Polymyalgia rheumatica (PMR)

Polymyalgia rheumatica is an inflammatory condition, which means the immune system becomes overactive and drives inflammation in the tissues around the shoulders, neck and hips, particularly the lining of the joints and the bursae. Why this happens is not fully understood, and in most people no single cause can be identified. It is thought to arise from a combination of an ageing immune system and, in some, a trigger such as an infection.

A few patterns are well recognised:

• It is uncommon under the age of 50 and becomes more frequent with increasing age.
• It affects women somewhat more often than men.
• It is more common in people of Northern European background.

PMR shares mechanisms with giant cell arteritis, and the two conditions sometimes occur together.

PMR has a fairly recognisable pattern. Typical features include:

• Aching and stiffness in the shoulders, neck and hips, often on both sides
• Marked stiffness in the morning that can make getting going difficult
• Difficulty with everyday movements such as dressing, or rising from a chair
• Sometimes tiredness, a general sense of being unwell, or a mildly raised temperature

It is important to be aware that PMR is sometimes associated with another condition affecting the arteries (giant cell arteritis). New headaches, scalp tenderness, jaw pain on chewing or any change in vision should be assessed urgently.

Diagnosis is based on the characteristic symptoms, an examination and blood tests, which usually show signs of inflammation. Because several other conditions can produce similar symptoms, a careful assessment helps confirm that PMR is the right explanation and excludes other causes.

Ultrasound can help by showing inflammation around the shoulders and hips, supporting the diagnosis. Dr Borukhson uses point-of-care ultrasound during the consultation, so this can often be done in the same visit. You can read more on the ultrasound clinic page.

PMR usually responds promptly to steroid (corticosteroid) treatment, most often with prednisolone in tablet form, and many people feel substantially better within days of starting. This rapid response to steroids is a defining feature of the condition. The prednisolone dose is then reduced slowly, often over many months, guided by symptoms and kept under review, as stopping too quickly can allow symptoms to return; steroid treatment should never be stopped suddenly. Because the course is prolonged, bone protection is usually considered as part of the plan, and any new headache, scalp tenderness, jaw pain on chewing or change in vision needs immediate medical attention, as giant cell arteritis can occur with PMR.

For many people, steroids can be reduced and eventually stopped. If the dose proves difficult to lower, if symptoms keep returning as it is reduced, or if the steroids are causing troublesome side effects, a disease-modifying medicine (DMARD) such as methotrexate can be added as a steroid-sparing option, allowing the condition to be controlled on a lower steroid dose. In the smaller number of people whose PMR remains difficult to control, a biologic medicine that blocks the inflammatory signal interleukin-6 may be considered under specialist supervision: sarilumab is licensed in the UK for this situation, while tocilizumab is used off-label, based on its established role in the related condition giant cell arteritis. These treatments need regular monitoring while they are taken.

Because treatment continues for a while and is tailored to the individual, regular specialist review helps find the lowest effective dose and monitor progress. The plan is always discussed with you.

The outlook is generally good: most people improve quickly once treatment starts and many are eventually able to stop it altogether, though the course often runs over a year or two. A few practical measures help things along:

• Keep gently active. Regular, comfortable movement and stretching protect the strength and flexibility that morning stiffness can erode.
• Support your bones and general health while taking steroids, with a balanced diet, adequate calcium and vitamin D, and weight-bearing activity. See our notes on bone protection.
• Take prednisolone consistently and never stop it abruptly, even when you feel well.
• Keep a simple symptom diary, which makes it easier to judge how far the dose can safely come down.

Pacing demanding days, and being patient through the gradual taper, both make a real difference.

Most PMR can be managed through planned reviews, but certain symptoms warrant prompt attention.

Seek same-day or emergency care for any feature suggesting giant cell arteritis: a new or severe headache, tenderness of the scalp, pain in the jaw when chewing, or any disturbance of vision. Sudden loss of vision is an emergency, so go straight to your nearest eye casualty or emergency department.

Arrange an earlier review, rather than waiting, if:

• Your usual stiffness returns or worsens as the steroid dose is reduced.
• You develop a fever, drenching night sweats or unexplained weight loss.
• You notice troublesome side effects from treatment, such as mood changes, marked swelling or signs of raised blood sugar.

If symptoms do not respond to steroids as expected, the diagnosis may need revisiting.

PMR is very treatable, and prompt diagnosis can bring quick relief from what can be quite disabling stiffness. Equally important, assessment allows the associated artery condition (giant cell arteritis) to be considered and acted on quickly if needed. If you have new shoulder and hip stiffness, particularly over the age of 50, a specialist review is worthwhile.

How quickly should I be seen if PMR is suspected?

PMR is not usually an emergency, but the stiffness can be quite disabling and the condition typically improves rapidly once treatment begins, so an early specialist review is worthwhile. Prompt assessment also allows giant cell arteritis, which sometimes accompanies PMR, to be considered from the outset.

What happens at the first appointment?

Dr Borukhson takes a detailed history, examines you and arranges blood tests, which in PMR usually show signs of inflammation. Because she uses point-of-care ultrasound during the consultation, the shoulders and hips can often be scanned at the same visit to look for the changes that support the diagnosis. The findings and the proposed treatment plan are then talked through with you.

How long will I need to take steroids?

Treatment usually brings a marked improvement within days, but the dose then comes down gradually, typically over a period of months, guided by how you are feeling. Coming down too fast can let symptoms return, so the course is never stopped abruptly. Because steroids are taken for some time, protecting your bones is usually considered as part of the overall plan.

What monitoring will I need during treatment?

Regular review while the dose is being reduced helps find the lowest amount of steroid that keeps your symptoms controlled. It is also a chance to check your overall progress and keep the rest of the plan, including bone protection, on track. If stiffness returns between appointments, it is worth getting in touch rather than waiting for the next review.

When should I seek urgent help?

A new headache, tenderness of the scalp, pain in the jaw when chewing or any change in your vision should be assessed urgently, because PMR is sometimes accompanied by giant cell arteritis, a related condition affecting the arteries that can threaten sight. If your vision changes suddenly, go to your nearest emergency department rather than waiting for a routine appointment.