What is polymyalgia rheumatica?

Polymyalgia rheumatica (PMR) is an inflammatory condition that causes many painful muscles (poly = many, myalgia = muscle pain). Any muscles can be affected, but it mainly affects the muscles of the shoulder and thigh.

PMR can start at any age from 50 but mainly affects people over the age of 60. Women are affected 2–3 times as often as men and it affects about 1 in 2,000 people.

Symptoms

If you have polymyalgia rheumatica (PMR) you’ll usually have severe and painful stiffness, which is often worse in the morning, especially in your shoulders and thighs and usually affecting both sides. PMR often strikes suddenly, appearing over a week or two and sometimes just after a flu-like illness.

The symptoms are quite different from the ache you may feel after exercise. The pain and stiffness is often widespread, is worse when resting and improves with activity or as the day goes on. However, it may also wake you at night.

Other symptoms include:

  • feeling unwell
  • a slight fever
  • weight loss
  • overwhelming tiredness
  • feeling low, anxious or depressed.

Diagnosis

Your GP may be able to diagnose polymyalgia rheumatic straight away if you're over 60 and have the following symptoms:

  • shoulder pain on both sides
  • morning stiffness that lasts at least 45 minutes
  • high levels of inflammation measured by blood tests
  • new hip pain on both sides
  • no swelling in the small joints of the hands and feet
  • no evidence of rheumatoid arthritis, such as swollen joints or positive blood tests.

However, you may be referred to a rheumatologist if there's any doubt about the diagnosis or if there are complicating factors – for example, if the symptoms don't improve with steroid treatment or if you have side-effects from the treatment.

There's no specific test for PMR, but you may have blood tests to check for inflammation. There are three tests that could be used:

  • erythrocyte sedimentation rate (ESR)
  • plasma viscosity (PV)
  • C-reactive protein (CRP)

Inflammation alone isn't enough to confirm a diagnosis of PMR as it's also a feature of many other conditions, including infections and rheumatoid arthritis. You may therefore have tests – for example, for rheumatoid factor or anti-CCP antibodies – to help rule out these other conditions and confirm the diagnosis of PMR.

Different types of imaging may be used to help in the diagnosis of PMR and to help rule out other conditions. Ultrasound of the shoulders and hips may be used and can often show inflammation in the tissues. Other forms of imaging, such as magnetic resonance imaging (MRI) and positron emission tomography (PET) scans, may occasionally be requested by a rheumatologist.

Anaemia (a lack of red blood cells) is quite common in PMR so your doctor may test for this, but this can also occur in other conditions.

If your doctor suspects you have GCA, a biopsy of a small piece of artery may be taken from your scalp and examined under a microscope.

Treatment

Standard painkillers or anti-inflammatory drugs alone aren't enough to ease the symptoms of PMR. However, steroid treatment is usually very effective.

Steroid tablets

Steroid tablets (corticosteroids) aren't the same as the steroids sometimes used by athletes and bodybuilders (which are known as anabolic steroids). Corticosteroids are similar to steroids produced naturally in the body, which play an important part in keeping you healthy.

Steroid treatment can have a powerful effect in reducing inflammation. They won’t cure PMR but the symptoms often improve significantly within about two weeks of starting treatment. The symptoms may have almost completely disappeared after four weeks. However, you’ll probably need to continue treatment for up to two years, and occasionally longer, to stop symptoms returning.

The steroid tablet most often prescribed is prednisolone. A starting dose of 15 mg a day usually makes symptoms disappear completely. If you have giant cell arteritis (GCA) you’ll need higher doses than this to begin with to protect your vision.

If you're at increased risk of side-effects from steroid tablets (for example, if you have diabetes, high blood pressure, a recent fracture, peptic ulcer, cataract or glaucoma) some doctors may suggest steroid injections (Depo-Medrone) into a muscle instead. Your doctor may also suggest bone protection treatment to reduce the risk of osteoporosis, which can be a problem with long-term steroid treatment.

After a time your doctor will try to gradually reduce your dose to avoid potential side-effects, such as weight gain and osteoporosis. This will be done in stages depending mainly on your symptoms but helped by repeat ESR or CRP test results. If your symptoms return when the dose is reduced your doctor may have to increase it for a short time. They’ll then try to reduce it again after several weeks. Raised ESR or CRP test results alone don’t necessarily mean your steroid dose needs to be increased.

Even when you feel well, your doctor may want to see you regularly so that they can check you for signs of a relapse or side-effects from the steroids. They may want to check your general health or ask you to have a bone density (DEXA) scan to assess the strength of your bones.

You shouldn’t stop taking your steroid tablets suddenly or alter the dose unless your doctor tells you, even if your symptoms have completely cleared up. This is because your body stops producing its own steroids (cortisol) while you’re taking steroid tablets and needs a period of time to resume normal production of natural steroids when the drug is stopped.

Steroids alert card

When taking steroid tablets you must carry a steroid card, which shows your current dose and how long you’ve been taking them. This will help if you need to see another doctor or healthcare professional, for example a dentist. Depending what additional treatment you need the steroid dose may need to be adjusted. Steroid cards are available from most pharmacies.

Managing your symptoms

Because steroid tablets can increase the risk of osteoporosis it’s important to think about any other risk factors you may have. Factors that increase your risk include:

  • smoking
  • drinking a lot of alcohol.

Factors that can reduce your risk include:

  • eating a diet that contains plenty of calcium and vitamin D
  • doing some weight-bearing exercise.

Sitting for any length of time may cause stiffness, making driving, for instance, more difficult. Stop from time to time on a long journey to stretch your legs, arms and shoulders.

Simple measures like a hot bath or shower first thing in the morning or after exercise can help to ease pain and stiffness.

Exercise

You’ll need to find the right balance between rest and activity. Too much exercise is likely to make your symptoms worse, but activity usually helps to ease morning stiffness. Physiotherapy can be helpful in reducing pain and maintaining mobility.

Weight-bearing exercise (any exercise that involves walking or running) is best for maintaining bone strength and guarding against osteoporosis, but walking is usually most suitable for people with PMR.