Confusable diagnoses · PANCE / PANRE

Rheumatoid Arthritis vs Polymyalgia Rheumatica

Written & clinically reviewed by Ryan Busch, PA-C · Updated August 2026 · Report an error

Rheumatoid Arthritis and Polymyalgia Rheumatica are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.

Rheumatoid Arthritis vs Polymyalgia Rheumatica at a glance

  • Rheumatoid Arthritis: Chronic symmetric inflammatory polyarthritis with autoantibodies and erosive joint damage.
  • Polymyalgia Rheumatica: Inflammatory syndrome of shoulder and hip girdle stiffness in adults over 50; dramatic response to low-dose steroids.

Try two board-style questions on Rheumatoid Arthritis vs Polymyalgia Rheumatica

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Question 1MusculoskeletalMedium
A 55-year-old female with longstanding rheumatoid arthritis on methotrexate 20 mg weekly and etanercept for 4 years has persistent synovitis in 4 joints (Disease Activity Score 28 (DAS28) 4.2). She is adherent to therapy. Which of the following is the most appropriate next step in management?
  • ADiscontinue methotrexate
  • BSwitch etanercept to abatacept
  • CAdd infliximab to etanercept
  • DIncrease methotrexate to 25 mg weekly
Reveal answer & full explanation
Correct answer: B — Switch etanercept to abatacept
  • ADiscontinue methotrexate
  • BSwitch etanercept to abatacept✓
  • CAdd infliximab to etanercept
  • DIncrease methotrexate to 25 mg weekly

Why Switch etanercept to abatacept is correct

  • Inadequate response to an anti-tumor necrosis factor (TNF) agent after an adequate trial of 3–6 months calls for switching to a biologic with a different mechanism of action.
  • Abatacept provides T-cell co-stimulation blockade, a distinct mechanism from TNF inhibition.
  • Other non-TNF options include rituximab (anti-CD20, preferred in seropositive rheumatoid arthritis (RA)), interleukin-6 (IL-6) inhibitors (tocilizumab, sarilumab), and Janus kinase (JAK) inhibitors (tofacitinib, upadacitinib, baricitinib).
  • Before starting JAK inhibitors: screen for tuberculosis (TB) and hepatitis B virus (HBV); avoid in high cardiovascular (CV) risk per the ORAL Surveillance trial.

Why the others are wrong

  • Add infliximab to etanercept — Two biologics are never combined because infection risk rises without added benefit; after TNF-inhibitor failure, switching to a different mechanism is generally preferred over cycling to another TNF inhibitor.
  • Discontinue methotrexate — Methotrexate is an anchor DMARD in RA and should generally be continued; removing it would likely worsen disease control.
  • Increase methotrexate to 25 mg weekly — The patient has already had an inadequate response on combination therapy; escalating methotrexate dose alone is insufficient when biologic failure has occurred.
Question 2MusculoskeletalEasy
A 72-year-old woman presents with 6 weeks of bilateral aching and stiffness in her shoulders, neck, and hips, worst in the morning and lasting more than an hour. She has difficulty getting out of bed and lifting her arms to comb her hair. She reports fatigue and a 6 lb weight loss but no muscle weakness on formal testing. ESR is 92 mm/hr and CRP is markedly elevated. Creatine kinase is normal. Which is the most likely diagnosis?
  • APolymyalgia rheumatica
  • BRheumatoid arthritis
  • CInflammatory polymyositis
  • DFibromyalgia syndrome
Reveal answer & full explanation
Correct answer: A — Polymyalgia rheumatica
  • APolymyalgia rheumatica✓
  • BRheumatoid arthritis
  • CInflammatory polymyositis
  • DFibromyalgia syndrome

Why Polymyalgia rheumatica is correct

  • Polymyalgia rheumatica (PMR) classically affects adults over age 50 and presents with bilateral shoulder and pelvic girdle aching and stiffness, prolonged morning stiffness (lasting more than an hour), constitutional symptoms, and markedly elevated ESR and CRP.
  • Formal muscle testing shows no true weakness in PMR — pain limits effort — and creatine kinase (CK) is normal, distinguishing PMR from polymyositis.
  • PMR responds dramatically to low-dose prednisone (15–20 mg/day), and the rapid response is itself supportive of the diagnosis.

Why the others are wrong

  • Inflammatory polymyositis — produces true proximal muscle weakness on formal testing and an elevated creatine kinase; both are absent here.
  • Fibromyalgia syndrome — has normal inflammatory markers and widespread tender points without elevated ESR or CRP.
  • Rheumatoid arthritis — typically involves small joints (metacarpophalangeal (MCP), proximal interphalangeal (PIP), wrist) symmetrically with synovitis, rather than the bilateral shoulder and pelvic girdle pattern seen here.
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Side-by-side comparison

FeatureRheumatoid ArthritisPolymyalgia Rheumatica
At a glanceChronic symmetric inflammatory polyarthritis with autoantibodies and erosive joint damage.Inflammatory syndrome of shoulder and hip girdle stiffness in adults over 50; dramatic response to low-dose steroids.
Classic presentationSymmetric MCP/PIP/wrist swelling with positive MCP/MTP squeeze test, plus rheumatoid nodules in seropositive disease.; Insidious symmetric polyarthritis of small joints (MCP, PIP, wrists, MTPs); Morning stiffness lasting >1 hour, improving with activity; Fatigue, low-grade fever, weight loss; Hand weakness and difficulty with grip;…Subacute onset of bilateral shoulder and hip girdle aching and stiffness; Morning stiffness >45 minutes (often hours); Difficulty rising from a chair or lifting arms above the head; Constitutional symptoms in 30-50%: fatigue, low-grade fever, anorexia, weight loss; No true muscle weakness once pain is controlled; Restricted active…
Workup / key labs2010 ACR/EULAR classification: score ≥6 of 10 across (a) joint involvement, (b) serology (RF/anti-CCP), (c) acute-phase reactants, and (d) symptom duration ≥6 weeks classifies as RA.; RF and anti-CCP (anti-CCP higher specificity; both predict erosive disease); ESR and CRP (elevated, used to track activity); CBC (normocytic anemia of…2012 EULAR/ACR provisional criteria: age ≥50, bilateral shoulder pain, abnormal CRP or ESR, plus weighted morning stiffness, hip involvement, absence of other joint pain, and absence of RF/anti-CCP.; ESR — characteristically >40 mm/h (often >50-100); CRP elevated and may be more sensitive; CBC — normochromic normocytic anemia,…
ImagingPlain radiographs of hands and feet — periarticular osteopenia, symmetric joint-space narrowing, marginal erosions (MTPs often earliest); Ultrasound or MRI — more sensitive for early synovitis and erosions before plain-film changes; Cervical spine flexion/extension films in established disease to assess atlantoaxial subluxation prior to…Shoulder ultrasound or MRI — subacromial-subdeltoid bursitis, biceps tenosynovitis, glenohumeral synovitis (supportive but not required); Temporal artery ultrasound or biopsy if GCA features develop; PET-CT in atypical cases — can show large-vessel uptake
First-line treatmentEarly DMARD therapy within 3 months of diagnosis — methotrexate is anchor drug; start 10-15 mg PO/SC weekly with folic acid 1 mg daily; Conventional DMARDs — methotrexate, hydroxychloroquine, sulfasalazine, leflunomide (often combined as 'triple therapy'); Bridging low-dose prednisone (≤10 mg/day) until DMARD takes effect; taper as…Prednisone 12.5-25 mg/day — dramatic improvement within 48-72 hours is both therapeutic and diagnostic; Slow taper over 1-2 years guided by symptoms and inflammatory markers (EULAR/ACR 2015: taper to 10 mg/day within 4-8 weeks, then by 1 mg every 4 weeks until discontinuation while remission is maintained); Bone-protective therapy:…

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Full outlines

Rheumatoid Arthritis (RA) Polymyalgia Rheumatica (PMR) All 514 diagnoses

Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.