In Sri Lanka, polymyalgia Rheumatica is managed by rheumatologists. 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.
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..
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.
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.
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.
Find specialists →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.
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.
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.
Medically reviewed by AIHealz Medical Editorial Board · May 13, 2026
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