Can you have polymyalgia rheumatica (PMR) without pain in the pelvic girdle?

Polymyalgia Rheumatica Without Pelvic Girdle Pain

Yes, polymyalgia rheumatica (PMR) can occur without pain in the pelvic girdle, as the condition primarily affects the shoulder girdle and may present with only shoulder involvement. 1

Clinical Presentation of PMR

• PMR is characterized by bilateral inflammatory pain typically involving the shoulder girdle, and less commonly the neck and pelvic girdle 2
• The classic presentation includes bilateral pain and morning stiffness in the shoulder area, with variable involvement of the pelvic region 3
• Shoulder girdle pain is the predominant feature, with proximal arm involvement being more consistent than pelvic girdle symptoms 4

Diagnostic Considerations

• The diagnosis of PMR relies mainly on symptoms and signs combined with laboratory markers of inflammation, not requiring pelvic girdle involvement for diagnosis 3
• When evaluating suspected PMR, a complete rheumatologic history and examination of all peripheral joints should be performed, but pelvic girdle involvement is not mandatory for diagnosis 5
• Inflammatory markers (ESR/CRP) are typically elevated in PMR, regardless of the specific pain distribution pattern 1

Variations in Clinical Presentation

• PMR can present with variable clinical patterns, including cases with isolated shoulder involvement without pelvic girdle pain 6
• Some patients may develop PMR-like syndromes (particularly in the context of immune checkpoint inhibitor therapy) that may not follow the classic distribution pattern 5
• In immune checkpoint inhibitor-induced PMR-like syndromes, patients can develop severe myalgia in their proximal upper extremities resembling PMR, sometimes without significant lower extremity involvement 5

Differential Diagnosis

• When PMR presents without pelvic girdle pain, it's important to consider other conditions that can cause isolated shoulder pain, such as bilateral shoulder capsulitis, rotator cuff tendinitis, and other soft tissue rheumatic disorders 5
• Inflammatory myositis should be considered in the differential diagnosis, as it can mimic PMR but typically presents with true weakness rather than just pain 5
• Rheumatoid arthritis in older adults can sometimes present with PMR-like symptoms but may have a different distribution of joint involvement 6

Management Approach

• The treatment approach for PMR remains the same regardless of whether pelvic girdle involvement is present - starting with prednisone 12.5-25 mg daily 1
• Patients typically experience a rapid response to glucocorticoids within less than a week, which can be a useful diagnostic feature 4
• For patients with relapsing disease, consider increasing glucocorticoid dose temporarily followed by a more gradual reduction schedule 7
• Methotrexate (7.5-10 mg/week) may be considered as a glucocorticoid-sparing agent for patients with multiple relapses or prolonged therapy requirements 8

Monitoring and Follow-up

• Regular monitoring for glucocorticoid-related adverse effects is essential during the entire disease course, regardless of pain distribution 8
• Follow-up visits are recommended every 4-8 weeks during the first year of treatment to assess response and manage any disease evolution 1
• Systematic evaluation of inflammatory markers helps assess treatment response and disease activity 8

Important Considerations

• Always consider the possibility of giant cell arteritis (GCA) in PMR patients, as up to one-fifth of PMR patients may develop GCA, regardless of the initial pain distribution 6
• Female sex is associated with longer treatment duration and higher risk of glucocorticoid-related adverse events, which should be considered in treatment planning 8
• The presence of peripheral arthritis may be associated with higher relapse rates and prolonged therapy requirements 8