or health



A little background:

In 1986 a flurrie of research began by 25 researchers from differing multicentres were brought together through research to help create a classification set of diagnostic/classification criteria for Fibromyalgia, they were ‘The Multicentre Criteria Committee’.

25 researchers, which included Frederick Wolfe, Hugh A Smythe and M B Yunus, developed the 1990 criteria by performing research and studies into how best to diagnose/classify Fibromyalgia.  They took many elements from those studies to create the final criteria.  This involved looking back at the works of Smythe & Moldovsky from 1977 and the suggestion of TpT and another form of testing including symptoms, also at more recent works like that of Yunus et al regarding the inclusion of other physical symptoms such IBS (Irritable Bowel Syndrome), factors like sensitivities to touch, light and sound, and not just tender point tests.

Many sets of possible criteria were developed but, unfortunately, most of them were not clinically trialed and none of them were tested beyond the test centres that they were developed at.    There was also found to be an inconsistency in the definition of Fibromyalgia throughout their findings which also became a part of the ACR’s classification process, a definitive definition of Fibromyalgia was required. The prior studies as a combination did however, help to provide valuable information and ideas that were used to mould the ACR 1990 diagnostic criteria for Fibromyalgia.  Information such as the classification criteria would be different for someone with primary fibromyalgia to that of someone with secondary Fibromyalgia and also revealed a list of symptoms an modulating factors to be taken into consideration.



The commitee then decided on the following 4 main objectives:

  1. Provide a consensus definition of Fibromylagia.  >>> Fibromyalgia Syndrome with fibromyalgia replacing the previous term ‘fibrositis’ and taking the nature of it’s symptoms into account.
  2. Establish new classification/diagnostic criteria for Fibromyalgia
  3. Study Primary Fibromyalgia in relation Secondary Fibromyalgia in terms of diagnostic criteria(symptoms may be from the primary illness in someone with secondary fibromyalgia, like myself with Hypermobility Syndrome as my primary illness, which needed to be accounted for)  >>>>> It was decided not to include a differential set of criteria for primary and secondary Fibromyalgia patients in the 1990 criteria.
  4. Check to see how previous criteria worked in other multicentre data sets and compare to their own (1990 ACR classification criteria for Fibromyalgia)


To read the full report, methodologies and findings: Download the PDF – ACR 1990 criteria for the classification of fibromyalgia



1990 ACR Diagnostic criteria for the classification of Fibromyalgia:

The patient is to have a history of widespread pain has been present for at least three months –

Definition of widespread pain: Pain is considered widespread when all of the following are present:

  • Pain in both sides of the body
  • Pain above and below the waist In addition, axial skeletal pain (cervical spine, anterior chest, thoracic spine or low back pain) must be present. Low back pain is considered lower segment pain.


The Tender-Point-Test  (TpT):  (No longer used!)

The patient should also experience ‘Pain’ in 11 of 18 tender point sites on digital palpation – TpT

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

  • Occiput (2) – at the suboccipital muscle insertions.
  • Low cervical (2) – at the anterior aspects of the intertransverse spaces at C5-C7.
  • Trapezius (2) – at the midpoint of the upper border.
  • Supraspinatus (2) – at origins, above the scapula spine near the medial border.
  • Second rib (2) – upper lateral to the second costochondral junction.
  • Lateral epicondyle (2) – 2 cm distal to the epicondyles.
  • Gluteal (2) – in upper outer quadrants of buttocks in anterior fold of muscle.
  • Greater trochanter (2) – posterior to the trochanteric prominence.
  • Knee (2) – at the medial fat pad proximal to the joint line.


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

A tender point has to be painful at palpation, not just ‘tender’.

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

Taken from: – classification of fibromyalgia/

During studies this was measured by gauging the patients facial expression and reaction from a grimace to an ‘all-out’ didn’t get to touch the spot because of the extreme sensitivity to pain and touch .



Symptoms to take into consideration:

  • Sleep disturbance (poor sleep, waking up unrefreshed)
  • Fatigue (extreme tiredness and no energy)
  • Morning Stiffness
  • Parasthesia (Numbness & Tingling)
  • Widespread Pain (Experience pain all over the body and not just in isolated parts)
  • Anxiety
  • Irritable Bowel Syndrome (IBS)
  • Headaches
  • Autonomic nervous system problems with temperature sensitivities and others such as Allodynia.

Other variables to consider:  Modulating factors (related to sensitivities)

  • Noise
  • Cold
  • Poor sleep
  • Anxiety
  • Humidity
  • Stress
  • Fatigue
  • Weather change
  • Warmth


How are these variables measured for diagnosis of Fibromalgia?

The team from the ACR found the scoring system to be most useful measures the variables using a score system based on the variable’s prevalence to the patient as in never, seldom, often/usually.

Collating a list of your symptoms and scoring whether you are experiencing them or not and where, how long, type of pain helps to establish a more holistic approach to diagnosing Fibromyalgia, alongside the results of the TpT.

However, the 1990 criteria came under criticism because it still didn’t cover all necessary variables via appropriate methods in the clinical setting, how could a doctor clearly gauge how to score a patients experience with fatigue for instance going off word alone?, so it was back off to the drawing board.



In ‘How is Fibromyalgia Classified/Diagnosed Part 3 I will discuss the next part of ACR diagnostic history where the criteria evolve to include measuring markers for those other contributing factors that couldn’t be gauged correctly in the ACR criteria of 1990 as shown above.

Please note that this post is for ‘historical’ and ‘knowledge-learning’ values only as this is not how Fibromyalgia is diagnosed anymore.
The links for information below have also been checked and updated 17th March 2018.


Fibromyalgia diagnosis Info HOTSPOT’s:

‘The ACR supports criteria development projects in different topic areas related to rheumatic disease. Projects generally focus on classification, response, and remission criteria. The ACR has previously endorsed diagnostic criteria. This article provides more detail on the differences between classification and diagnostic criteria, and why the ACR no longer endorses diagnostic criteria.’  Taken from the website link above

Pdf > Distinctions Between Diagnostic and Classification Criteria Aggarwal et al


Places to go for information about Fibromyalgia Diagnosis.  They all say pretty much similar things but people have differing preferences of where they like to read their info so there’s a selection of sources.


Got a website you feel should be listed please just e-mail us your suggestion for consideration.

Many thanks for reading and wishing you wellness & less pain