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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Bilateral shoulder and hip girdle pain and stiffness in patient >50 years, with raised ESR/CRP
- Dramatic response to prednisolone 15 mg/day within 1–3 days (lack of response should prompt diagnostic review)
- Always screen for giant cell arteritis (GCA) — PMR and GCA are closely related (15–20% of PMR develop GCA)
- Treatment: prednisolone starting at 15 mg/day, with slow taper over 1–2 years
- If no response to 15 mg prednisolone by 1 week: reconsider diagnosis (late-onset RA, malignancy, infection)
Overview
Polymyalgia rheumatica (PMR) is an inflammatory condition causing proximal muscle pain and stiffness, predominantly affecting the shoulder and hip girdles. Despite the name, the primary pathology is synovitis and bursitis (shoulder, hip, interspinous) rather than myositis — muscle enzymes (CK) are normal. PMR is closely related to giant cell arteritis (GCA/temporal arteritis): approximately 15–20% of PMR patients develop GCA, and ~50% of GCA patients have PMR symptoms. PMR is a clinical diagnosis supported by raised inflammatory markers and a dramatic response to low-dose corticosteroids.
Epidemiology
PMR almost exclusively affects those over 50 years (mean age at diagnosis ~73). Female:male ratio is approximately 2.5:1. It is most common in White European populations (especially Scandinavian and northern European descent). Annual incidence in the UK is approximately 50 per 100,000 in those over 50. PMR is the most common inflammatory rheumatic disease of older adults.
Clinical Features
Symptoms
Bilateral shoulder pain and stiffness — most prominent symptom. Difficulty with overhead activities (combing hair, dressing)
Hip girdle pain and stiffness — difficulty rising from chair, climbing stairs
Severe morning stiffness >45 minutes
Rapid onset (days-weeks)
Systemic features: fatigue, malaise, low-grade fever, weight loss, depression
Screen for GCA symptoms: new headache, jaw claudication, scalp tenderness, visual disturbance
Signs
Restricted active shoulder movement (pain-limited), but PASSIVE range is often preserved (distinguishes from frozen shoulder)
Tender and restricted hip movements
No true muscle weakness (pain limits effort — once pain treated with steroids, strength is normal)
No synovitis of small joints (if present, consider RA)
Temporal artery tenderness or thickening (GCA feature) — check at EVERY visit
Investigations
First-line
ESR and CRPTypically markedly raised (ESR >40 mm/hr, often >60–100). CRP also raised. Normal ESR/CRP does not completely exclude PMR but should prompt reconsideration
FBCNormocytic anaemia, thrombocytosis (reactive)
Bloods to exclude mimicsCK (normal in PMR — raised suggests myositis), TFTs, calcium, LFTs, protein electrophoresis (myeloma), U&Es
Second-line
USS shouldersMay show subacromial/subdeltoid bursitis and biceps tenosynovitis — supports diagnosis. Increasingly used in specialist settings
Prednisolone responseA dramatic response to 15 mg prednisolone within 1–3 days strongly supports the diagnosis. Lack of response should trigger diagnostic review
Specialist
PET-CTMay show vascular and periarticular inflammation — used in diagnostic uncertainty
1
Initial treatment
- Prednisolone 15 mg/day (BSR/BHPR recommendation). Some guidelines suggest 12.5–25 mg/day
- Expect dramatic improvement within 1–3 days — if not, reconsider diagnosis
- Start bone protection: alendronate, calcium, vitamin D (steroid-induced osteoporosis)
- PPI if GI risk factors
2
Steroid tapering
- Taper slowly: reduce by 1–2.5 mg every 2–4 weeks initially, then by 1 mg/month below 10 mg
- Total treatment duration typically 1–2 years (some patients need longer)
- Monitor ESR/CRP with each dose reduction — if symptoms recur, increase to previous effective dose
- Relapse is common (~50%) — usually on steroid reduction
3
Steroid-sparing agents
- Methotrexate: consider if relapsing disease, steroid-related adverse effects, or unable to taper below 7.5 mg prednisolone
- Evidence for methotrexate as steroid-sparing agent is modest but widely used
4
Monitoring
- Screen for GCA symptoms at EVERY visit — headache, jaw claudication, visual disturbance
- Monitor for steroid side effects: glucose, BP, bone density, weight, mood
- Monitor inflammatory markers with each dose change
Complications
- Giant cell arteritis: ~15–20% of PMR patients develop GCA — must screen at every visit
- Steroid side effects: Osteoporosis, diabetes, weight gain, hypertension, cataracts, adrenal suppression, skin thinning, infection risk
- Relapse: ~50% relapse during steroid taper — requires dose increase
- Misdiagnosis: Late-onset RA, malignancy, myeloma, hypothyroidism can mimic PMR
UKMLA Exam Tips
- 1Bilateral shoulder/hip girdle stiffness + age >50 + raised ESR/CRP + dramatic steroid response = PMR
- 2CK is NORMAL in PMR — if raised, think polymyositis/dermatomyositis (different condition)
- 3Always screen for GCA symptoms — headache, jaw claudication, visual symptoms. PMR and GCA coexist
- 4No response to prednisolone 15 mg by 1 week = reconsider diagnosis (RA, malignancy, infection)
- 5Treatment duration: 1–2 years of steroids. Taper slowly. Relapse common on reduction
- 6Prednisolone dose for PMR: 15 mg/day. For GCA: 40–60 mg/day (much higher)
practicetest your knowledge on polymyalgia rheumaticaApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — musculoskeletal and beyond.
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