Polymyalgia Rheumatica
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Direct answer
A single morning dose of 12.5–25 mg prednisolone that abolishes bilateral shoulder and pelvic girdle pain within 48–72 hours is both the treatment and the strongest diagnostic support for polymyalgia rheumatica. The syndrome affects patients over 50, produces morning stiffness longer than 45 minutes, raises ESR and CRP, and overlaps closely with giant cell arteritis, which develops in roughly a sixth of patients. For NEET-PG Medicine, the response to steroid is itself a criterion worth quoting.
What you must remember
- Age over 50 years with bilateral shoulder and upper-arm pain, plus hip girdle aching, is the core presentation.
- Morning stiffness exceeds 45 minutes; stiffness after inactivity (the "gelling" phenomenon) is characteristic.
- ESR is typically above 40 mm/h and CRP elevated, but normal inflammatory markers do not fully exclude PMR.
- RF and anti-CCP are absent; their presence points to late-onset rheumatoid arthritis instead.
- 2012 EULAR/ACR scoring includes age over 50, morning stiffness, hip pain or restricted range, absence of peripheral joint pain, and absent RF/ACPA; the ultrasound option adds subacromial–subdeltoid bursitis with biceps tenosynovitis.
- Prednisolone 12.5–25 mg daily, tapered over one to two years, is standard; lack of response within a week demands diagnostic review.
- Around 16–21% of PMR patients develop giant cell arteritis — new headache, jaw claudication or visual symptoms require immediate 40–60 mg prednisolone.
- Red flags mimicking PMR: true proximal weakness (polymyositis — check CK), fever or weight loss, night pain, and age under 50.
A typical exam case walked through
A 68-year-old woman reports three months of difficulty getting out of bed and lifting her arms to comb her hair, worst in the morning, easing by afternoon. There is no joint swelling; shoulder and hip movements are limited by pain rather than weakness; grip strength at the bedside is preserved once pain is bypassed. ESR is 82 mm/h, CRP 46 mg/L, RF negative.
Step one: confirm the girdle pattern and stiffness duration — over 45 minutes of morning stiffness at this age with inflammatory markers is PMR until excluded. Step two: exclude the mimics with a short checklist — normal CK against polymyositis, no distal polyarthritis against late-onset RA, normal thyroid function against a myopathy, no proximal pain referred from cervical or lumbar spine disease. Step three: screen hard for giant cell arteritis — ask specifically about temporal headache, scalp tenderness, jaw claudication and any transient blurring or diplopia, because a missed GCA costs sight. Step four: start prednisolone 15 mg each morning and review at one week; a near-complete response confirms the diagnosis clinically, while partial or absent response sends you back to the differential.
Step five: taper by around 1 mg every four weeks after the first month, watching for relapse (raised ESR with recurring stiffness), and cover bone health from day one — calcium, vitamin D and fracture-risk assessment, since virtually every patient will accumulate well over three months of steroid. If relapses repeatedly push the dose up, methotrexate is a sparing adjunct, and IL-6 pathway blockade is reserved for selected patients per current guidance.
Where students slip
The classic error is calling pain "weakness". Ask the patient to hold the arms abducted against your push once analgesia has taken effect: PMR patients are strong, polymyositis patients are genuinely weak with a raised CK. The second trap is steroid myopathy — a patient on 10 mg for months who develops new proximal weakness with a normal CK is worsening from the drug, not the disease, so the right move is to taper, not escalate. Third, examiners present an "PMR non-responder" with fever and weight loss to see whether you consider malignancy, infection such as endocarditis, or inflammatory myopathy before simply raising the dose. Finally, always state the GCA screening step explicitly — forgetting it is the single most penalised omission in viva.
Frequently asked questions
What is the starting steroid dose in polymyalgia rheumatica?
Prednisolone 12.5–25 mg once daily in the morning; a dramatic response within 48–72 hours supports the diagnosis, and tapering proceeds over one to two years.
How does PMR differ from polymyositis?
PMR causes pain-limited function with normal creatine kinase and no true weakness, whereas polymyositis produces genuine proximal muscle weakness with raised CK and myopathic changes on electromyography and biopsy.
Which complication must be screened at every PMR visit?
Giant cell arteritis — ask about new headache, jaw claudication, scalp tenderness and visual symptoms, and start 40–60 mg prednisolone immediately if suspected.
Which investigation is expected in the 2012 EULAR/ACR criteria?
Ultrasound showing subacromial–subdeltoid bursitis, with or without biceps tenosynovitis and trochanteric bursitis, forms the imaging arm of the classification criteria.
Why must every PMR patient receive bone protection?
Because treatment nearly always exceeds three months of glucocorticoid, fracture risk rises early — calcium, vitamin D and fracture-risk assessment with bisphosphonate therapy for moderate-to-high risk are standard care.