Polymyalgia rheumatica (PMR) is an inflammatory condition of older adults marked by sudden bilateral pain and stiffness of the shoulders, neck, and hips, almost always with elevated inflammatory markers and a striking response to low-dose glucocorticoid therapy. It affects approximately 50-70 per 100,000 adults over 50 per year in Northern European populations, making it the second most common inflammatory rheumatic disease after rheumatoid arthritis in this age group.
Polymyalgia rheumatica (ICD-10: M35.3) is an inflammatory disorder primarily affecting the synovium and bursae of the shoulder and pelvic girdles in adults over 50, producing aching and morning stiffness in the neck, shoulders, upper arms, hips, and thighs that lasts at least 45 minutes after waking. The pathophysiology involves activation of innate immunity with infiltration of macrophages and CD4+ T cells in synovial tissues, raised circulating interleukin-6, and an acute-phase response with elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). It is strongly linked to giant cell arteritis (GCA): up to 20% of patients with PMR develop GCA, and up to 50% of patients with GCA have PMR symptoms. The two conditions share genetic susceptibility (HLA-DRB1*04 alleles), age distribution, and responsiveness to glucocorticoids, but PMR rarely causes vascular complications by itself.
key facts
Prevalence
50-70 per 100,000 adults over 50 per year (Olmsted County, Minnesota); lifetime prevalence approximately 2%
Demographics
Women 2-3× more affected than men; almost exclusively in adults over 50; rarely seen in non-Caucasian populations
Avg. age
Mean age at diagnosis 70-75 years; peak incidence 70-80 years; very uncommon under 50
Global cases
Estimated 700,000+ adults living with PMR in the United States and 250,000+ in the United Kingdom
Specialist
Rheumatology
§ 02
How you might notice it
The key symptoms of Polymyalgia Rheumatica are: Sudden bilateral aching pain in the shoulders, upper arms, neck, hips, and thighs developing over days to weeks., Morning stiffness lasting more than 45 minutes (often 1-2 hours), severely limiting dressing, washing, and combing hair., Difficulty rising from a chair, climbing stairs, or lifting the arms above the head., Constitutional symptoms including low-grade fever, fatigue, anorexia, depression, and weight loss in 30-50% of patients., Pain at rest and at night that wakes the patient and improves with movement during the day., Tender, mildly swollen shoulders and hips on examination with restricted active range of motion but preserved passive movement., Distal joint involvement (wrists, hands, ankles) in 20-30% of patients with mild synovitis but no joint deformity..
01Sudden bilateral aching pain in the shoulders, upper arms, neck, hips, and thighs developing over days to weeks.
02Morning stiffness lasting more than 45 minutes (often 1-2 hours), severely limiting dressing, washing, and combing hair.
03Difficulty rising from a chair, climbing stairs, or lifting the arms above the head.
04Constitutional symptoms including low-grade fever, fatigue, anorexia, depression, and weight loss in 30-50% of patients.
05Pain at rest and at night that wakes the patient and improves with movement during the day.
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How it’s diagnosed
diagnosis
Diagnosis is primarily clinical, applying the 2012 ACR/EULAR provisional classification criteria: age 50 or above, bilateral shoulder aching, and abnormal CRP or ESR, together with at least 4 points from morning stiffness over 45 minutes, hip pain or limited range of movement, absence of rheumatoid factor or anti-CCP antibodies, and absence of other joint involvement. Ultrasound criteria add points for bursitis and tenosynovitis. The differential diagnosis is broad and includes rheumatoid arthritis (especially elderly-onset RA), polymyositis, hypothyroidism, paraneoplastic syndromes, infection (endocarditis, occult abscess), spondyloarthritis, and statin myopathy, all of which must be excluded by examination and targeted tests. Blood work should include full blood count, ESR, CRP, thyroid function, calcium and phosphate, liver enzymes, creatine kinase (to exclude myositis), urea and creatinine, rheumatoid factor, anti-CCP, antinuclear antibody, and a serum protein electrophoresis if myeloma is suspected. ESR is typically over 40 mm/hr and CRP over 10 mg/L, but normal inflammatory markers do not exclude PMR (5-15% of cases). Bilateral shoulder ultrasound demonstrating subacromial-subdeltoid bursitis or biceps tenosynovitis supports the diagnosis. MRI of the shoulders or pelvis is reserved for atypical presentations. PET-CT and large-vessel ultrasound or temporal artery biopsy are used when GCA is suspected. A rapid and dramatic response to 15-25 mg prednisolone within 72 hours is highly characteristic; failure to respond within 7 days should prompt reconsideration of the diagnosis. New temporal headache, scalp tenderness, jaw claudication, or visual symptoms warrant urgent referral to a GCA fast-track clinic.
Key tests
01
Full blood count and inflammatory markers (ESR, CRP)Confirms systemic inflammation; baseline for monitoring response
✓Prednisolone 12.5-25 mg orally once daily (typically start 15 mg)
✓Methotrexate 7.5-15 mg weekly (oral or subcutaneous)
✓Tocilizumab (IL-6 receptor antagonist) 162 mg weekly subcutaneous or 8 mg/kg monthly IV
✓Calcium 1000 mg and vitamin D 800-1000 IU daily
surgical options
Temporal artery biopsy (diagnostic)Sensitivity 70-90% in adequate-length biopsies; specificity near 100%
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Causes & risk factors
known causes
Inflammation of synovium and bursae
Subacromial-subdeltoid bursitis, glenohumeral synovitis, biceps tenosynovitis, and trochanteric bursitis are consistently demonstrated on shoulder and hip ultrasound and MRI in PMR. Inflammation is non-erosive and resolves with steroid therapy.
Innate immune activation and elevated interleukin-6
Circulating interleukin-6 (IL-6) is markedly elevated in active PMR; IL-6 drives the hepatic acute-phase response producing the high ESR and CRP. Tocilizumab, which blocks the IL-6 receptor, is effective as a steroid-sparing agent.
Genetic predisposition (HLA-DRB1)
HLA-DRB1*04 alleles are over-represented in PMR and GCA, shared with rheumatoid arthritis. First-degree relatives have approximately 2× background risk. Ethnic distribution suggests a strong genetic component.
Older age and immunosenescence
PMR is almost exclusively a disease of adults over 50, with steeply rising incidence after 70. Age-related changes in T-cell repertoire and innate immunity are thought to permit the breakdown of self-tolerance.
Possible infectious trigger
Epidemiological clustering and seasonal peaks in some studies have implicated viral and bacterial triggers (parvovirus B19, Mycoplasma pneumoniae, parainfluenza) but no consistent organism has been confirmed.
Shared pathogenesis with giant cell arteritis
PMR and GCA exist on a spectrum; large-vessel imaging shows subclinical vasculitis in 20-30% of patients with apparent isolated PMR. The two conditions share genetic, demographic, and therapeutic features.
risk factors
Age over 50non-modifiable
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Living with it
01There are no proven primary prevention strategies; PMR cannot currently be prevented in genetically susceptible individuals.
02Seek prompt assessment of new bilateral shoulder or hip pain over age 50 to reduce delay to diagnosis and steroid initiation.
03Maintain bone health through weight-bearing exercise, calcium and vitamin D intake, and avoiding smoking.
04Stay up to date with annual influenza and pneumococcal vaccination if at elevated risk of inflammatory illness.
05Monitor for new headache, scalp tenderness, jaw pain, or visual changes in patients with PMR — early treatment of GCA prevents blindness.
06Promote regular physical activity in older adults to maintain musculoskeletal reserve and detect early loss of function.
•Vitamin D sources (oily fish, eggs, fortified products) plus supplementation
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When to seek help
why see a rheumatology
A rheumatologist confirms the diagnosis by excluding mimics (RA, polymyositis, malignancy, infection), designs a tapering schedule, manages steroid complications, and decides on steroid-sparing therapy. Urgent rheumatology or ophthalmology referral is needed when giant cell arteritis is suspected — vision loss is irreversible if treatment is delayed beyond hours.
01Giant cell arteritis (15-20% of patients) with risk of irreversible blindness, stroke, and aortic aneurysm — recognize early temporal headache, jaw claudication, scalp tenderness, and visual symptoms.
02Glucocorticoid-induced osteoporosis and vertebral fractures — prevent with calcium, vitamin D, bisphosphonates, and DEXA monitoring.
03Steroid-induced diabetes or worsening of pre-existing diabetes — monitor fasting glucose and HbA1c every 3-6 months.
04Cataract and glaucoma — annual ophthalmology review for patients on long-term steroids.
05Infections including reactivation of varicella zoster, tuberculosis, and pneumonia — keep vaccinations updated.
06Steroid-induced weight gain, hypertension, and cardiovascular risk — modify diet and monitor BP and lipids.
Classic polymyalgia rheumatica (without GCA)Bilateral shoulder and pelvic girdle pain and stiffness, raised ESR and CRP, and rapid response to 15-20 mg prednisolone. Roughly 80% of patients have this form without overt vasculitis.
Polymyalgia rheumatica with giant cell arteritisApproximately 15-20% develop GCA features such as new-onset temporal headache, scalp tenderness, jaw claudication, visual disturbance, or constitutional symptoms; requires high-dose prednisolone (40-60 mg) and urgent ophthalmology assessment.
Refractory or relapsing PMRPatients who relapse during tapering or require persistent prednisolone above 5 mg after 12 months. Steroid-sparing agents (methotrexate, tocilizumab) are considered.
Steroid-resistant PMRRare; failure of 20-25 mg prednisolone to produce dramatic improvement within 7 days should prompt re-evaluation of the diagnosis and consideration of malignancy, infection, or rheumatoid arthritis.
Living with Polymyalgia Rheumatica
Timeline
Symptoms typically improve within 72 hours of starting prednisolone. ESR and CRP normalize within 1-3 weeks. Most patients reach 5 mg prednisolone by 6-9 months and discontinue between 18 and 24 months. Relapses are most common in the first year; full sustained remission off all therapy is the goal by 2-3 years.
Lifestyle
01Take prednisolone in the morning with food to mimic the natural cortisol rhythm and reduce insomnia.
02Adopt a Mediterranean-style diet rich in fruit, vegetables, oily fish, olive oil, and whole grains to reduce inflammation and cardiovascular risk.
03Limit added sugars and simple carbohydrates to control steroid-induced weight gain and hyperglycaemia.
04Restrict sodium intake to under 5 g per day to reduce steroid-related fluid retention and hypertension.
05Engage in regular weight-bearing and resistance exercise to preserve bone density and muscle mass.
06Stop smoking and limit alcohol to under 14 units per week to support bone health.
07Use sunscreen daily — steroids increase skin fragility and photosensitivity.
Daily management
01Take prednisolone every morning with food at the same time.
Complementary approaches
Physiotherapy and gentle range-of-motion exercisesMaintains shoulder and hip mobility during treatment; particularly important after the first weeks of steroid therapy to prevent secondary stiffness and capsulitis.
Mind-body interventions (CBT, mindfulness)Helps patients cope with the chronic illness, steroid-related mood changes, and concerns about relapse. Modest improvements in fatigue and quality of life in trials of chronic inflammatory disease.
Choosing a doctor
Choose a rheumatologist with experience in older adults and access to ultrasound, PET-CT, and a GCA fast-track clinic. Coordinated care with the primary care physician for monitoring blood pressure, weight, glucose, and bone health is essential during the 1-3 year course.
Polymyalgia rheumatica is an inflammatory disorder of older adults that causes sudden bilateral pain and stiffness in the shoulders, neck, and hips with prolonged morning stiffness, raised inflammatory markers, and a striking response to low-dose oral steroids. Up to 20% of patients also develop giant cell arteritis.
What are the symptoms of polymyalgia rheumatica?▾▴
Typical symptoms are bilateral shoulder, neck, and hip aching that develops over days to weeks, morning stiffness lasting more than 45 minutes, difficulty getting out of a chair or lifting the arms, fatigue, low-grade fever, and unintended weight loss. New headache or visual changes suggest associated giant cell arteritis.
How is polymyalgia rheumatica diagnosed?▾▴
Diagnosis is clinical, supported by raised ESR and CRP, exclusion of mimics (rheumatoid arthritis, polymyositis, hypothyroidism, infection), and a dramatic response to a trial of oral prednisolone 15-25 mg within 72 hours. Shoulder ultrasound and the 2012 ACR/EULAR classification criteria support diagnosis.
What is the treatment for polymyalgia rheumatica?▾▴
First-line treatment is oral prednisolone 12.5-25 mg daily (most commonly 15 mg), with a tapering schedule over 1-2 years. Methotrexate or tocilizumab is added for relapsing or steroid-intolerant patients. Calcium, vitamin D, and bisphosphonate prophylaxis are essential for bone protection.
How long do you take steroids for PMR?▾▴
Most patients need prednisolone for 1-3 years, tapered slowly from the starting dose. About 50-70% successfully discontinue steroids by 2 years. Relapses are common during tapering and respond to a small dose increase. Tapering too quickly is the leading cause of relapse.
Can polymyalgia rheumatica be cured?▾▴
Polymyalgia rheumatica is generally self-limiting and most patients enter sustained remission within 2-3 years. There is no curative treatment, but steroid therapy reliably controls symptoms while the disease runs its course. Some patients have a more persistent or relapsing pattern.
Is polymyalgia rheumatica the same as giant cell arteritis?▾▴
PMR and giant cell arteritis are related conditions that share genetic susceptibility, demographics, and steroid response, but they are not identical. PMR causes shoulder and pelvic girdle pain without vasculitis; GCA is a large-vessel vasculitis with headache, scalp tenderness, jaw claudication, and risk of blindness.
Will I lose my sight from polymyalgia rheumatica?▾▴
Isolated PMR does not cause blindness, but 15-20% of patients develop giant cell arteritis, which can. New temporal headache, scalp tenderness, jaw pain when chewing, or visual disturbance in a patient with PMR requires emergency referral and high-dose steroids within hours.
What are the side effects of steroids in PMR?▾▴
Long-term steroid side effects include weight gain, fluid retention, raised blood pressure, raised blood glucose, osteoporosis and vertebral fracture, cataract, glaucoma, skin fragility, increased infection risk, and mood changes. Active prevention with diet, exercise, calcium, vitamin D, and bisphosphonates is essential.
Can polymyalgia rheumatica come back after treatment?▾▴
Yes. Relapses occur in 40-60% of patients during steroid tapering, most often when the dose falls below 5 mg. Relapse is treated by raising the prednisolone dose back to the last effective level plus a small increment, then tapering more slowly. Methotrexate or tocilizumab is considered for repeated relapses.
Is exercise safe with polymyalgia rheumatica?▾▴
Yes, exercise is encouraged. Gentle walking, swimming, or cycling at moderate intensity preserves muscle and bone. Resistance training twice weekly counteracts steroid-induced muscle loss. Avoid high-impact activity during severe flares and resume as pain allows. Physiotherapy supervises early mobilisation in stiff patients.
Does diet affect polymyalgia rheumatica?▾▴
A Mediterranean diet rich in fruit, vegetables, oily fish, olive oil, and whole grains reduces inflammation and cardiovascular risk during long-term steroid therapy. Limit added sugars and sodium to reduce steroid-related weight gain and hypertension. Adequate calcium, vitamin D, and protein protect bone and muscle.
Can polymyalgia rheumatica affect younger adults?▾▴
PMR is extremely rare under age 50 and the diagnosis should be reconsidered in younger patients with shoulder and hip pain. Other inflammatory diseases such as rheumatoid arthritis, ankylosing spondylitis, and viral arthritides should be excluded before treating presumed PMR in a younger person.
What blood tests detect polymyalgia rheumatica?▾▴
Erythrocyte sedimentation rate (ESR) above 40 mm/hr and C-reactive protein (CRP) above 10 mg/L are typical. Creatine kinase, thyroid function, rheumatoid factor, anti-CCP, antinuclear antibodies, and protein electrophoresis exclude mimics. ESR and CRP guide treatment response.
What is methotrexate for in PMR?▾▴
Methotrexate 7.5-15 mg weekly is a steroid-sparing agent recommended for patients who relapse repeatedly during tapering, who are intolerant of steroids, or who have high risk of steroid complications (diabetes, osteoporosis, previous fracture). It modestly reduces cumulative steroid dose and relapse rate.
When is tocilizumab used in PMR?▾▴
Tocilizumab, an interleukin-6 receptor antagonist, is used in refractory or relapsing PMR and is licensed for giant cell arteritis. The SEMAPHORE 2022 trial showed prednisone discontinuation in 67% of patients with PMR taking tocilizumab versus 31% on placebo. It is given as weekly subcutaneous injection or monthly infusion.
Do I need a temporal artery biopsy?▾▴
Biopsy is performed when giant cell arteritis is suspected, not for uncomplicated PMR. A 2-3 cm segment of the superficial temporal artery is removed under local anaesthetic and examined for vasculitis. Temporal artery ultrasound is now used as a first-line non-invasive alternative in many centres.
Can polymyalgia rheumatica cause headaches?▾▴
Generalized fatigue-related headache can occur, but new, severe temporal or scalp pain suggests giant cell arteritis and warrants emergency assessment. Patients should report any new headache, scalp tenderness, jaw claudication, or visual disturbance to their clinician without delay.
Does polymyalgia rheumatica run in families?▾▴
There is a modest genetic component, with HLA-DRB1*04 alleles over-represented and first-degree relatives having approximately 2-3 times background risk. Most patients have no family history. Northern European ancestry confers higher risk.
What is the long-term outlook for polymyalgia rheumatica?▾▴
Most patients enter sustained remission within 2-3 years and have a normal life expectancy. Long-term complications relate mainly to steroid therapy (osteoporosis, diabetes, cataract). With proactive bone and metabolic management, quality of life returns to near normal in the majority of patients.
Should I get vaccinations on PMR steroids?▾▴
Yes. Annual influenza and pneumococcal vaccinations are recommended for all patients on long-term steroids. Herpes zoster (shingles) vaccination is advisable; live vaccines should be avoided in patients on biologics or high-dose steroids. Discuss timing with the rheumatology team.
10Pitting oedema of the hands or feet (remitting seronegative symmetrical synovitis with pitting oedema variant, RS3PE) in a minority.
early warning signs
•Bilateral shoulder or hip aching of new onset in an adult over 50, especially with morning stiffness over an hour
•Difficulty turning over in bed or getting out of a chair without using the arms in an otherwise well older adult
•Unexplained ESR or CRP elevation in an older adult with vague aches
•Constitutional symptoms (low-grade fever, weight loss, fatigue) without an obvious cause in a person over 50
•Sudden inability to raise the arms to wash or comb hair, particularly with night-time waking from pain
● emergency signs
•New severe temporal headache, scalp tenderness, or jaw claudication — exclude giant cell arteritis with urgent rheumatology or ophthalmology referral
•Sudden vision loss, transient monocular blindness (amaurosis fugax), or diplopia — refer to emergency department for high-dose steroids within hours
•Limb claudication, asymmetric pulses, or new-onset stroke symptoms in a patient with PMR or GCA
•High fever, rigors, or focal infection in a patient on long-term steroids — investigate for opportunistic infection
•Sudden severe back pain with neurological deficit in a steroid-treated patient — exclude vertebral fracture
03
Rheumatoid factor, anti-CCP antibodies, ANAExcludes rheumatoid arthritis and connective tissue disease, both of which can mimic PMR in older adults
04
Shoulder and hip ultrasoundDemonstrates subacromial-subdeltoid bursitis, biceps tenosynovitis, glenohumeral synovitis, and trochanteric bursitis
05
Trial of oral prednisolone 15-20 mg dailyDiagnostic and therapeutic; near-complete symptom relief within 72 hours is highly characteristic
06
Imaging for suspected giant cell arteritis (temporal artery ultrasound, MRI, PET-CT, or temporal artery biopsy)Confirms or excludes GCA when cranial or large-vessel symptoms are present
07
DEXA scan (bone densitometry)Establishes baseline bone density before long-term glucocorticoid therapy; informs osteoporosis prophylaxis
Outlook
Outlook is generally excellent. With prompt steroid therapy, more than 80% of patients achieve symptomatic remission within 4 weeks and 50-70% successfully discontinue steroids within 2 years. The condition is self-limiting in most cases, with median duration of treatment 1.5-3 years. Mortality directly from PMR is not increased compared with the age-matched population, but morbidity from long-term steroid therapy (vertebral fracture, diabetes, cataract, infection) is significant if osteoporosis and metabolic prophylaxis are neglected. Relapses occur in 40-60% during tapering, particularly when prednisolone falls below 5 mg, and most respond to a small dose increase. About 15-20% of patients develop giant cell arteritis, which carries a meaningful risk of irreversible blindness without prompt high-dose steroid therapy. Patients with PMR have a small (1.5-2 fold) increased risk of large-vessel vasculitis and possibly cardiovascular events in some series, reinforcing the importance of cardiovascular risk reduction. Five-year remission rates exceed 75% in modern series.
Incidence rises steeply after age 50, peaking between 70 and 80 years. PMR is extremely rare under age 50 and the diagnosis should be reconsidered in younger patients.
Female sexnon-modifiable
Women have a 2-3× higher incidence than men in epidemiological studies from Europe and North America.
Northern European ancestrynon-modifiable
Highest incidence in Scandinavians and people of Northern European descent (~50-70 per 100,000); roughly half this rate in Southern European populations and much lower in African, Asian, and Hispanic populations.
Family history of PMR or GCAgenetic
First-degree relatives have approximately 2-3× increased risk; HLA-DRB1*04 alleles confer susceptibility.
Recent infection or vaccinationenvironmental
Seasonal peaks and clustering in some studies suggest infectious or immunological triggers; cases have followed influenza vaccination and COVID-19 infection, though causation is unproven.
History of giant cell arteritisnon-modifiable
Up to 50% of patients with GCA have PMR symptoms at presentation or develop them during follow-up.
•
Lean protein (1.0-1.2 g/kg/day) to preserve muscle mass during steroid therapy
•Excess sodium (>5 g/day) which worsens steroid-related fluid retention and hypertension
•Added sugars and refined carbohydrates that worsen steroid-induced hyperglycaemia
•Heavy alcohol intake which damages bone and liver
•Grapefruit juice, which interacts with several drugs including tocilizumab and statins
choosing the right hospital
01Rheumatology outpatient clinic with same-week urgent slots
02Musculoskeletal ultrasound capability
03DEXA bone densitometry available
04Access to PET-CT and vascular imaging for large-vessel GCA
05Ophthalmology service for suspected GCA
Essential facilities
Rheumatology specialist centresGiant cell arteritis fast-track clinicsOphthalmology services with same-day capacityBone health and osteoporosis clinicsPrimary care with shared-care protocols
02Track shoulder and hip stiffness duration and pain score in a simple diary.
03Monitor blood pressure weekly at home; report readings above 140/90 to the GP.
04Check finger-prick blood glucose monthly if at risk of diabetes; more often in those with established hyperglycaemia.
05Weigh weekly and report unexplained gain of more than 3 kg.
06Practice gentle daily shoulder and hip range-of-motion exercises.
07Keep an up-to-date list of all medications and steroid card to show in emergencies.
Exercise
Encourage daily walking, swimming, or stationary cycling at moderate intensity. Add resistance training twice weekly to preserve muscle mass and bone density. Avoid high-impact loading during severe flares but resume as soon as pain allows. Physiotherapy supervises early mobilisation in stiff patients.