PMR — SCE Rheumatology MCQ

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A 74-year-old man has a 4-week history of bilateral shoulder and hip girdle aching with morning stiffness lasting 90 minutes. Active shoulder abduction is limited by pain, but passive range of movement is preserved. There is no objective muscle weakness or peripheral synovitis. His ESR is 68 mm/hour and creatine kinase is normal. What is the most likely diagnosis?

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Correct answer: B — Polymyalgia rheumatica

The most likely diagnosis is polymyalgia rheumatica. The decisive features are age over 50 years, subacute bilateral shoulder and hip girdle aching, morning stiffness exceeding 45 minutes and a raised inflammatory marker. Pain-limited active movement with preserved passive movement and normal CK support periarticular inflammation rather than primary muscle injury. Statin myopathy usually causes myalgia or weakness without this inflammatory pattern and may raise CK. Elderly-onset rheumatoid arthritis can mimic PMR, but peripheral synovitis is absent. Cervical myelopathy would produce neurological signs rather than symmetrical hip girdle stiffness, while fibromyalgia does not explain the markedly raised ESR. Patients diagnosed with PMR should also be assessed for symptoms or signs of associated giant cell arteritis.

Reference: NHS, Polymyalgia rheumatica – Diagnosis, page last reviewed 23 April 2023. https://www.nhs.uk/conditions/polymyalgia-rheumatica/diagnosis/