Pain arising out of soft tissue structures around the joints (soft tissue rheumatism) may be more common than symptoms arising from joints and bone. In the absence of diagnostic tests, attractive imaging techniques and exiting immunological theories to explain the pathogenesis of soft tissue rheumatism, research activities take a back seat. Soft tissue rheumatism could be classified as diffuse (Fibromyalgia), regional (Complex regional pain syndrome-CRPS) or localized such as in tennis elbow. Early diagnosis and use of multi- modal approach to therapy are essential.

Neuropathic arm pain (NAP), commonly referred to as 'RSI', diffuse upper limb disorder or type II work related upper limb disorder (WRULD) is a regional pain syndrome affecting the upper limb(s), characterized by persistent pain and dysaesthesiae. It is commonly associ- ated with long periods of keyboard use, though may also occur in workers engaged in other types of repetitive stereotyped activities of the hands. Adverse ergonomics is commonly present. Sleep pattern is usually disturbed, and depression, headaches, chronic fatigue, and frustration are frequently experienced. The pathogenesis of NAP is probably linked to overloading of sensorineural mechanisms responsible for pain production and perception. Clinical findings include muscle tension and hyperalgesia in the upper limbs and shoulder girdles, adverse neural dynamics, and frequently (and importantly) proximal dorsal spinal dysfunction. Other factors that are often associated with the development of neuro- sensitisation include premorbid psychological profile, environmental stresses, mis- attributions and beliefs, adverse posture and ergonomics, iatrogenesis, and litigation. Conventional investigations such as cervicodorsal spinal radiographs, nerve conduction studies, and MRI are negative. Clinical management is structured on reduction of pro- vocative stresses and treatment of neuromusculoskeletal dysfunction. The differential diagnosis is discussed in this article.

The successful management of fibromyalgia starts with establishing a firm diagnosis, followed by an evaluation of all other comorbid pain conditions (e.g. osteoarthritis, temporomandibular pain disorder, migraine headaches, myofascial trigger points) and fi- bromyalgia associated comorbidities (e.g. restless leg syndrome, irritable bowel syndrome). Then, it is necessary to systematically go through a list of problems that need to be addressed: pain, sleep, fatigue, mood disorders, cognitive dysfunction, functional limita- tions, social functioning, prior therapies and expectations. The most fundamental issue in successful management is initiating patient directed therapies. This involves education regarding the nature of fibromyalgia, the various tools for treating different aspects of the disorder and the development of a constructive and flexible treatment program that will be modified according to the results. All fibromyalgia patients should be given a trial of medications that have been shown to help pain. Non-restorative sleep diminishes the effectiveness of the descending inhibitory pain pathway, thus effective treatment is an essential component of pain management, as well as helping fatigue and cognition. It is important to rule out treatable associated sleep disruptors such as restless legs syndrome and sleep apnea. The basis of attaining effective sleep is the patient's adherence to basic sleep hygiene measures. Cognitive behavioral therapy where feasible, should be pursued. Ideally, hypnotics should be used as a short-term bridge while the patient is establishing behavioral modifications. Regular gentle exercise has repeatedly been shown to benefit fibromyalgia patients and needs to be incorporated in every patient's management strat- egy. Practicing mindfulness is a useful strategy for minimizing stress and can be incor- porated into gentle exercise in the form of yoga and Tai chi. Having fibromyalgia creates an existential crisis for most patients, the management of these clients can be a rewarding experience for the well-informed and empathetic physician.

Myofascial pain syndrome (MFPS) is described as the sensory, motor, and autonomic symptoms caused by trigger points which typically develop after muscle overuse. Etiology for the development of trigger points is unclear. The pain found with MFPS is frequently described as a "chronic dull aching pain" and is associated with muscle and soft tissue tenderness. Diagnosis is mainly clinical and treatment manual. The key to successful management of MPS is to diagnose it early, followed by intensive, protocol based, multi- disciplinary rehabilitation utilizing a combination of medication, splints, collars, rest, physiotherapy, and effective use of various trigger point management techniques.

Purpose of review: This review presents a brief synopsis in the current concepts in diagnosis of a perplexing clinical condition that has the potential to be under diagnosed. In addition, it briefly summarizes evidence base for treatment options. Recent concepts in CRPS: The variability in establishing a diagnosis of CRPS has been reduced by introducing the stricter "Budapest Diagnostic Criteria for CRPS", a consensus among international experts to introduce some uniformity in the diagnosis of the CRPS which still continues to be a clinical diagnosis. There is increasing recognition of dystonia (motor manifestation) as a part of CRPS. New drugs and treatment approaches like immuno- globulins and bisphosphonates are being investigated with promising early results, while the mainstay of therapy remains multidisciplinary individualized regime with emphasis on achieving compliance with physical therapy. Traditional therapies have been recently reevaluated, some having found to be ineffective. The individual therapies with reasonable acceptance include graded motor imagery, anti-neuropathic medications, sympathetic blocks and spinal cord stimulation (in refractory CRPS). Summary: CRPS is a complex difficult to diagnose and difficult to treat medical condition with significant impact on quality of life for the individual. There is gradual improving body of evidence for traditional and emerging therapies, while emphasis on functional improvement with physical therapy continues.

Benign joint hypermobility syndrome is the presence of musculoskeletal symptoms in subjects with joint hypermobility in the absence of demonstrable systemic rheumatic disease. Unlike the heritable disorders of connective tissue with which it shares consid- erable overlap in manifestations, most subjects with hypermobility remain asymptomatic. Prevalence of hypermobility varies considerably with age, gender and ethnicity. Muscle weakness and decreased proprioception contribute to recurrent micro trauma and joint pains in this otherwise benign condition. Supervised exercises designed to improve joint stability and proprioception remain the mainstay of treatment.

Disorders of the foot and ankle are common in the rheumatology clinic and are frequently soft tissue in origin. In this context, pain can arise from tendon, ligament, nerve, bursa and muscle. Pain and disability are common consequences and hence the rheumatologist must have a comprehensive understanding of the diagnosis and management of such complaints.

Neck and back pains are features of life worldwide. Few with spinal pain (SP) have serious medical (non-spinal) conditions; significant spinal pathology; or compression of root or cord such as to require surgery. Although the causes of most episodes of SP remain unclear in practice, physical stress and its consequences on discs, facet joints and supporting soft tissue structures at work or leisure activities are thought to trigger many initial attacks. But prognosis usually depends on psychosocial issues. A minority of episodes are prolonged, intractable and disabling, contributing to the high cost for society. Around 10% of those presenting to a rheumatological service have non-spinal conditions. There is good evi- dence to support prevention of SP through primary, secondary and tertiary routes. Modern management of chronic SP emphasises the role of self-care, which should begin in general practice at presentation of the first episode and be reinforced by all health professionals. In the absence of root compression, bed rest should be minimal. A positive approach is encouraged, acknowledging that returning to a normal life may require working through pain. More emphasis is laid on actively encouraging a return to physical fitness and other activities, including employment. Medication plays a secondary role by facilitating these objectives.

Pain as a result of 'dysfunction' of the sacroiliac joint is commonly due to non- inflammatory disorders. Sacroiliac joint dysfunction is considered a cause of pain by os- teopaths, chiropractors and physiotherapists. Musculoskeletal physicians, sport and ex- ercise medicine specialists and pain physicians have researched further into the concepts of SIJ pain and dysfunction. History, clinical signs and radiological investigations individ- ually are inadequate to diagnose sacroiliac joint pain. However, as with all musculoskeletal assessment, careful analysis of all the presenting features can direct the physician to the diagnosis with reasonable accuracy.

Exercise programs for patients with arthritis have been shown to produce a variety of benefits like increase and maintenance of range of motion, re-education and strengthening of muscles, increase in static and dynamic endurance, decrease in the number of swollen joints, enabling joints to function better biomechanically, increase the locomotor ability, increase the bone density, decrease in pain, increase in patients' overall function and well- being, decrease inflammation and increase in aerobic capacity. Patients value exercise prescription which is designed to improve function.