AKT · Musculoskeletal/Vasculitis, PMR & GCA

Polymyalgia rheumatica

Inflammatory condition of proximal girdle pain/stiffness in the over-50s (GCA overlap)

Overview

An inflammatory condition of people over 50 causing bilateral pain and prolonged morning stiffness of the shoulder and pelvic girdles, with raised inflammatory markers and a dramatic response to low-dose steroids. There is NO true muscle weakness (stiffness limits movement). It overlaps with giant cell arteritis, so cranial symptoms must be sought.

Recognise

Bilateral shoulder and/or pelvic girdle pain and stiffness, morning stiffness >45 min, in someone over 50; difficulty rising/dressing
Constitutional symptoms (fatigue, low-grade fever, weight loss); raised ESR/CRP; rapid response to low-dose steroid
Power is preserved (it's stiffness/pain, not weakness); overlap with GCA — ask about headache/jaw claudication/visual symptoms

Red flags

Cranial symptoms (headache, jaw claudication, visual change) → coexisting GCA → high-dose steroids
Poor/incomplete steroid response → reconsider the diagnosis (malignancy, inflammatory arthritis, myositis)

Differentials & how to tell them apart

Polymyositistrue proximal WEAKNESS with markedly raised CK

Rheumatoid arthritis (elderly-onset)synovitis, RF/anti-CCP, erosions

Hypothyroidism / malignancyabnormal TFTs / systemic features; incomplete steroid response

Investigations

Raised ESR/CRP; normal CK (distinguishes from myositis); a marked response to a trial of low-dose prednisolone supports the diagnosis; exclude mimics (TFTs, myeloma screen, RF/anti-CCP if joint-predominant).

Management

Low-dose prednisolone (~15 mg) with a dramatic response, then slow taper

1Diagnose in over-50s with bilateral girdle stiffness, raised ESR/CRP and normal CK; start low-dose prednisolone (~15 mg) — expect a dramatic response within days.Gate: A poor or incomplete steroid response should prompt reconsideration (myositis with high CK, RA, malignancy, hypothyroidism); and always screen for coexisting GCA (headache/jaw claudication/visual symptoms → high-dose steroids).
2Taper steroids slowly over 1–2 years with bone/GI protection; methotrexate as a steroid-sparing agent for relapsing disease.

Low-dose oral prednisolone (~15 mg) with a dramatic response — first-line; a poor response should prompt rethinking the diagnosis

Slow taper over 1–2 years — guided by symptoms and inflammatory markers; relapses common

Bone and GI protection — bisphosphonate/calcium-vitD and PPI with long-term steroids

Methotrexate as a steroid-sparing agent — for relapsing or steroid-dependent disease

Key points

Over-50 + bilateral shoulder/pelvic-girdle stiffness >45 min + raised ESR + NORMAL CK + dramatic response to low-dose prednisolone = PMR. No true weakness (vs myositis). Always ask about GCA symptoms. A poor steroid response means rethink the diagnosis.

Monitor & prognosis

Symptoms and ESR/CRP on tapering, steroid complications, watch for GCA.

Good; most can taper off steroids over 1–2 years, though relapses occur.

Source: BSR PMR; cross-ref GCA