What is the diagnosis and treatment for a patient with severe bilateral shoulder pain, bilateral hip pain, and bilateral leg pain, described as a stinging, shooting sensation, with significant functional impairment, including no strength in arms, and a 2.5-month history of progressive symptoms?

Polymyalgia Rheumatica (PMR) - Diagnosis and Treatment

This presentation of bilateral shoulder and hip pain with profound proximal muscle weakness, progressive symmetric distribution, and 2.5-month duration is highly consistent with polymyalgia rheumatica (PMR), which requires immediate corticosteroid therapy after confirming elevated inflammatory markers.

Clinical Diagnosis

The clinical picture strongly suggests PMR based on:

• Bilateral shoulder and hip girdle pain with profound functional impairment (inability to open doors with one hand) indicating severe proximal muscle weakness 1
• Progressive symmetric pattern starting in one shoulder, spreading to the contralateral shoulder, then involving hips and legs over 2.5 months 1
• Age consideration - while not specified, PMR typically affects patients over 50 years old 1
• Shooting, stinging leg pain after prolonged sitting suggests inflammatory involvement with possible nerve compression from inflammatory changes 1

Key Diagnostic Steps

Immediate laboratory evaluation required:

• Erythrocyte sedimentation rate (ESR) - typically markedly elevated (>40 mm/hr, often >50-100 mm/hr) in PMR 1
• C-reactive protein (CRP) - elevated in active inflammation 1
• Complete blood count - may show normocytic anemia 1
• Rheumatoid factor and anti-CCP antibodies - to exclude rheumatoid arthritis 1
• Creatine kinase - should be normal in PMR (elevated would suggest myositis) 1

Critical differential diagnoses to exclude:

• Giant cell arteritis (GCA) - assess for headache, jaw claudication, visual symptoms, temporal artery tenderness 1
• Rheumatoid arthritis - particularly given bilateral symmetric presentation 2
• Psoriatic arthritis - though bilateral shoulder pain is unusual in PA 2
• Rotator cuff pathology - bilateral involvement would be atypical for primary rotator cuff disease 3

Treatment Algorithm

First-Line Treatment: Corticosteroids

Immediate initiation of prednisone 15-20 mg daily is the standard treatment for PMR 1:

• Dramatic response within 24-72 hours is characteristic and helps confirm diagnosis 1
• If no improvement within one week, reconsider diagnosis 1
• Continue initial dose for 2-4 weeks until symptoms controlled 1

Tapering schedule:

• Reduce by 2.5 mg every 2-4 weeks until reaching 10 mg daily 1
• Then taper by 1 mg every 4-8 weeks 1
• Total treatment duration typically 12-24 months 1
• Monitor ESR/CRP during tapering to detect flares 1

Adjunctive Management

Physical therapy considerations:

• Gentle range-of-motion exercises to prevent adhesive capsulitis during acute phase 1
• Avoid aggressive passive range-of-motion which could worsen shoulder pain 1
• Progressive strengthening only after inflammation controlled 1
• The American Heart Association guidelines emphasize proper positioning and maintenance of shoulder range of motion for shoulder pain management 1

Pain management:

• NSAIDs (ibuprofen, naproxen) may provide additional symptomatic relief but are insufficient as monotherapy 3
• Acetaminophen for breakthrough pain 4

Monitoring and Follow-up

Essential monitoring parameters:

• Clinical response assessment at 1 week (should show dramatic improvement) 1
• ESR/CRP monitoring every 4-8 weeks during tapering 1
• Screen for corticosteroid side effects: bone density, glucose, blood pressure, weight 1
• Assess for GCA symptoms at every visit (15-20% of PMR patients develop GCA) 1

Critical Red Flags

Urgent ophthalmology referral if any visual symptoms develop - GCA can cause irreversible blindness 1:

• New headache, especially temporal
• Jaw claudication
• Visual changes or diplopia
• Scalp tenderness

Consider alternative diagnoses if:

• No response to corticosteroids within one week 1
• Normal inflammatory markers (though 10-20% of PMR patients may have normal ESR) 1
• Persistent weakness despite inflammation control (suggests myopathy or neurologic disease) 1
• Age under 50 years 1

The multidisciplinary rheumatology approach is essential for managing chronic progressive musculoskeletal conditions, requiring close supervision and expert monitoring 1. Referral to rheumatology should occur if diagnosis uncertain, atypical features present, or difficulty tapering corticosteroids 1.