Inflammatory syndrome of shoulder and hip girdle stiffness in adults over 50; dramatic response to low-dose steroids.
Also known as: PMR, polymyalgia
Overview
Inflammatory syndrome of older adults characterized by bilateral aching and morning stiffness of the shoulder and pelvic girdle, markedly elevated inflammatory markers, and rapid response to low-dose corticosteroids. Closely related to giant cell arteritis.
Epidemiology
Almost exclusively in adults over 50; peak incidence 70-80. Female predominance 2-3:1. More common in people of Northern European ancestry. About 15-20% of PMR patients develop GCA, and about 40-50% of GCA patients have PMR features.
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Subclinical large-vessel and bursal inflammation driven by IL-6 and innate immune activation. Subdeltoid bursitis, biceps tenosynovitis, and hip trochanteric bursitis underlie the proximal stiffness rather than primary muscle disease.
Clinical presentation
Symptoms
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
Signs / physical exam
Restricted active shoulder and hip motion limited by pain, not weakness
Statin myopathy — Recent statin use, elevated CK, weakness more than stiffness
Fibromyalgia — Diffuse pain, normal ESR/CRP, age usually <60
Paraneoplastic / lymphoma — Atypical features, poor or delayed steroid response, weight loss; pursue malignancy workup if response inadequate
Osteoarthritis of shoulders/hips — Mechanical pain, normal inflammatory markers, no constitutional symptoms
Diagnostic workup
Diagnostic criteria
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.
Labs
ESR — characteristically >40 mm/h (often >50-100); CRP elevated and may be more sensitive
RF, anti-CCP, ANA — usually negative; help exclude RA and SLE
Comprehensive metabolic panel (baseline before steroids)
Imaging
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
Diagnostic algorithm
Feature
PMR
Giant Cell Arteritis
Age
>50
>50
Key symptoms
Shoulder/hip stiffness, morning stiffness >45 min
New headache, jaw claudication, scalp tenderness, visual loss
ESR/CRP
Markedly elevated
Markedly elevated
Imaging
Bursitis on US/MRI
Temporal artery US (halo) or biopsy
Initial steroid dose
Prednisone 12.5-25 mg/day
Prednisone 40-60 mg/day (or 1 g IV pulse if vision threat)
Overlap
15-20% develop GCA
40-50% have PMR features
PMR vs GCA — overlapping spectrum, very different steroid doses.
Treatment
First-line
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 (typical schedule: reduce by 2.5 mg every 2-4 weeks until 10 mg, then 1 mg every 1-2 months)
Bone-protective therapy: calcium 1000-1200 mg/day, vitamin D 800-2000 IU/day, plus bisphosphonate if at risk (almost all elderly patients on chronic steroids qualify)
PPI for GI protection if NSAIDs or anticoagulants coadministered
Complications
Relapse during taper (very common — usually managed with small dose increases)
Steroid-related: osteoporosis, hyperglycemia/diabetes, hypertension, weight gain, cataracts, infection, adrenal insufficiency
Progression to or unmasking of giant cell arteritis
Misdiagnosis: occult RA, malignancy, or polymyositis
PANCE pearls
A truly dramatic response to 15-20 mg of prednisone within 72 hours is one of the most useful clinical signs in rheumatology.
Always screen for GCA at every PMR visit — sudden vision loss is a preventable catastrophe.
Normal CK separates PMR from inflammatory myopathies.
Failure to taper below 10 mg or atypical features should prompt reconsideration of the diagnosis.
References
EULAR/ACR 2012 — 2012 Provisional Classification Criteria for PMR (Dasgupta et al., Ann Rheum Dis 2012)
EULAR/ACR 2015 — 2015 Recommendations for the Management of PMR (Dejaco et al., Ann Rheum Dis 2015)
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