Polymyalgia Rheumatica (PMR)
Summary
Polymyalgia Rheumatica (PMR) is an Inflammatory Rheumatic Disorder characterised by Bilateral Proximal Muscle Pain and Morning Stiffness affecting the Shoulders, Hip Girdle, and Neck in individuals Over 50 Years of Age. It is one of the most common inflammatory rheumatic conditions in older adults, With a prevalence of approximately 500-700 per 100,000 in those over 50. PMR is closely associated with Giant Cell Arteritis (GCA), with ~15-20% of PMR patients developing GCA and ~50% of GCA patients having PMR features. The aetiology is unknown but involves Systemic Inflammation with markedly elevated ESR and CRP. Diagnosis is clinical, Supported by raised inflammatory markers, Normal Creatine Kinase, And Dramatic Response to Low-Dose Corticosteroids (Which also serves as a diagnostic test). Treatment is with Prednisolone starting at 15-20mg daily, With gradual tapering over 1-2 years. Relapses are common. Screening for GCA is essential due to the risk of Irreversible Visual Loss. [1,2,3]
Clinical Pearls
"Bilateral Shoulder and Hip Girdle Pain + Morning Stiffness + Age >50 = Think PMR": Classic triad.
"Dramatic Response to Steroids is Diagnostic": Improvement within 24-72 hours expected.
"Always Ask About GCA Symptoms": Headache, Scalp tenderness, Jaw claudication, Visual symptoms. GCA can cause blindness.
"CK is Normal in PMR": Distinguishes from polymyositis.
Demographics
| Factor | Notes |
|---|---|
| Prevalence | ~500-700 per 100,000 in >50 years. |
| Age | greater than 50 years (By definition). Peak 70-80 years. Very rare under 50. |
| Sex | Female > Male (2-3:1). |
| Ethnicity | More common in Northern European / Scandinavian populations. |
Association with Giant Cell Arteritis (GCA)
| Association | Notes |
|---|---|
| PMR patients developing GCA | ~15-20%. |
| GCA patients having PMR features | ~40-60%. |
| Shared pathogenesis | Both considered part of the same disease spectrum. |
Mechanism (Incompletely Understood)
- Genetic Susceptibility: HLA-DR4 association.
- Environmental Trigger: Unknown. ? Infection.
- Systemic Inflammation: IL-6 driven. Elevated acute phase reactants.
- Synovitis and Bursitis: Ultrasound/MRI shows inflammation of Subacromial/Subdeltoid Bursae, Biceps Tenosynovitis, Glenohumeral Synovitis, Hip Synovitis/Bursitis.
Note: PMR is NOT primarily a muscle disease. Muscle enzymes (CK) are normal. The pain is referred from periarticular structures.
Symptoms
| Symptom | Notes |
|---|---|
| Bilateral Shoulder Pain | Most common. Aching. Affects deltoid area. |
| Bilateral Hip Girdle / Thigh Pain | Buttock, Lateral hip, Thigh. |
| Neck Pain | |
| Morning Stiffness | Prolonged (>45-60 minutes). Difficulty getting out of bed. |
| Sudden Onset | Patients often remember the day symptoms started. |
| Constitutional Symptoms | Fatigue, Malaise, Low-grade fever, Weight loss, Anorexia, Depression. |
| Difficulty with ADLs | Raising arms (Dressing, Brushing hair), Getting out of chair, Climbing stairs. |
What is NOT typical: Distal small joint involvement (Consider RA). Muscle weakness (Consider polymyositis).
Examination Findings
| Finding | Notes |
|---|---|
| Limited Active Range of Motion (Shoulders/Hips) | Due to pain. Passive ROM may be preserved. |
| Tenderness over Shoulders / Hips | Periarticular. |
| NO Muscle Weakness | Power normal on testing (May be limited by pain). |
| NO Synovitis of Small Joints | Hands/Feet not typically involved. |
| Low-Grade Fever | Sometimes. |
Red Flags for GCA (MUST Ask)
| Symptom | Concern |
|---|---|
| New Headache (Especially Temporal) | GCA. |
| Scalp Tenderness | GCA. |
| Jaw Claudication | Pain on chewing. Highly specific for GCA. |
| Visual Symptoms | Amaurosis fugax, Diplopia, Visual loss. EMERGENCY. |
| Temporal Artery Abnormality | Thickened, Beaded, Reduced pulse. |
Laboratory
| Test | Findings |
|---|---|
| ESR | Markedly Elevated (Usually >40, Often >50-100 mm/hr). |
| CRP | Markedly Elevated. |
| FBC | Normocytic anaemia (Chronic disease). Thrombocytosis. |
| LFTs | Mildly raised ALP sometimes (Hepatic acute phase response). |
| Creatine Kinase (CK) | NORMAL. Key to exclude Polymyositis. |
| Rheumatoid Factor / Anti-CCP | Negative (Exclude RA). |
| ANA | Usually negative. |
| Protein Electrophoresis | Exclude myeloma (If suspicion). |
Imaging (Not Routinely Required for Diagnosis)
| Modality | Findings |
|---|---|
| Ultrasound (Shoulders/Hips) | Subacromial/Subdeltoid Bursitis, Biceps Tenosynovitis, Glenohumeral Synovitis, Hip Bursitis/Synovitis. Supportive. |
| MRI | Similar findings. More sensitive. Research/Atypical cases. |
| PET-CT | Shows diffuse uptake in shoulders, Hips, Spine. Used in research/Difficult cases. May help differentiate from malignancy. |
Diagnosis (Clinical – ACR/EULAR 2012 Classification Criteria)
| Criterion | Points |
|---|---|
| Morning Stiffness >45 mins | 2 |
| Hip Pain or Limited ROM | 1 |
| Absence of RF and Anti-CCP | 2 |
| Absence of Other Joint Involvement | 1 |
| Ultrasound Findings (If done) | 1 or 2 |
Score ≥4: Classifies as PMR.
Practical Diagnosis: Age >50 + Bilateral shoulder pain + Raised ESR/CRP + Normal CK + Dramatic response to steroids.
Management Algorithm
SUSPECTED PMR
(Age >50, Bilateral shoulder/Hip pain, Morning stiffness,
Raised ESR/CRP, Normal CK)
↓
EXCLUDE MIMICS
- Rheumatoid Arthritis (RF, Anti-CCP, Joint exam)
- Polymyositis (CK, Weakness)
- Malignancy (History, Age-appropriate screening)
- Hypothyroidism (TFTs)
- Fibromyalgia (Widespread tender points, Normal ESR/CRP)
- Infection (Septic arthritis, Endocarditis)
↓
SCREEN FOR GIANT CELL ARTERITIS (GCA)
- Ask about: Headache, Scalp tenderness, Jaw claudication,
Visual symptoms
- If ANY present → Suspect GCA. Urgent action.
┌────────────────┴────────────────┐
NO GCA SYMPTOMS GCA SYMPTOMS
(PMR alone) (PMR + GCA or GCA alone)
↓ ↓
LOW-DOSE STEROIDS HIGH-DOSE STEROIDS
(See below) + Urgent Rheumatology / Temporal
Artery Biopsy / Imaging
↓
TREATMENT: CORTICOSTEROIDS (PMR)
┌──────────────────────────────────────────────────────────┐
│ **INITIAL DOSE** │
│ - **Prednisolone 15-20 mg/day** (Single morning dose) │
│ - Lower end (12.5-15mg) if milder symptoms, Frail, Low │
│ weight, Comorbidities. │
│ │
│ **EXPECTED RESPONSE** │
│ - **Dramatic improvement within 24-72 hours** │
│ ("Like a miracle") │
│ - >70% improvement in symptoms. │
│ - ESR/CRP should fall. │
│ - If NO response → Reconsider diagnosis. │
└──────────────────────────────────────────────────────────┘
↓
STEROID TAPERING (Slow and Guided by Symptoms/ESR/CRP)
┌──────────────────────────────────────────────────────────┐
│ - Typical total duration: **1-2 years** (Often longer). │
│ - **Example Taper (BSR Guideline)**: │
│ - 15-20 mg for 4-6 weeks (Until symptom control) │
│ - Reduce by 2.5 mg every 2-4 weeks → to 10 mg │
│ - Reduce by 1 mg every 4-8 weeks → to 0 │
│ - Monitor ESR/CRP throughout. │
│ - **Relapse Common (~50%)**. Increase dose to last │
│ effective dose + 10% and taper more slowly. │
└──────────────────────────────────────────────────────────┘
↓
STEROID-SPARING AGENTS (If Relapses, High Doses Needed)
┌──────────────────────────────────────────────────────────┐
│ - **Methotrexate 7.5-15 mg/week**: First-line steroid- │
│ sparing agent. Reduces relapse rate. │
│ - **Tocilizumab (IL-6 Inhibitor)**: Evidence growing. │
│ Particularly for GCA. Limited availability/Cost. │
└──────────────────────────────────────────────────────────┘
↓
BONE PROTECTION (All Patients on Prolonged Steroids)
- Calcium + Vitamin D
- Bisphosphonate (Alendronate) if ≥3 months steroids
(FRAX assessment)
- PPI (Gastric protection if needed)
↓
MONITORING
- Symptoms, ESR/CRP at each visit
- Blood glucose (Steroid-induced diabetes)
- Blood pressure
- Bone health (DEXA if prolonged)
- Eyes (Cataracts, Glaucoma)
- Ongoing screening for GCA symptoms
| Condition | Key Differentiating Features |
|---|---|
| Giant Cell Arteritis (GCA) | Overlaps. Headache, Jaw claudication, Visual symptoms, Temporal artery abnormality. |
| Rheumatoid Arthritis (Late-Onset RA) | Synovitis of small joints. RF/Anti-CCP positive. Different distribution. |
| Polymyositis | Muscle Weakness (Proximal). Elevated CK. EMG/Biopsy abnormal. |
| Malignancy | Weight loss, Atypical features, Failure to respond to steroids. Consider paraneoplastic. |
| Fibromyalgia | Widespread pain. Tender points. Normal ESR/CRP. Younger. |
| Hypothyroidism | Can cause myalgia/Stiffness. Check TFTs. |
| Osteoarthritis (Shoulders/Hips) | Localised. Mechanical. Normal ESR/CRP. |
| Adhesive Capsulitis (Frozen Shoulder) | Usually unilateral. Restriction of ROM in all directions. |
| RS3PE (Remitting Seronegative Symmetrical Synovitis with Pitting Oedema) | Pitting oedema of hands/Feet. Steroid-responsive. May overlap with PMR. |
| Complication | Notes |
|---|---|
| Giant Cell Arteritis (GCA) | Can develop during or after PMR. Risk of visual loss. |
| Steroid Side Effects | Osteoporosis, Diabetes, Hypertension, Weight gain, Cataracts, Skin thinning, Infection risk. |
| Relapse | ~50% relapse during taper. |
| Prolonged Treatment | Many patients require steroids for >2 years. |
| Factor | Notes |
|---|---|
| Response to Steroids | Excellent. Dramatic improvement expected. |
| Duration of Treatment | Average 1-2 years. Some require longer. |
| Relapse | ~50%. Manageable with dose adjustment. |
| Long-Term Outcome | Good if GCA prevented. Morbidity often from steroid side effects. |
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| PMR | BSR/BHPR 2010, EULAR/ACR 2015 | Prednisolone 15-20mg initial. Slow taper over 1-2 years. Monitor for GCA. Bone protection. |
What is Polymyalgia Rheumatica?
PMR is an inflammatory condition that causes pain and stiffness in the shoulders, Hips, And neck. It mainly affects people over 50.
What are the symptoms?
- Aching pain in the shoulders, Upper arms, Hips, And thighs (Both sides).
- Severe morning stiffness (Lasting more than 45 minutes).
- Difficulty with everyday tasks (Getting dressed, Getting out of a chair).
- Tiredness, Feeling unwell, Sometimes low-grade fever or weight loss.
What causes it?
We don't know the exact cause. It involves inflammation in the body, But the muscles themselves are not damaged.
How is it treated?
Steroid tablets (Prednisolone) work very well – Most people feel much better within days. Treatment usually lasts 1-2 years, With the dose gradually reduced.
Are there any risks?
Long-term steroid use can cause side effects (Bone thinning, Weight gain, Blood sugar changes). Your doctor will monitor for these and may prescribe medication to protect your bones.
What is the link with Giant Cell Arteritis?
PMR is related to another condition called GCA, Which affects arteries and can cause headaches, Jaw pain, And vision problems. If you develop a new headache, Jaw pain when chewing, Or any change in vision, Seek medical attention urgently – GCA can cause permanent blindness if not treated quickly.
Primary Sources
- Dasgupta B, et al. 2012 Provisional classification criteria for polymyalgia rheumatica: A European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis. 2012;71(4):484-492. PMID: 22388996.
- Dejaco C, et al. EULAR recommendations for the management of polymyalgia rheumatica. Ann Rheum Dis. 2015;74(10):1799-1807. PMID: 26359495.
- BSR/BHPR. Guidelines for the management of polymyalgia rheumatica. 2010. Rheumatology. 2010;49(1):186-190. PMID: 19843754.
Common Exam Questions
- Classic Triad: "What are the classic clinical features of PMR?"
- Answer: Bilateral Shoulder and Hip Girdle Pain, Prolonged Morning Stiffness (>45 mins), Age >50 years.
- Key Negative Finding: "Why is Creatine Kinase (CK) important in the workup of PMR?"
- Answer: CK is NORMAL in PMR. Elevated CK would suggest Polymyositis (Inflammatory muscle disease).
- Initial Steroid Dose: "What is the typical starting dose of Prednisolone for PMR?"
- Answer: 15-20 mg once daily.
- Dramatic Response: "What response to steroids is expected in PMR?"
- Answer: Dramatic improvement within 24-72 hours (>70% improvement). Failure to respond should prompt reconsideration of diagnosis.
Viva Points
- Always Screen for GCA: Headache, Jaw claudication, Visual symptoms. Can cause blindness.
- Not a Muscle Disease: CK normal. Inflammation is periarticular (Bursitis, Synovitis).
- Relapse Common (50%): Slow taper. May need >2 years treatment.
- Steroid-Sparing: Methotrexate: For frequent relapses or high steroid requirements.
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