Polymyalgia Rheumatica (PMR)

🔍 When to Suspect

A patient aged 50 or over presents with an acute onset of bilateral shoulder and/or hip girdle aching and significant morning stiffness lasting more than 45 minutes

From the full topic in The Ocean Library: Polymyalgia Rheumatica (PMR)

🧭 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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