Ep 213 – Polymyalgia rheumatica

In this episode, Dr Roger Henderson explores polymyalgia rheumatica (PMR), a common but often underestimated inflammatory condition affecting older adults. Although many clinicians recognise the classic presentation of shoulder and hip girdle stiffness, PMR is far more than a simple musculoskeletal complaint. Its overlap with giant cell arteritis (GCA), the challenges of long-term steroid management and the importance of recognising red-flag symptoms make it a condition that requires careful clinical judgement. Join us as we walk through the typical patient presentation, discuss the underlying inflammatory mechanisms, review current diagnostic approaches and explore practical management strategies, including relapse prevention and steroid-sparing therapies.

Key take-home points

• PMR should be suspected in older adults with rapid-onset bilateral shoulder and hip stiffness, especially when morning symptoms significantly impair daily function.
• The condition is often described by patients as stiffness rather than isolated pain, and the loss of independence in basic activities is frequently what drives presentation.
• PMR symptoms typically worsen after rest and improve somewhat with movement, creating the classic pattern of prolonged morning stiffness.
• Patients may describe “weakness”, but true muscle strength is generally preserved on examination; the limitation is caused by pain and stiffness rather than muscle disease.
• Systemic symptoms such as fatigue, malaise, weight loss and low-grade fever are common and reflect the inflammatory nature of the condition.
• Marked constitutional symptoms, including persistent high fever or significant weight loss, should prompt evaluation for alternative diagnoses such as malignancy, infection or vasculitis.
• PMR and GCA are closely linked conditions that likely exist on the same inflammatory spectrum.
• Every patient with PMR should be regularly screened for symptoms of GCA, particularly headache, jaw claudication, scalp tenderness and visual disturbance.
• Elevated erythrocyte sedimentation rate and C-reactive protein support the diagnosis, but normal inflammatory markers do not completely exclude PMR when the clinical picture is convincing.
• Ultrasound can be particularly useful in demonstrating bursitis or tenosynovitis around the shoulders and hips, helping support the diagnosis in uncertain cases.
• A dramatic response to low- to moderate-dose corticosteroids within days is highly characteristic of PMR and often reinforces diagnostic confidence.
• The real challenge in PMR management is not starting steroids, but tapering them slowly enough to avoid relapse while minimising long-term toxicity.
• Relapses are common during steroid reduction and do not necessarily indicate treatment failure; they often require a temporary return to the previous effective dose.
• Methotrexate and other steroid-sparing therapies may be useful in patients with recurrent relapses or significant corticosteroid-related adverse effects.
• Although the prognosis is generally excellent, long-term follow-up is essential to monitor for relapse, steroid complications and the potential development of GCA.

Key references

1. Buttgereit F, et al. JAMA. 2016;315(22):2442-2458. doi: 10.1001/jama.2016.5444.
2. Dejaco C, et al. Arthritis Rheumatol. 2015;67(10):2569-2580. doi: 10.1002/art.39333.
3. Toyoda T, et al. Rheumatol Adv Pract. 2024;8(1):rkae002. doi: 10.1093/rap/rkae002.
4. Gonzalez-Gay MA, et al. Expert Opin Pharmacother. 2010;11(7):1077-1087. doi: 10.1517/14656561003724739.