Polymyalgia Rheumatica: Symptoms, Causes & Treatment

What Is Polymyalgia Rheumatica?

Polymyalgia rheumatica (PMR) is an inflammatory condition that causes muscle pain and stiffness in large muscle groups, particularly around the shoulders, upper arms, hips, and thighs. It almost never occurs before age 50, with peak incidence between 70-80 years, and is 2-3 times more common in women than men.

Polymyalgia rheumatica is derived from Greek and Latin words meaning "pain in many muscles," which accurately describes the condition's hallmark symptom. Despite its name suggesting muscle disease, PMR primarily involves inflammation of the synovial membranes that line joints and tendon sheaths, particularly in the shoulders and hips. This inflammation causes the characteristic pain and stiffness that patients experience.

The exact cause of polymyalgia rheumatica remains unknown, though research suggests it involves an abnormal immune response. Scientists believe that genetic factors play a role, as the condition is more common in people of Northern European ancestry, particularly Scandinavians. Environmental triggers, possibly including certain viral infections, may initiate the inflammatory process in genetically susceptible individuals. However, PMR is not contagious and cannot be transmitted from person to person.

One of the most striking features of PMR is its responsiveness to corticosteroid treatment. Unlike many inflammatory conditions that require weeks or months to respond to therapy, PMR symptoms often improve dramatically within just a few days of starting treatment. This rapid response is so characteristic that it is considered a diagnostic feature - if symptoms do not improve quickly with corticosteroids, doctors may reconsider the diagnosis.

PMR is classified as a self-limiting condition, meaning it eventually resolves on its own. However, this natural healing process typically takes 1.5 to 3 years, and sometimes longer. During this time, treatment is necessary to control symptoms and maintain quality of life. The good news is that most patients can eventually stop treatment completely once the condition has run its course.

Who Gets Polymyalgia Rheumatica?

Polymyalgia rheumatica predominantly affects older adults. It is extremely rare before age 50, and the risk increases with advancing age. The peak incidence occurs between 70 and 80 years of age. The lifetime risk of developing PMR is approximately 2.4% for women and 1.7% for men.

Several factors influence the likelihood of developing PMR:

• Age: The single most important risk factor - PMR almost never occurs in people under 50
• Sex: Women are 2-3 times more likely to develop PMR than men
• Ethnicity: Higher prevalence in Northern European populations, particularly Scandinavians
• Genetics: Certain genetic markers, particularly HLA-DR4, are associated with increased risk
• Geographic location: Higher incidence rates in northern latitudes

PMR and Giant Cell Arteritis

About 15-20% of people with polymyalgia rheumatica also develop giant cell arteritis (GCA), an inflammation of the blood vessels. Conversely, about 50% of people with GCA have PMR symptoms. The relationship between these conditions is not fully understood, but they share similar demographic and genetic risk factors, suggesting a common underlying mechanism.

What Are the Symptoms of Polymyalgia Rheumatica?

The main symptoms of polymyalgia rheumatica are pain and stiffness in the shoulders, upper arms, hips, and thighs. Symptoms typically develop gradually over several weeks, are usually bilateral (affecting both sides), and are characteristically worse in the morning or after periods of inactivity.

Polymyalgia rheumatica symptoms usually develop insidiously over 2-4 weeks, though some patients experience more sudden onset over just a few days. Understanding the characteristic symptom pattern is important for recognizing the condition and distinguishing it from other causes of muscle pain.

Many patients first notice general symptoms before the muscle pain becomes prominent. These prodromal symptoms may include fatigue, general malaise, low-grade fever, and unintentional weight loss. Some patients describe feeling like they have the flu for several weeks before the typical muscle symptoms develop. These systemic symptoms reflect the inflammatory nature of the condition.

The hallmark symptoms of PMR involve pain and stiffness in specific muscle groups. The shoulders and upper arms are almost always affected, while the hips and thighs are involved in about 50-70% of patients. The pain is typically described as aching, and patients often have difficulty pinpointing the exact location - it feels diffuse rather than localized to a specific point.

Morning Stiffness

One of the most distinctive features of PMR is pronounced morning stiffness that typically lasts more than 45 minutes. Patients often describe difficulty getting out of bed in the morning due to stiffness and pain. Simple activities like turning over in bed, getting dressed, or reaching for objects become challenging. This morning stiffness is a key diagnostic criterion and helps distinguish PMR from conditions like osteoarthritis, which typically causes brief morning stiffness.

Bilateral Symptoms

PMR almost always affects both sides of the body symmetrically. If you have pain only on one side, your doctor will likely consider other diagnoses. This bilateral pattern affects:

• Shoulders and upper arms: Difficulty raising arms, pain when reaching overhead, trouble with activities like combing hair or putting on a coat
• Hips and thighs: Difficulty getting up from a chair or climbing stairs, pain when walking
• Neck: Stiffness and discomfort, often noticed when turning the head

What PMR Does Not Cause

Understanding what PMR does not typically cause is equally important for accurate diagnosis:

• Hand or foot symptoms: Pain or swelling in the hands and feet suggests rheumatoid arthritis rather than PMR
• Muscle weakness: While patients may feel weak due to pain, true muscle weakness (inability to perform movements) is not a feature of PMR
• Joint swelling: Visible joint swelling is uncommon; if present, other conditions should be considered
• Skin rashes: PMR does not cause skin manifestations

When Should You See a Doctor for Muscle Pain?

See a doctor if you have muscle pain and stiffness that persists for more than 2 weeks, especially if it affects your shoulders and hips, is worse in the morning, and significantly impacts your daily activities. Seek immediate care if you develop headaches, jaw pain, or vision changes.

Many people experience occasional muscle aches and pains, which are usually temporary and resolve on their own. However, certain patterns of symptoms warrant medical evaluation, as they may indicate polymyalgia rheumatica or other conditions requiring treatment.

You should schedule an appointment with your doctor if you experience:

• Persistent muscle pain and stiffness lasting more than 2 weeks without improvement
• Morning stiffness that lasts more than 45 minutes
• Difficulty performing daily activities due to pain and stiffness
• Pain that is present on both sides of the body (bilateral)
• Unexplained fatigue, fever, or weight loss accompanying muscle symptoms
• Symptoms that are not explained by recent physical activity or injury

Early diagnosis and treatment of PMR can significantly improve quality of life and prevent complications. The dramatic response to corticosteroid treatment means that patients can experience substantial relief within days of starting therapy, making it worthwhile to seek medical attention rather than suffering unnecessarily.

How Is Polymyalgia Rheumatica Diagnosed?

Polymyalgia rheumatica is diagnosed based on characteristic symptoms, elevated inflammatory markers (ESR and/or CRP) in blood tests, and rapid response to corticosteroid treatment. There is no single definitive test - diagnosis relies on the overall clinical picture and ruling out other conditions.

Diagnosing polymyalgia rheumatica can be challenging because there is no specific test that definitively confirms the condition. Instead, doctors use a combination of clinical features, blood tests, and response to treatment to make the diagnosis. The 2012 ACR/EULAR provisional classification criteria provide a framework that helps standardize diagnosis.

The diagnostic process typically begins with a thorough medical history and physical examination. Your doctor will ask detailed questions about your symptoms, including their location, duration, and pattern. The physical examination focuses on assessing range of motion in the shoulders and hips, looking for tenderness, and evaluating for signs of other conditions.

Blood Tests

Blood tests play an important role in supporting the diagnosis of PMR and ruling out other conditions. The most important tests include:

• ESR (Erythrocyte Sedimentation Rate): Usually significantly elevated, often above 40-50 mm/hour. This non-specific marker of inflammation is elevated in about 80% of PMR patients.
• CRP (C-Reactive Protein): Another inflammatory marker that is typically elevated. Some patients have elevated CRP even when ESR is normal.
• Complete Blood Count: May show mild normocytic anemia (anemia of chronic disease) and sometimes elevated platelets
• Liver function tests: Alkaline phosphatase may be mildly elevated
• Rheumatoid factor and anti-CCP antibodies: Usually negative; positive results suggest rheumatoid arthritis instead
• Creatine kinase (CK): Normal in PMR; elevation suggests muscle disease (myositis)

It is important to note that approximately 10-20% of patients with PMR may have normal or only slightly elevated inflammatory markers. In these cases, the clinical presentation and response to treatment become even more important for diagnosis.

Imaging Studies

While not always necessary for diagnosis, imaging studies can be helpful in certain situations:

• Ultrasound: Can show inflammation in the shoulders (subdeltoid bursitis, biceps tenosynovitis) and hips. Increasingly used to support diagnosis.
• MRI: May reveal synovitis and bursitis; useful when diagnosis is uncertain
• PET-CT: Can show increased uptake in affected areas; typically reserved for complex cases

The Response to Treatment as a Diagnostic Tool

One of the most characteristic features of PMR is its dramatic and rapid response to corticosteroid treatment. Most patients experience significant improvement within 24-72 hours of starting therapy, with some reporting feeling better within hours. This rapid response is so consistent that failure to improve within 2 weeks of starting adequate corticosteroid doses should prompt reconsideration of the diagnosis.

How Is Polymyalgia Rheumatica Treated?

Polymyalgia rheumatica is primarily treated with corticosteroids (usually prednisone or prednisolone), starting with a medium dose that is gradually reduced over 1.5-3 years. Treatment provides rapid symptom relief but does not cure the disease - it controls inflammation until the condition naturally resolves.

Corticosteroids remain the cornerstone of PMR treatment and are remarkably effective at controlling symptoms. The treatment strategy involves starting with a dose sufficient to completely suppress symptoms, then gradually reducing the dose to the minimum effective level, and eventually stopping once the disease has run its course.

Treatment with corticosteroids works by suppressing the inflammatory process that causes PMR symptoms. While this effectively controls symptoms, it is important to understand that corticosteroids do not cure the underlying condition - they manage inflammation while waiting for the disease to naturally resolve. This is why treatment must be continued for an extended period, typically 1.5-3 years.

Initial Treatment

Treatment typically begins with a medium dose of prednisone or prednisolone, usually 12.5-25 mg daily. Most patients experience dramatic improvement within the first few days - many report feeling significantly better within 24-72 hours. This rapid response is one of the hallmarks of PMR and helps confirm the diagnosis.

During the initial phase, your doctor will monitor your symptoms and blood tests (ESR and CRP) to ensure the treatment is working effectively. If symptoms don't improve adequately within 2 weeks, the dose may need to be increased or the diagnosis reconsidered.

Tapering the Dose

Once symptoms are well controlled and inflammatory markers have normalized (typically 2-4 weeks), the corticosteroid dose is gradually reduced. This tapering process is crucial and must be done slowly to prevent relapse:

• Initial reduction: The dose is typically reduced by 2.5 mg every 2-4 weeks until reaching about 10 mg daily
• Slower reduction: Below 10 mg, reductions become smaller (usually 1 mg every 4-8 weeks) and slower
• Final phase: The last few milligrams are tapered very slowly, sometimes by 0.5 mg at a time

Managing Relapses

Relapses occur in approximately 30-50% of patients during treatment, most commonly during dose reduction. Signs of relapse include return of muscle pain and stiffness, and rising inflammatory markers. If a relapse occurs:

• The dose is temporarily increased (usually to the last effective dose)
• Once symptoms are controlled again, tapering resumes but often at a slower rate
• Relapses do not mean the disease is getting worse - they simply indicate that the dose was reduced too quickly for that individual

Alternative Treatments

For patients who cannot take corticosteroids or who experience significant side effects, some alternatives may be considered:

• NSAIDs: Non-steroidal anti-inflammatory drugs may help mild cases but are generally less effective than corticosteroids
• Methotrexate: May be used as a corticosteroid-sparing agent in patients who cannot taper corticosteroids adequately
• Tocilizumab: An IL-6 inhibitor being studied for PMR, particularly for patients with frequent relapses

What Are the Side Effects of Corticosteroid Treatment?

Long-term corticosteroid treatment can cause side effects including weight gain, elevated blood sugar, high blood pressure, skin changes, mood disturbances, and osteoporosis. However, side effects are generally manageable with appropriate monitoring and preventive measures.

While corticosteroids are highly effective for PMR, long-term use can cause various side effects. The risk of side effects is related to both the dose and duration of treatment. Since PMR typically requires treatment for 1.5-3 years, understanding and managing potential side effects is an important part of care.

During the initial treatment period when doses are higher, patients may experience:

• Sleep disturbances: Difficulty falling or staying asleep, sometimes feeling "wired"
• Mood changes: Feeling overactive, anxious, or sometimes irritable
• Increased appetite: Can lead to weight gain if not managed
• Fluid retention: Swelling in hands and feet

With longer-term treatment, additional side effects may develop:

• Weight gain: Particularly around the face (moon face) and trunk
• Elevated blood sugar: May cause or worsen diabetes
• High blood pressure: Requires monitoring and sometimes treatment
• Skin changes: Thinner, more fragile skin that bruises easily, slower wound healing
• Osteoporosis: Bone loss increases fracture risk
• Cataracts: Risk increases with cumulative dose and duration
• Increased infection risk: Corticosteroids suppress immune function

Preventing Osteoporosis

Osteoporosis is one of the most important complications to prevent during long-term corticosteroid treatment. Bone loss begins within the first few months of treatment and can lead to fractures, particularly in the spine and hips. Preventive measures include:

• Calcium supplementation: Typically 1000-1200 mg daily through diet and/or supplements
• Vitamin D: Usually 800-1000 IU daily, sometimes higher based on blood levels
• Bisphosphonates: Medications like alendronate that prevent bone loss; often prescribed for patients expected to need corticosteroids for more than 3 months
• Weight-bearing exercise: Helps maintain bone density
• Bone density testing: May be recommended to monitor bone health

What Monitoring Is Needed During Treatment?

Regular follow-up appointments are essential during PMR treatment to monitor symptoms, check blood tests (ESR/CRP), assess for side effects, adjust medication doses, and screen for complications like giant cell arteritis. Visits are typically more frequent early in treatment and during dose changes.

Effective management of polymyalgia rheumatica requires ongoing monitoring throughout the treatment period. Regular follow-up allows your healthcare team to optimize your treatment, minimize side effects, and detect any complications early.

Regular Blood Tests

Blood tests are an important part of monitoring PMR treatment:

• ESR and CRP: Used to assess disease activity; rising levels may indicate relapse
• Blood glucose: Monitored regularly as corticosteroids can cause or worsen diabetes
• Blood pressure: Checked at each visit as corticosteroids can raise blood pressure
• Complete blood count: Periodically to monitor for anemia or other abnormalities

Symptom Monitoring

Between appointments, pay attention to:

• Return of muscle pain or stiffness (may indicate relapse)
• New symptoms like headaches, jaw pain, or vision changes (may indicate GCA)
• Signs of infection (fever, cough, unusual symptoms)
• Side effects from medication

What Lifestyle Changes Help with Polymyalgia Rheumatica?

Regular physical activity helps maintain muscle strength and bone density during PMR treatment. A balanced diet, adequate calcium and vitamin D intake, maintaining a healthy weight, and not smoking all support better outcomes. Physical therapy can provide tailored exercise programs.

While medication is the primary treatment for PMR, lifestyle modifications play an important supporting role in managing the condition and minimizing treatment-related complications.

Exercise and Physical Activity

Regular physical activity is beneficial for several reasons during PMR treatment:

• Maintains muscle strength: Corticosteroids can cause muscle wasting; exercise helps counteract this
• Preserves bone density: Weight-bearing exercise helps protect against corticosteroid-induced osteoporosis
• Improves cardiovascular health: Reduces the cardiovascular risks associated with corticosteroid use
• Enhances mood and energy: Helps combat fatigue and supports mental wellbeing
• Maintains flexibility: Gentle stretching can help with stiffness

Choose activities appropriate for your fitness level and symptoms. Walking, swimming, cycling, and gentle yoga are often well-tolerated. A physical therapist can design an exercise program tailored to your individual needs and limitations.

Nutrition

A balanced diet supports overall health during PMR treatment:

• Calcium-rich foods: Dairy products, fortified plant milks, leafy greens, and fish with bones
• Vitamin D sources: Fatty fish, fortified foods, and sensible sun exposure
• Protein: Adequate protein intake helps maintain muscle mass
• Limit sodium: Helps control blood pressure and fluid retention
• Moderate portions: Corticosteroids increase appetite; being mindful of portions helps prevent weight gain

Smoking Cessation

If you smoke, quitting is particularly important during PMR treatment. Smoking increases the risk of osteoporosis, cardiovascular disease, and may affect treatment response. Your healthcare team can provide resources and support for smoking cessation.