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Polymyalgia Rheumatica (PMR)

NICE CKS Polymyalgia rheumatica. Feb 2024.

Background Information

Suspect PMR in >50 y/o with at least 2 weeks of core symptoms:
  • Bilateral shoulder and/or pelvic pain that worsens with movement and affects sleep
    • Usually unilateral initially but quickly becomes bilateral
    • Shoulder pain may radiate to the elbows and is the presenting feature (70-95%)
 
  • Stiffness lasting >45 min after waking or resting
    • May cause difficulty in turning over in bed / rising from bed or chair / raising arms above shoulder height

Additional features:
  • Systemic features - fever, fatigue, anorexia, weight loss, depression
  • Peripheral MSK signs
    • Carpal tunnel syndrome
    • Asymmetric peripheral arthritis
    • Oedema of the hands, wrists, feet, ankles
  • Bilateral upper arm tenderness

 

Muscle strength is not usually impaired in PMR but muscle pain makes testign difficult.

In exams, presence of muscle weakness points away from PMR and any denial of muscle weakness in the stem should prompt one to consider PMR.

Guidelines

There are no clear diagnostic criteria for PMR, NICE CKS states that diagnosis is made by:
  • Core clinical features, and
  • Excluding PMR mimics, and
  • +ve response to steroids

1st line test: ESR and/or CRP
  • Raised inflammatory markers supports PMR
  • But not necessary for diagnosis, if clinical features are typical and inflammatory markers are normal, the diagnosis can still be made
 

The following must be excluded:
  • Giant cell arteritis - as immediate high-dose steroids is necessary
  • Active infection / cancer
  • Other PMR mimics
    • Arthritis
    • Thyroid disease
    • Statin-induced myalgia
    • Myositis

To exclude PMR mimics, preform the following tests before starting steroids:
  • FBC, U&E, LFT
  • Calcium, ALP
  • Protein electrophoresis
  • TSH
  • Creatine kinase
  • Rheumatoid factor
  • Urinalysis

1st line: trial of oral prednisolone 15mg daily
  • Assess clinical resposne after 1 week
  • Check ESR and/or CRP after 3-4 weeks to assess response
  • Arrange routine reviews 1 week after any changes to steroid dose and at least 3 monthyl in the first year following diagnosis

Only start tapering steroid dose slowly once symptoms are fully controlled.

 

Unlike in giant cell arteritis, where high-dose steroids needs to be started urgently, it is not as urgent in PMR.

However, since giant cell arteritis is associated with PMR, one must exclude it at diagnosis and at follow ups to ensure prompt treatment.

References

Author: Adams Lau
Reviewer:
Last edited: 23/07/25