What are the symptoms of polymyalgia rheumatica?

Symptoms of Polymyalgia Rheumatica

The primary symptoms of polymyalgia rheumatica (PMR) include pain and stiffness in the proximal upper and lower extremities, particularly affecting the shoulder girdle, hip girdle, and neck, with pronounced morning stiffness lasting more than 30 minutes to 1 hour. 1

Key Clinical Manifestations

Cardinal Symptoms

• Bilateral shoulder pain and stiffness - most consistent and prominent feature
• Hip girdle and neck pain - commonly affected areas
• Morning stiffness - typically lasting more than 30-60 minutes
• Pain and stiffness after periods of inactivity - characteristic feature

Specific Presentation Pattern

• Proximal distribution - primarily affects shoulder and hip girdle muscles
• Bilateral and symmetrical involvement - distinguishing feature
• Acute or subacute onset - symptoms often develop over days to weeks
• Systemic inflammation - elevated inflammatory markers (ESR, CRP) 1

Associated Symptoms and Features

• Functional limitations - difficulty with activities requiring arm elevation
• Constitutional symptoms - may include:
  • Low-grade fever
  • Fatigue
  • Weight loss
  • Malaise 2

Diagnostic Considerations

PMR diagnosis is primarily clinical, as there is no single pathognomonic test. Key diagnostic elements include:

• Age over 50 years - PMR rarely occurs in younger patients 3
• Rapid response to glucocorticoids - characteristic dramatic improvement within 24-48 hours 4
• Elevated inflammatory markers - ESR and CRP are typically elevated 1

Differential Features

Several conditions can mimic PMR, particularly:

• Elderly-onset rheumatoid arthritis - may present similarly but typically has more peripheral joint involvement 3
• Late-onset seronegative spondyloarthritis - different pattern of joint involvement 2
• Myositis - important to rule out when evaluating PMR-like symptoms 1

Clinical Evaluation

When evaluating a patient with suspected PMR, the following assessments are recommended:

• Joint examination - assess for swelling, tenderness, and range of motion
• Laboratory tests - ESR, CRP, rheumatoid factor, anti-CCP antibodies
• Creatine kinase (CK) - to rule out myositis which can present similarly 1
• Imaging - ultrasound may show bursitis in symptomatic areas 4

Important Clinical Considerations

• Giant cell arteritis (GCA) association - PMR can be associated with GCA, which requires urgent evaluation due to risk of vision loss 2
• Warning signs requiring immediate attention - new headache, visual disturbances, or jaw claudication may indicate concurrent GCA 4
• Atypical presentations - peripheral arthritis can occur in some PMR patients 1

Monitoring and Follow-up

For patients diagnosed with PMR, regular monitoring is essential:

• Follow-up visits - recommended every 4-8 weeks in the first year 1
• Inflammatory markers - should be monitored to assess disease activity 1
• Symptom assessment - particularly morning stiffness duration and pain levels

PMR typically responds dramatically to low-dose glucocorticoids, and this response can be considered a diagnostic feature. Lack of response should prompt reconsideration of the diagnosis.