Polymyalgia Rheumatica: What It Is, Why It Matters

What Is Polymyalgia Rheumatica?

Polymyalgia rheumatica (PMR) is an inflammatory condition affecting predominantly older adults, characterised by bilateral aching and stiffness in the shoulder girdle, neck, and pelvic girdle. The name derives from the Greek poly (many) and myalgia (muscle pain) — though the pathology is primarily synovitis and periarticular inflammation of the proximal joints, rather than disease of the muscle tissue itself. It is one of the most common inflammatory rheumatic diseases in adults over 50, with an incidence that rises significantly with age and a markedly higher prevalence in individuals of northern European ancestry.

Despite its dramatic presentation — often developing over days to weeks — PMR is highly responsive to corticosteroid therapy, which is both diagnostic and therapeutic. The challenge lies in accurate and timely identification, as its presentation can mimic several other conditions including late-onset rheumatoid arthritis, inflammatory myopathies, hypothyroidism, and occult malignancy.

Clinical Presentation

The hallmark features of PMR are bilateral proximal limb girdle pain and stiffness, most prominent in the morning and typically lasting more than 45 minutes. Patients frequently describe difficulty raising their arms above shoulder height, rising from a chair, or climbing stairs. The stiffness often has a distinctive gelling quality — worsening after periods of rest and improving, though not resolving, with gentle movement.

Onset is usually rapid, sometimes occurring over days, and is occasionally associated with systemic features including low-grade fever, fatigue, weight loss, and depression. Crucially, despite the description of muscle pain, true muscle weakness is absent — differentiating PMR from inflammatory myopathies such as polymyositis where weakness is a defining feature.

Laboratory findings typically reveal significantly elevated inflammatory markers: C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are raised in the vast majority of cases, often substantially so. A normal ESR and CRP significantly reduces diagnostic likelihood. Anaemia of chronic disease and thrombocytosis may also be present.

The Critical Link to Giant Cell Arteritis

PMR carries an important and clinically serious association with giant cell arteritis (GCA), a large-vessel vasculitis primarily affecting the temporal and ophthalmic arteries. Approximately 15–20% of PMR patients develop GCA, and the risk of irreversible visual loss from ophthalmic artery occlusion makes early recognition a genuine clinical emergency. Conversely, approximately 40–60% of GCA patients have concurrent PMR symptoms.

Red flags for concurrent GCA include new headache (particularly temporal), jaw claudication, scalp tenderness, visual disturbance, and a tender or thickened temporal artery on palpation. Any patient presenting with these features alongside PMR symptoms requires same-day medical referral. This is not an incidental clinical detail — visual loss from untreated GCA can occur within days of symptom onset and is frequently irreversible.

Management and the Role of Manual Therapy

First-line treatment for PMR is low-dose oral prednisolone (typically 15–25mg/day), which produces a dramatic and often near-complete resolution of symptoms within days — a response that is itself diagnostically informative. Steroid therapy is tapered slowly over 12–24 months; relapse is common on premature reduction, and treatment duration frequently exceeds two years. The complications of prolonged corticosteroid use — osteoporosis, diabetes, adrenal suppression, skin fragility, and immunosuppression — require active monitoring and preventative strategies.

Physiotherapy, myotherapy, and exercise rehabilitation play a meaningful adjunctive role in PMR management. During remission or on adequate steroid dosing, these focus on maintaining shoulder and hip range of motion, addressing the secondary muscle inhibition and postural adaptation that develops during the acute phase, and implementing resistance training and weight-bearing activity to counteract steroid-induced bone density loss. Patients on prolonged corticosteroids have substantially elevated fracture risk and benefit significantly from targeted exercise prescription and calcium/vitamin D supplementation.