GPAtlas🧭 When to suspect
Polymyalgia rheumatica (PMR) is the commonest inflammatory rheumatic disease of older adults and one of the largest single indications for long-term oral steroids in primary care. Suspect it in a patient aged 50 or over with relatively rapid-onset (typically less than 2 weeks) bilateral aching and stiffness of the shoulder and/or pelvic (hip) girdle, with prominent morning stiffness lasting more than 45 minutes. Systemic features – fatigue, malaise, low-grade fever, weight loss, low mood – are common.
Two clinical skills matter most: confirm the diagnosis against the “core four” (and exclude mimics) before committing to a long steroid course, and screen persistently for giant cell arteritis (GCA), the sight-threatening large-vessel vasculitis that overlaps with PMR. The British Society for Rheumatology (BSR) frames PMR as a working diagnosis confirmed over time. Because viral myalgia can mimic early PMR, confirm symptoms have persisted for at least 2 weeks before labelling.
| Core diagnostic feature | Typical finding |
|---|---|
| Age | 50 or over – PMR is rare below 50, so reconsider the diagnosis in younger patients. |
| Onset & duration | Relatively acute, evolving over < 2 weeks; symptoms present for ≥ 2 weeks before diagnosis. |
| Pain distribution | Bilateral aching/stiffness of the shoulder and/or pelvic girdle, often with the neck. |
| Morning stiffness | > 45 minutes, with “gelling” after periods of inactivity. |
| Inflammatory markers | Raised ESR and/or CRP – but normal or borderline in around 1 in 5. |
| Steroid response | A rapid, marked response to low-dose prednisolone supports the diagnosis. |
Raise suspicion particularly in those of European family origin and consider the overlap with GCA throughout: up to 1 in 5 PMR patients develop GCA, and a substantial minority have subclinical large-vessel involvement.
Source: BSR · EULAR/ACR 2015
|
⚠️ Common pitfall Reaching for steroids before the work-up is complete. In pure PMR (no GCA features) there is no urgency to treat before excluding mimics – premature prednisolone masks alternative diagnoses and confounds the inflammatory markers you will rely on later. Remember too that a response to steroids does not confirm PMR: late-onset rheumatoid arthritis (RA), spondyloarthritis, inflammatory myopathy and occasionally malignancy or infection can all partially respond. |
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