PassFinals
Musculoskeletal

Polymyalgia Rheumatica

An inflammatory syndrome in adults over 50 causing new bilateral shoulder or pelvic-girdle pain and prolonged stiffness, diagnosed by clinical pattern and exclusion of mimics, with urgent screening for associated giant cell arteritis.

In a nutshell

Polymyalgia rheumatica causes new bilateral shoulder or pelvic-girdle pain and prolonged morning stiffness in adults over 50, with raised inflammatory markers in most cases and no objective focal weakness. Diagnosis is clinical and by exclusion; a rapid response to low-dose prednisolone supports it. Screen for giant cell arteritis at every review, taper steroids gradually and protect against steroid toxicity.

Classic presentation

A person over 50 develops several weeks of bilateral shoulder and hip-girdle stiffness, difficulty dressing or rising from a chair, prolonged morning stiffness and raised CRP or ESR, without small-joint synovitis or true muscle weakness.

Key points

  • PMR is a clinical syndrome; no single blood test or steroid response proves the diagnosis.
  • Pain-limited movement is expected, but true proximal weakness, rash, dysphagia or markedly raised CK suggests myositis or another diagnosis.
  • Screen for GCA at diagnosis and every review; new headache, jaw or tongue claudication, visual disturbance or focal neurological symptoms need urgent GCA escalation.
  • Start low-dose oral prednisolone after considering mimics and GCA, then taper gradually over many months with symptom, function and inflammatory-marker monitoring.
  • Assess fracture risk and protect bone during prolonged glucocorticoid treatment; monitor blood pressure, glucose, infection, mood, eyes and adrenal-insufficiency risk.
  • Relapses are managed through diagnostic review and specialist-guided return to the last effective dose followed by a slower taper; methotrexate may help selected steroid-dependent patients.

First-line investigation

Clinical assessment with CRP and ESR, FBC, renal and liver function, CK, thyroid and bone-profile testing, plus targeted tests for infection, malignancy or inflammatory arthritis; confirm the pattern and document GCA symptoms.

Management

Exclude GCA and important mimics

  • Document GCA symptoms, objective strength, peripheral synovitis, systemic features and medication or infection risks; escalate immediately if GCA is suspected.1,2,5

Start and assess low-dose steroid treatment

  • For supported uncomplicated PMR, start low-dose oral prednisolone according to current CKS, local protocol and the BNF, and expect substantial improvement within days; poor response requires diagnostic review.1,6,7

Taper gradually

  • Once controlled, taper prednisolone through a structured symptom-guided plan over many months, with slower reductions at lower doses and specialist input for relapse or toxicity.1,6,3

Prevent steroid toxicity

  • Assess fracture risk and provide indicated bone protection, calcium or vitamin D measures, steroid-card and sick-day advice, and monitoring for blood-pressure, glucose, infection, mood, ocular and adrenal complications.8,9,6,7

Refer relapsing or atypical disease

  • Recheck diagnosis, adherence, GCA, inflammatory markers and mimics when response is poor or symptoms relapse; refer difficult-to-taper or steroid-dependent disease for specialist options such as methotrexate.1,6,3

Safety-net GCA throughout follow-up

  • Give written same-day emergency advice for new headache, scalp tenderness, jaw or tongue claudication, visual disturbance, diplopia or focal neurological symptoms at any point during the taper.1,4,5

Exam traps

  • PMR causes pain-limited movement, not true muscle weakness; check CK and reconsider myositis if strength is objectively reduced.
  • A rapid steroid response supports PMR but does not exclude infection, malignancy or inflammatory arthritis.
  • GCA can develop during PMR follow-up; repeat the GCA symptom screen at every review.
  • Visual symptoms or focal neurological symptoms require emergency GCA treatment and specialist assessment, not a routine PMR appointment.
  • Do not stop prolonged prednisolone abruptly; relapse and adrenal insufficiency are separate safety concerns.
  • Normal inflammatory markers or atypical symptoms should prompt specialist review rather than automatic steroid escalation.

Illustrations

Girdle distribution of painDiagram highlighting the bilateral shoulder, neck and pelvic-girdle distribution of pain and stiffness characteristic of polymyalgia rheumatica.PassFinals · original
Overlap with giant cell arteritisVenn diagram showing shared age group and inflammatory features, with GCA cranial and visual red flags separated as an emergency pathway.PassFinals · original

Key sources

  1. NICE CKS: Polymyalgia rheumatica (UK primary-care knowledge summary on diagnosis, differential diagnosis, glucocorticoid treatment, tapering, relapse, monitoring and GCA safety-netting; access restricted in the automated source sweep)
  2. NHS: Polymyalgia rheumatica diagnosis (NHS information on clinical assessment, blood tests, differential diagnosis and response to steroids)
  3. BSR and BHPR guideline for the management of polymyalgia rheumatica (UK specialist guideline published 2010; the BSR update was in development in the latest live source check, so current NICE CKS and NHS sources take precedence for routine review)Published 12 Nov 2009
  4. NHS: Polymyalgia rheumatica (NHS information on symptoms, age group, treatment and the link with temporal arteritis)
  5. NHS: Temporal arteritis (NHS urgent-care information on GCA symptoms, immediate steroid treatment and visual-loss risk)
  6. NHS: Polymyalgia rheumatica treatment (NHS information on prednisolone, gradual reduction, relapse, methotrexate, follow-up and steroid adverse effects)
  7. BNF online (Check current prednisolone, glucocorticoid-protection, methotrexate and relevant interacting-medicine monographs for dose, contraindications, monitoring and adverse effects)
  8. NOGG 2024: Clinical guideline for the prevention and treatment of osteoporosis (Current UK guidance for fracture-risk assessment and bone protection during prolonged glucocorticoid treatment)Updated 1 Dec 2024
  9. NICE CG146: Osteoporosis: assessing the risk of fragility fracture (NICE guidance supporting glucocorticoid-associated fracture-risk assessment and bone-protection planning; last reviewed October 2024)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.