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 aetiology affecting the bursae and synovium around the shoulders and hips; large-vessel vasculitis is the feature of the related giant cell arteritis, which can coexist. 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

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

No accuracy study

Erythrocyte Sedimentation Rate (ESR)

Procedure

Blood test ordered by a doctor.

Positive Finding

Raised ESR.

Interpretation

Usually raised in PMR, but a normal result does not exclude it, and it is raised in many other conditions including infection and cancer. New headache, scalp tenderness, jaw pain when chewing, or any visual disturbance in someone over 50 suggests giant cell arteritis: same-day emergency assessment, because it can cause permanent loss of vision.

Sources

No accuracy study

C-Reactive Protein (CRP)

Procedure

Blood test ordered by a doctor.

Positive Finding

Raised CRP.

Interpretation

Usually raised in PMR and used with ESR to diagnose and monitor it; not specific to PMR.

Sources

No accuracy study

Shoulder and Hip Girdle Movement and Strength Check

Procedure

Ask the patient to lift both arms above the head and to rise from a chair without using their hands. Then test shoulder and hip strength gently against resistance, as pain allows.

Positive Finding

Painful, stiff, limited active movement of both shoulders (often hips too), with strength preserved when pain allows.

Interpretation

PMR causes pain and stiffness of the shoulders and hips, typically in people over 50, with long morning stiffness. True weakness is not a feature: it suggests a muscle disease such as myositis and needs medical review. Suspected PMR needs GP referral for blood tests; symptoms usually improve dramatically with steroids. New headache, scalp tenderness, jaw pain when chewing, or any visual disturbance in someone over 50 suggests giant cell arteritis: same-day emergency assessment, because it can cause permanent loss of vision. PMR causes pain and stiffness, not true weakness, so a strength test does not diagnose it; the figure previously stored could not be matched to a study. The 2012 EULAR/ACR criteria (Dasgupta et al.: 125 people with PMR and 169 with conditions that mimic it) score morning stiffness over 45 minutes, hip pain or reduced hip movement, negative RF/anti-CCP and no other joint pain, in people aged 50 or over with new pain in both shoulders and raised CRP or ESR. A score of 4 or more gave 68% / 78% overall (the 78% rose to 88% against shoulder conditions and fell to 65% against rheumatoid arthritis). The authors state the criteria are for classification, not diagnosis.

Sources

No accuracy study

Morning Stiffness Duration (History)

Procedure

Ask how long the stiffness in the shoulders and hips lasts after getting up in the morning, and whether it eases with movement.

Positive Finding

Morning stiffness lasting more than 45 minutes.

Interpretation

Long morning stiffness is one of the scored items in the 2012 EULAR/ACR criteria for PMR and points towards an inflammatory cause rather than a mechanical one.

Sources

No accuracy study

Ultrasound Examination (Shoulder and Hip)

Procedure

Ultrasound of both shoulders and hips by a sonographer or rheumatologist.

Positive Finding

Subdeltoid bursitis, biceps tenosynovitis or shoulder joint effusion, often on both sides; hip effusion or trochanteric bursitis.

Interpretation

Supports PMR and is included in the 2012 criteria. These findings also occur in other shoulder and hip conditions, so they must be read with the clinical picture.

Sources

No accuracy study

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

Procedure

Ask about new headache, scalp tenderness, jaw pain when chewing, and visual symptoms. Gently palpate both temporal arteries in front of the ears.

Positive Finding

Tender, thickened or nodular temporal artery with a weak or absent pulse, or any of the symptoms above.

Interpretation

Giant cell arteritis occurs in a minority of people with PMR. A normal artery does not exclude it. New headache, scalp tenderness, jaw pain when chewing, or any visual disturbance in someone over 50 suggests giant cell arteritis: same-day emergency assessment, because it can cause permanent loss of vision.

Sources

⚠ 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

Refer first

Polymyalgia rheumatica is treated with oral glucocorticoids, tapered over at least 12 months, sometimes with methotrexate. Check every visit for signs of giant cell arteritis (new headache, vision or jaw symptoms, a tender temporal artery) and refer if present. Physical therapy can help later deconditioning but has no role in initial management.

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