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78 Correspondences / Joint B

ositive test has also to be clearly defined. Results should be ana-yzed according to this definition and to the reference criterion:eakness usually corresponds to tear, pain to tendinopathy. Clin-

cal tests have been proposed for studying either supraspinatus,nfraspinatus or subscapularis. These points have to be consid-red in analysis and presentation of results in further studies.

We finally stress the fact that clinical examination is of areat importance in rotator cuff disorders. It is the recommendedrst-line investigation for diagnosing degenerative rotator cuffisease [3]. Second-line investigation is complementary imagingncluding MRI that should be restricted to selective indicationsuch as surgical decision. Clinical tests for subacromial impinge-ent and for evaluation of rotator cuff tendons are part of clinical

xamination. We therefore agree with Silva et al. that knowledgef their performance is crucial.

eferences

1] Beaudreuil J, Nizard R, Thomas T, et al. Contribution of clinical tests to thediagnosis of rotator cuff disease: A systematic literature review. Joint BoneSpine 2009;76:15–9.

2] Silva L, Andréu JL, Munoz P, et al. Accuracy of physical examination insubacromial impingement syndrome. Rheumatology 2008;47:679–83.

3] Clinical practice guidelines. Management of chronic painful shoulder with-out instability in adults. Available from: http://www.has-sante.fr;2005.(accessed date 28.12.2007).

Johann BeaudreuilService de rhumatologie, hôpital Lariboisière, AP–HP, 2, rue

Ambroise-Paré, 75010 Paris, FranceE-mail address: johann.beaudreuil@lrb.aphp.fr

15 May 2009

Available online 29 September 2009

oi:10.1016/j.jbspin.2009.05.009

omments on the original article by Bannwarth et al:Fibromyalgia syndrome in the general population ofrance:prevalence study”

eyword: Fibromyalgia syndrome

ir,

I read with great interest the paper by B.Bannwarth et al.:Fibromyalgia syndrome in the general population of France:prevalence study” which appeared in Joint Bone Spine 2009.would like to point out the fact that the method used by theuthors seems peculiar. Actually, for the second phase, the clini-al examination of the selected people, the authors do not use theecommended method for the study of disease prevalences. Astated by the authors “ideally, the subjects selected by the phone

nquiry (first phase) should have been examined by a physician inrder to confirm or exclude fibromyalgia”. Indeed, this diagnosiss difficult and remains a diagnosis of exclusion in the absence ofeal objective criterion. Now, amazingly, the authors examined

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pine 76 (2009) 577–580

group of outpatients in a rheumatology department, assuminghat the positive predictive value (PPV) for the two question-aires used is similar for the two studied populations. However,he question is not to know if PPV is similar in the two groupsut if the two groups may be compared. A clinical exam of theubjects of the two groups was absolutely necessary to prove it.his step lacking, the authors are not allowed to conclude as theyo about the prevalence or fibromyalgia in France. In my opin-on, this work should not have been published because of thisaw in the method. The results are aberrant for the male/femaleatio and for the level of prevalence in elderly people, espe-ially for males. As mentioned by the authors, although it isot known enough, diagnosis of fibromyalgia is actually evenore difficult in this sample of the population because of more

umerous etiologies of diffuse pain.

Paul Le GoffService de rhumatologie, hôpital de la Cavale-Blanche,

boulevard Tanguy-Prigent, 62 bis, rue Yves-Collet,29200 Brest, France

E-mail address: legoff.paul@orange.fr.

25 May 2009

Available online 1 October 2009

oi:10.1016/j.jbspin.2009.05.008

ibromyalgia syndrome in the general population of France:prevalence study. Reply to comments by P. Le Goff

eyword: Fibromyalgia syndrome

I am deeply grateful to P. Le Goff for having scrutinized sohoroughly a study he deems worthless.

I acknowledge the methodological flaws that he lists painstak-ngly, if not tactfully, in our study of the prevalence ofbromyalgia in the general population of France [1]. These flawsre pointed out clearly in the article [1]. That they invalidateny conclusions drawn from our work is an opinion P. Le Goffill no doubt allow me to disagree with. Although he describesur results as “aberrant”, they are consistent overall with theiterature.

Regarding our estimate of the overall prevalence ofbromyalgia, we explicitly acknowledged that our approach waspen to criticism. It does, however, have the advantage of guard-ng effectively against overestimation. Our estimate of 1.4 to.2% is in agreement with data from the US, Spain, and Italy1]. As indicated in the discussion of our article, simply applyinghe positive predictive value (PPV) of the London fibromyal-ia epidemiology study screening questionnaire (LFESSQ) [2]o the individuals contacted by phone would have produced arevalence estimate of 3.5% or even 5.6% [1].

Although the low female-to-male ratio in our survey is con-

istent with ratios found in Canada and Finland, we discussedossible sources of bias in our article [1]. The low ratio wasrobably ascribable to unavoidable sampling effects and to thenfluence of sex on the PPV of the LFESSQ [1].

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Correspondences / Joint B

Regarding the criticism about age, it should be noted that weound a first peak of prevalence between 45 and 54 years of age,n keeping with earlier studies, and a second peak between 75nd 84 years. We discussed the relevance of this second peak inhe article, while pointing out that in the US the prevalence ofbromyalgia was reported to increase with age until the eighthecade [1].

eferences

1] Bannwarth B, Blotman F, Le Lay K, et al. Fibromyalgia syndrome inthe general population of France: a prevalence study. Joint Bone Spine2009;76:184–7.

2] White KP, Speechley M, Harth M, et al. Testing an instrument to screenfor fibromyalgia syndrome in general population studies: the Londonfibromyalgia epidemiology study screening questionnaire. J Rheumatol1999;26:880–4.

Bernard BannwarthEA 525, service de rhumatologie, département de

rhumatologie et thérapeutiques, groupe hospitalier Pellegrin,université de Bordeaux-II, place Amélie-Raba-Léon, 33076

Bordeaux cedex, FranceE-mail address: bernard.bannwarth@u-bordeaux2.fr

25 May 2009

Available online 29 September 2009

oi:10.1016/j.jbspin.2009.08.001

steoporosis in men: Other secondary causes

eywords: Osteoporosis; Adult acquired growth hormone deficiency; Idiopathichosphate diabetes; Mild hypercortisolism

ear Editor,

Briot et al., in their interesting review on osteoporosisn men [1], state that in 50% of osteoporotic men at leastne secondary cause is identified. Therefore, the authorsall attention to the importance of a careful screening foretection of secondary osteoporosis in men. It is notablehat other than those reported, additional and relevant causesf secondary osteoporosis may include adult acquiredrowth hormone deficiency (aGHD) [2], moderate idiopathichosphate diabetes (IPD) [3,4], mild hypercorticosolism5] and inherited disorders like Gaucher disease and [6]omocystinuria [7].

Low bone mineral density (BMD) and increased fractureisk have been reported in aGHD patients [2]. Diagnosis ofGHD should be hypothesized among those subjects with a his-ory of brain injury and hypothalamic-pituitary lesions. Otherhan osteoporosis, subjects with aGHD may have also reduced

ean body mass, increased abdominal adiposity, reduced mus-le strength, abnormal lipid and glucose metabolism [2,8].oderate IPD causes osteoporosis and sometimes diffuse pain

esembling fibromyalgia occurs. IPD should be suspected when

pine 76 (2009) 577–580 579

erum phosphate below 0.85 mmol/L is associated with phos-haturia, the latter finding being defined by a ratio of renalubular reabsorption of phosphate to glomerular filtration rateess than 0.83. Diagnosis of IPD requires also exclusion of otheronditions: hyperparathyroidism (either primary or secondary toitamin D deficiency), alcohol abuse, glucocorticoid treatment,ypophosphatemic osteomalacia [9,10]. Mild hypercortisolismelated to adrenal incidentalomas is associated with a hetero-eneous clinical presentation that is dependent on the extent ofortisol overproduction, including osteoporosis. Interestingly,mong subjects with established osteoporosis, the prevalencef subclinical hypercortisolism is about 10%. The presence ofsteoporosis in patients with hypercortisolism due to adrenalncidentalomas might represent a criteria to adrenal surgicalxcision [11]. Finally, Gaucher disease type 1 and homocystin-ria are rare inherited disorders frequently associated withsteopenia and osteoporosis [6,7].

Although the rarity of some of these disorders, evidence thatecondary male osteoporosis is at least as prevalent as idiopathicale osteoporosis should solicit to seek all these possible under-

ying causes of osteoporosis. A thorough patient’s and family’sistory and a careful physical examination may allow to formu-ate a reasonable clinical suspicious of some of these disorders.ence, an extensive screening of secondary causes of osteoporo-

is in men should not neglect the search of the above-mentionedisease conditions.

eferences

[1] Briot K, Cortet B, Trémollières, et al. Male osteoporosis: Diagnosis andfracture risk evaluation. Joint Bone Spine 2009;76:129–33.

[2] Doga M, Bonadonna S, Gola M, et al. GH deficiency in the adult and bone.J Endocrinol Invest 2005;28:18–23.

[3] Laroche M, Arlet J, Ader JL, et al. Male osteoporosis, an unrecognisedetiology: moderate idiopathic proximal tubulopathy (MIPT). Rev RhumMal Osteoartic 1992;59:3–9.

[4] Cortet B, Vasseur J, Grardel B. Management of male osteoporosis. JointBone Spine 2001;68:252–6.

[5] Chiodini I, Mascia ML, Muscarella S, et al. Subclinical hypercorti-solism among outpatients referred for osteoporosis. Ann Intern Med2007;147:541–8.

[6] Guggenbuhl P, Grosbois B, Chalès G. Gaucher disease. Joint Bone Spine2008;75:116–24.

[7] Parrot F, Redonnet-Vernhet I, Lacombe D, et al. Osteoporosis inlate-diagnosed adult homocystinuric patients. J Inherit Metab Dis2000;23:338–40.

[8] Itoh E, Hizuka N, Fukuda I, et al. Metabolic disorders in adult growthhormone deficiency: A study of 110 patients at a single institute in Japan.Endocr J 2006;53:539–45.

[9] Laroche M, Boyer JF. Phosphate diabetes, tubular phosphate reabsorptionand phosphatonins. Joint Bone Spine 2005;72:376–81.

10] Laroche M, Boyer JF, Jahafar H, et al. Normal FGF23 levels in adultidiopathic phosphate diabetes. Calcif Tissue Int 2009;84:112–7.

11] Francucci CM, Caudarella R, Rilli S, et al. Adrenal incidentaloma: effectson bone metabolism. J Endocrinol Invest 2008;31:48–52.

Gianluigi Fabbriciani ∗Matteo Pirro

Anna Maria ScarponiElmo Mannarino