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Polymyalgia Rheumatica — SCE Rheumatology MCQ

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ModerateSoft Tissue RheumatologyPolymyalgia RheumaticaSCE Rheumatology

A 55-year-old woman presents with 6 weeks of bilateral shoulder-girdle aching and morning stiffness lasting 90 minutes. Examination shows pain-limited active shoulder abduction, preserved proximal muscle power and no peripheral synovitis. ESR is 55 mm/hour, CRP is 45 mg/L and creatine kinase is normal. She has no headache, scalp tenderness, jaw claudication or visual symptoms. Which additional investigation result would most strongly support a diagnosis of polymyalgia rheumatica?

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Correct answer: D — Bilateral subacromial-subdeltoid bursitis on shoulder ultrasound

The correct answer is D. PMR is a clinical diagnosis, but bilateral subacromial-subdeltoid bursitis is a characteristic supportive ultrasound finding. The EULAR/ACR classification algorithm also recognises bilateral subdeltoid bursitis, biceps tenosynovitis or glenohumeral synovitis. The prolonged morning stiffness, raised inflammatory markers, preserved muscle power and normal creatine kinase support PMR rather than inflammatory myopathy. Rotator cuff tears suggest structural shoulder disease. High-titre anti-CCP antibodies would favour elderly-onset rheumatoid arthritis, particularly if synovitis developed. Temporal artery biopsy is reserved for suspected giant cell arteritis and does not establish PMR; this patient has no cranial ischaemic features. HLA-B27 supports a spondyloarthritis phenotype rather than PMR. Ultrasound is an adjunct and must not be treated as independently diagnostic.

Reference: EULAR/ACR, EULAR/ACR Provisional Classification Criteria for Polymyalgia Rheumatica, ultrasound scoring algorithm, 2012. https://www.eular.org/document/download/207/9972709c-8e69-44b7-8152-d50da37f3916/311