Polymyalgia Rheumatica

Definition

Inflammatory disorder of people aged 50 or over, causing bilateral shoulder and hip girdle pain and stiffness with raised inflammatory markers.

Pathology

  • Subdeltoid and trochanteric bursitis with tenosynovitis produce the symptoms
  • Giant cell arteritis coexists in about 15 to 20%

Epidemiology

  • Rare before 50, peaking in the eighth decade
  • Women affected more often
  • Highest incidence in people of Northern European descent

Classification

  • EULAR and ACR 2012 entry criteria are age 50 or over, bilateral shoulder aching and raised CRP or ESR
  • Morning stiffness over 45 minutes scores 2
  • Negative rheumatoid factor and ACPA scores 2
  • Hip pain or limited hip motion scores 1
  • No other joint pain scores 1
  • 4 or more points classifies PMR, or 5 or more with ultrasound

Clinical Features

  • Bilateral shoulder pain and stiffness, often of sudden onset
  • Difficulty dressing and rising from a chair
  • Fatigue, weight loss and low grade fever
  • Strength preserved, though pain limits testing
  • Headache, jaw claudication or visual change suggests giant cell arteritis

Investigations

  • ESR and CRP raised in most
  • Normal creatine kinase
  • Rheumatoid factor and ACPA negative
  • Ultrasound shows bilateral subdeltoid bursitis in about 69%

Differential Diagnosis

Management

  • Prednisolone. 12.5 to 25 mg daily, with a rapid response supporting the diagnosis
  • Glucocorticoid taper. Individualised slow reduction, with relapse common
  • Methotrexate. Steroid sparing for relapse risk or steroid toxicity
  • Bone protection. Calcium, vitamin D and bisphosphonate during prolonged glucocorticoid use
  • High dose prednisolone. 40 to 60 mg daily for suspected giant cell arteritis

References

  1. Dasgupta B, Cimmino MA, Maradit-Kremers H, Schmidt WA, Schirmer M, Salvarani C, Bachta A, Dejaco C, Duftner C, Jensen HS, Duhaut P, Poór G, Kaposi NP, Mandl P, Balint PV, Schmidt Z, Iagnocco A, Nannini C, Cantini F, Macchioni P, Pipitone N, Amo MD, Espígol-Frigolé G, Cid MC, Martínez-Taboada VM, Nordborg E, Direskeneli H, Aydin SZ, Ahmed K, Hazleman B, Silverman B, Pease C, Wakefield RJ, Luqmani R, Abril A, Michet CJ, Marcus R, Gonter NJ, Maz M, Carter RE, Crowson CS, Matteson EL. 2012 provisional classification criteria for polymyalgia rheumatica. A European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis. 2012, 71(4), 484-92. PubMed
  2. Buttgereit F, Dejaco C, Matteson EL, Dasgupta B. Polymyalgia rheumatica and giant cell arteritis. A systematic review. JAMA. 2016, 315(22), 2442-58. PubMed

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 19 October 2026.