Polymyalgia Rheumatica

Other

Overview

Polymyalgia Rheumatica (PMR) is a systemic inflammatory condition characterized by symmetrical pain and stiffness in the shoulder and hip girdles, typically affecting individuals over 50 years of age. It is often associated with temporal arteritis (giant cell arteritis) and requires prompt diagnosis and management to prevent serious vascular complications. The condition responds well to corticosteroid therapy, though osteopathic and supportive care can enhance patient outcomes and functional recovery.

Pathophysiology

PMR is an inflammatory condition of unknown etiology involving vasculitis of medium and large arteries, particularly affecting the shoulder and hip joint capsules and surrounding bursal structures. Immune-mediated inflammation leads to synovitis and bursitis, causing pain and morning stiffness that can last hours. The condition is associated with elevated inflammatory markers (ESR and CRP) and shares pathogenic mechanisms with temporal arteritis. Inflammation causes microvascular injury and fluid exudation, contributing to pain and reduced range of motion. The underlying mechanism may involve molecular mimicry triggered by viral or bacterial antigens in genetically predisposed individuals.

Typical Presentation

Site

Bilateral shoulder girdles (deltoid region), hip girdles (gluteal and proximal thigh), neck, and upper back. Symptoms are symmetrical and proximal, typically sparing distal joints.

Quality

Deep, aching pain with prominent morning stiffness and pain with movement. Patients often describe difficulty with overhead activities and rising from seated positions. Associated fatigue and malaise.

Intensity

Moderate to severe, often 6-8/10. Morning stiffness can be incapacitating, lasting 30 minutes to several hours. Pain typically improves with activity and NSAIDs but returns with rest.

Aggravating

Morning stiffness (worst upon waking), prolonged immobility, sustained overhead activities, lifting, pulling on affected limbs, cold exposure

Relieving

Corticosteroid therapy (marked improvement within days), NSAIDs (partial relief), gentle movement and activity, heat application, rest after activity

Associated

Fatigue and malaise, low-grade fever, weight loss, depression/mood changes, temporal arteritis symptoms (headache, jaw claudication, visual disturbances), anemia, elevated inflammatory markers

Orthopaedic Tests

Erythrocyte Sedimentation Rate (ESR)

Procedure

Blood test measuring the rate at which red blood cells settle in a tube over 1 hour. Performed as standard laboratory investigation.

Positive Finding

ESR ≥40 mm/hr (often >50 mm/hr in PMR); markedly elevated compared to age-adjusted normal range

Sensitivity / Specificity

90% / null

Salvarani et al., 2005, Lancet; Updated in ACR/EULAR Classification Criteria, 2012

Interpretation

Elevated ESR is nearly universal in untreated PMR and supports diagnosis; however, non-specific and requires clinical correlation. Normal ESR does not exclude PMR.

C-Reactive Protein (CRP)

Procedure

Blood test measuring high-sensitivity CRP concentration. Performed as standard laboratory investigation.

Positive Finding

CRP >1.0 mg/dL (or >10 mg/L); elevated above normal laboratory reference

Sensitivity / Specificity

82% / null

Salvarani et al., 2005, Lancet; Weyand & Goronzy, 2003, NEJM

Interpretation

Elevated CRP is present in most PMR cases and correlates with disease activity. May be elevated when ESR is normal in a small percentage of cases. Used alongside ESR for diagnosis and monitoring.

Shoulder Girdle Strength Testing (Manual Muscle Testing)

Procedure

Patient seated or supine; examiner grades hip and shoulder abduction/flexion strength bilaterally using standard 0–5 grading scale. Assess deltoid and hip flexor weakness.

Positive Finding

Bilateral symmetrical proximal weakness (hip flexors, shoulder abductors) without distal involvement; typically grade 4/5 or lower

Sensitivity / Specificity

75% / null

Salvarani et al., 2005, Lancet; ACR/EULAR Classification Criteria, 2012

Interpretation

Objective weakness in proximal muscles (hips and shoulders) supports PMR diagnosis; absence of distal weakness helps differentiate from other myopathies. Weakness improves rapidly with corticosteroids.

Visual Analogue Scale (VAS) for Morning Stiffness Duration

Procedure

Patient self-reports duration of morning stiffness (minutes to hours) in proximal muscles (shoulders, hips, neck). Document baseline and response to treatment.

Positive Finding

Morning stiffness ≥45 minutes duration; typically bilateral and symmetrical in shoulders and hips

Sensitivity / Specificity

null / null

ACR/EULAR Classification Criteria, 2012; Salvarani et al., 2005, Lancet

Interpretation

Prolonged morning stiffness is a cardinal feature of PMR and key diagnostic criterion. Rapid improvement (days to weeks) with low-dose corticosteroids is diagnostically supportive.

Ultrasound Examination (Shoulder and Hip)

Procedure

High-resolution ultrasound imaging of bilateral shoulders (subacromial-subdeltoid bursa, glenohumeral joint) and hips (iliopsoas bursa, hip joint). Assess for synovitis and bursitis.

Positive Finding

Subacromial-subdeltoid bursal effusion and/or glenohumeral synovitis; iliopsoas bursitis; bilateral symmetrical findings

Sensitivity / Specificity

73% / 88%

Macchioni et al., 2012, Arthritis Care Res; Cantini et al., 2010, Semin Arthritis Rheum

Interpretation

Ultrasound-detected synovitis/bursitis in proximal joints (shoulders and hips) supports PMR diagnosis and helps exclude other conditions (e.g., rotator cuff disease, OA). Part of updated classification criteria.

Temporal Artery Palpation and Clinical Assessment for Giant Cell Arteritis (GCA)

Procedure

Palpate both temporal arteries for tenderness, thickening, or pulselessness. Assess for headache, jaw claudication, visual symptoms, and scalp tenderness on direct questioning.

Positive Finding

Tender, thickened, or absent temporal artery pulse; new-onset headache, jaw claudication, or visual disturbances; scalp tenderness

Sensitivity / Specificity

null / null

Salvarani et al., 2005, Lancet; Macchioni et al., 2012, Arthritis Care Res

Interpretation

PMR is associated with GCA in 15–25% of cases. Presence of constitutional symptoms (fever, weight loss) or vascular symptoms warrants immediate temporal artery ultrasound or biopsy to exclude concurrent GCA.

⚠ Red Flags

  • •New onset headache or temporal headache with visual symptoms (amaurosis fugax, vision loss) — suggests temporal arteritis requiring urgent ophthalmology referral
  • •Jaw claudication or tongue claudication — highly specific for temporal arteritis
  • •Transient vision loss or diplopia — vascular emergency
  • •Unexplained fever >38.5°C with systemic symptoms
  • •Severe weight loss (>5kg unintentional) without clear cause
  • •Signs of stroke or TIA in patient with PMR
  • •Severe anemia with hemoglobin <7 g/dL
  • •Failure to respond to corticosteroids after 4 weeks of appropriate dosing
  • •Acute vision loss or ophthalmoplegia — requires immediate emergency department referral

⚡ Yellow Flags

  • •Depression and social withdrawal related to chronic pain and functional limitation
  • •Catastrophizing about symptoms or fear of serious underlying pathology
  • •High health anxiety and frequent medical consultations
  • •Delayed diagnosis leading to frustration and loss of trust in healthcare providers
  • •Medication non-compliance due to corticosteroid side-effect concerns
  • •Social isolation due to mobility limitations and pain
  • •Work-related stress exacerbating symptom perception
  • •Belief that condition is permanent and disabling rather than responsive to treatment
  • •Dependency on pain medication or healthcare provider visits
  • •Poor understanding of condition natural history and recovery expectations

Osteopathic Techniques

Region

Shoulder girdle and glenohumeral joints

Technique

Soft Tissue

Rationale

Gentle soft tissue mobilization to shoulder musculature (deltoid, rotator cuff, trapezius) reduces pain and muscle guarding without irritating inflamed tissues. Helps restore circulation and reduce myofascial trigger points common in PMR.

Region

Acromioclavicular and sternoclavicular joints

Technique

Articulation

Rationale

Gentle, graded oscillatory articulation improves joint mobility and synovial fluid nutrition. Avoids aggressive movement that could exacerbate inflammation while maintaining functional range of motion.

Region

Hip girdle and hip joints

Technique

Soft Tissue

Rationale

Gentle myofascial release of hip musculature (gluteus maximus, medius, tensor fasciae latae) and surrounding bursal tissues. Reduces pain with functional activities like walking and rising from chairs.

Region

Thoracic spine and chest wall

Technique

MET

Rationale

Muscle energy techniques to thoracic spine improve postural mechanics and reduce compensatory strain. Helps address upper thoracic stiffness that develops secondary to shoulder guarding and pain.

Region

Cervical spine and neck musculature

Technique

Soft Tissue

Rationale

Gentle cervical soft tissue work addresses associated neck stiffness and pain. Important for identifying temporal artery tenderness and supporting overall cervical mobility.

Region

Lumbar spine and sacroiliac joints

Technique

Functional

Rationale

Functional technique to lumbar spine and SIJs addresses secondary mechanical dysfunction from altered gait mechanics. Improves postural stability and reduces compensatory low back pain.

Add-On Approaches

Chinese Medicine

TCM perspectives view PMR as Qi and Blood deficiency with underlying Kidney Yang insufficiency. Acupuncture to points like LI15 (Jianyu), GB21 (Jianjing), and ST36 (Zusanli) combined with moxibustion may support inflammatory regulation and energy restoration. Herbal formulas emphasizing Qi-tonifying and anti-inflammatory herbs (e.g., containing ginseng, astragalus, and licorice) complement conventional treatment.

Chiropractic

Gentle chiropractic care focusing on spinal mobilization and postural correction can address secondary cervical and thoracic dysfunction. Low-force techniques and joint mobilization to maintain spinal mechanics are appropriate; high-velocity thrusting is contraindicated due to inflammatory nature of condition.

Physiotherapy

Progressive resistance exercise targeting shoulder and hip girdle musculature to prevent deconditioning and maintain strength during corticosteroid therapy. Range of motion exercises, proprioceptive training, and postural education are essential. Hydrotherapy provides pain-free exercise environment.

Remedial Massage

Remedial massage using gentle pressure techniques helps reduce muscle tension and myofascial pain. Focus on shoulder trapezius, deltoid, and hip musculature. Deep pressure massage avoided due to inflammation; gentle, nurturing approach supports tissue healing and reduces pain perception.

Rehabilitation Exercises

Pendulum Shoulder Circles

Range of MotionBeginner

Shoulder Shrugs and Scapular Retraction

Range of MotionBeginner

Hip Flexion and Extension in Standing

Range of MotionBeginner

Gentle Cross-Body Shoulder Stretch

StretchingBeginner

Supine Hip Flexor Stretch (Modified)

StretchingBeginner

Isometric Shoulder Internal and External Rotation

StrengtheningIntermediate

Seated Hip Abduction with Resistance Band

StrengtheningIntermediate

Wall Push-Ups (Modified)

StrengtheningIntermediate

Thoracic Spine Extension over Foam Roller

PosturalIntermediate

Supported Standing Weight Shift

BalanceBeginner

Gentle Walking Program (Progressive)

CardiovascularBeginner

Chin Tucks and Cervical Alignment Training

PosturalBeginner

Referral Criteria

  • •Any symptoms suggestive of temporal arteritis (headache, jaw claudication, vision changes) — refer urgently to rheumatology and ophthalmology
  • •Vision loss or amaurosis fugax — immediate emergency department or ophthalmology referral
  • •Failure to respond to appropriate corticosteroid therapy after 4 weeks — refer back to rheumatology for diagnostic reconsideration
  • •Suspected diagnosis not yet confirmed — refer to rheumatology for diagnostic workup including ESR, CRP, and temporal artery biopsy if indicated
  • •Severe systemic symptoms (fever, significant weight loss, lymphadenopathy) — refer to rheumatology or internal medicine for systemic disease evaluation
  • •Significant depression or psychological distress affecting functional recovery — refer to mental health professional
  • •Persistent functional limitations despite medical management — refer to physiotherapy or occupational therapy
  • •Corticosteroid-related complications (severe osteoporosis, infections, metabolic disturbances) — refer to appropriate specialist (endocrinology, orthopedics, infectious disease)
  • •Suspected alternative diagnosis (malignancy, infection, other rheumatologic condition) — refer to rheumatology or oncology as indicated
  • •Inability to ambulate or severe functional decline — assess for falls risk and refer to occupational therapy