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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Question 1MusculoskeletalMedium
A 70-year-old female has a 6-week history of bilateral proximal upper extremity pain and stiffness, especially in the morning, with difficulty raising her arms. ESR is 88 mm/hr and CRP is 42 mg/L. She has no headache or jaw claudication. Which of the following is the most likely diagnosis?
APolymyalgia rheumatica
BRheumatoid arthritis
CMultiple myeloma
DInflammatory myopathy
Reveal answer & full explanation
Correct answer: A — Polymyalgia rheumatica
APolymyalgia rheumatica✓
BRheumatoid arthritis
CMultiple myeloma
DInflammatory myopathy
Why Polymyalgia rheumatica is correct
Bilateral proximal shoulder and hip girdle pain and stiffness in patients over 50 with markedly elevated ESR/CRP fits polymyalgia rheumatica (PMR) precisely
No muscle weakness distinguishes PMR from inflammatory myopathy; creatine kinase (CK) is normal in PMR
Treatment: prednisone 15–20 mg/day — dramatic response within 24–72 hours is both therapeutic and diagnostic
Taper very slowly (10% per month) over 1–2 years
Why the others are wrong
B) Rheumatoid arthritis — affects distal small joints (MCPs, PIPs, wrists) symmetrically; morning stiffness is present but not the dominant proximal girdle pattern seen here
C) Multiple myeloma — also raises ESR markedly in older adults, but causes constant focal bone pain with anemia, hypercalcemia, and renal insufficiency rather than symmetric girdle stiffness that is worst on waking and eases with movement
D) Inflammatory myopathy — causes true muscle weakness with elevated CK; CK is normal in PMR
Additional high-yield points
Screen for giant cell arteritis (GCA) (temporal arteritis), which occurs in 15–20% of PMR patients
Absence of headache or jaw claudication in this case argues against GCA
Tocilizumab: approved for GCA and increasingly used for refractory PMR
Question 2MusculoskeletalMedium
A 65-year-old woman presents with bilateral shoulder and hip girdle pain and stiffness worse in the morning for 6 weeks. She also reports a 10 lb weight loss and fatigue. ESR is 88 mm/hr and CRP is elevated. No muscle weakness on exam. Which is the most likely diagnosis?
APolymyalgia rheumatica
BGiant cell arteritis
CMultiple myeloma
DElderly-onset rheumatoid arthritis
Reveal answer & full explanation
Correct answer: A — Polymyalgia rheumatica
APolymyalgia rheumatica✓
BGiant cell arteritis
CMultiple myeloma
DElderly-onset rheumatoid arthritis
Why Polymyalgia rheumatica is correct
Polymyalgia rheumatica (PMR) presents in patients over 50 with bilateral shoulder and hip girdle stiffness, elevated ESR/CRP, and constitutional symptoms.
Absence of muscle weakness distinguishes PMR from polymyositis.
Treatment: prednisone 15–20 mg/day with dramatic response within 24–72 hours (this rapid response is diagnostic).
Why the others are wrong
B) Giant cell arteritis — Giant cell arteritis (GCA) can coexist with PMR; headache, jaw claudication, or visual changes warrant higher-dose steroids to prevent blindness. This patient lacks those features.
C) Multiple myeloma — Myeloma is a classic mimic of a very high ESR with weight loss, but it causes focal bone pain from lytic lesions together with anemia, hypercalcemia, or renal insufficiency rather than symmetric girdle stiffness that is worst in the morning.
D) Elderly-onset rheumatoid arthritis — Elderly-onset RA can open with a polymyalgic picture, but it declares itself with persistent peripheral synovitis of the wrists and metacarpophalangeal joints and responds only partially to low-dose prednisone.
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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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