Polymyalgia rheumatica !
An inflammatory disease of people over 50 that causes aching and morning stiffness of the shoulders and hips. It responds quickly to corticosteroids.
Updated 2026-11-01
Structures involved
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Why it happens
- Systemic effects of inflammation: fever, acute-phase proteins, leukocytosis, sepsis
- C-reactive protein (CRP) as a lab test
- Synovial joints: capsule, synovial membrane and articular cartilage
What it is
An inflammatory disorder of older adults that causes pain and prolonged morning stiffness in the shoulder and hip girdles and the neck, with raised inflammatory markers. It is closely linked to giant cell arteritis.
Who gets it
Almost only seen after age 50, with a peak around 70–80; about twice as common in women. It is most frequent in people of northern European descent and less often reported in Latin America, but it is seen in rheumatology and internal medicine clinics as the population ages. Roughly 15–20% of patients also have giant cell arteritis.
Causes
- Cause unknown; an interaction of genetic susceptibility, ageing of the immune system and possibly environmental triggers
- Inflammation of the bursae, tendon sheaths and joint synovium around the shoulders and hips rather than of the muscle itself
Risk factors
- Age over 50 (key criterion)
- Female sex
- Northern European ancestry
- Giant cell arteritis
Pathophysiology
Activated immune cells and cytokines, especially interleukin-6, drive inflammation of the subacromial and subdeltoid bursae, the long biceps tendon sheath, the trochanteric bursae and the synovium of the shoulders and hips. The muscles hurt but are not damaged, so strength and muscle enzymes are normal. The same systemic inflammation explains the fatigue, low-grade fever, anaemia and high ESR and CRP.
Classification
- Isolated polymyalgia rheumatica
- Polymyalgia rheumatica with giant cell arteritis
Symptoms and signs
- Bilateral aching of the shoulders and upper arms, often also the neck, hips and thighs
- Morning stiffness lasting more than 45 minutes
- Difficulty getting out of bed, combing the hair or rising from a chair because of pain and stiffness, not weakness
- Fatigue, low-grade fever, poor appetite and weight loss
- Sometimes peripheral arthritis or swelling of the hands and wrists
Diagnosis
- Clinical
- A clinical diagnosis in a person over 50 with bilateral shoulder (and often hip) girdle pain, prolonged morning stiffness and normal strength. Classification criteria (ACR/EULAR) support it; a prompt response to corticosteroids is typical but does not prove the diagnosis.
- Tests
- High ESR and/or CRP, often with mild anaemia of inflammation. Rheumatoid factor and anti-CCP are usually negative and CK is normal; thyroid tests and other labs help exclude mimics.
- Imaging
- Ultrasound may show subdeltoid or subacromial bursitis, biceps tenosynovitis or hip bursitis/synovitis. When giant cell arteritis is suspected, temporal artery ultrasound or biopsy is done.
Differential diagnosis
- Late-onset rheumatoid arthritis
- Inflammatory myopathy
- Hypothyroidism
- Rotator cuff disease or bilateral frozen shoulder
- Fibromyalgia
- Cancer (myeloma, metastases) or chronic infection such as endocarditis
- Statin-induced myalgia
Goal of treatment
Control pain and stiffness quickly with the lowest effective corticosteroid exposure, taper slowly to prevent relapses, protect against corticosteroid side effects and watch for giant cell arteritis.
Treatment
- Medical
- Low-dose oral glucocorticoids are first-line; a dramatic improvement within days is typical. They are tapered slowly, usually over one to two years.
- Medical
- Steroid-sparing agents (methotrexate) for relapses or high risk of steroid toxicity; interleukin-6 receptor blockers in selected refractory cases.
- Follow-up
- Follow-up of symptoms and ESR/CRP during the taper, plus monitoring of glucose, blood pressure, weight and bone density; nursing care asks about headache and vision at every visit.
- Medical
- Bone protection while on glucocorticoids: calcium, vitamin D and, when indicated, bisphosphonates.
Complications
- Giant cell arteritis with permanent visual loss
- Relapses during the corticosteroid taper
- Corticosteroid adverse effects: osteoporosis and fractures, diabetes, hypertension, cataract, infections and weight gain
- Reduced mobility and falls in older adults
Prognosis
Usually good: most patients improve rapidly and the disease remits within a few years, although relapses during tapering are common and some need long-term low-dose treatment. Corticosteroid toxicity is the main source of harm.
Test yourself
Think of the answer, then tap the question to see it.
What is the classic presentation of polymyalgia rheumatica?
A person over 50 with bilateral shoulder and hip girdle aching, morning stiffness over 45 minutes, normal strength and high ESR/CRP.
Which vasculitis is closely associated with polymyalgia rheumatica?
Giant cell (temporal) arteritis; headache, jaw claudication or visual symptoms need urgent assessment.
How do you tell polymyalgia rheumatica from polymyositis?
In polymyalgia, pain and stiffness dominate with normal strength and normal CK; in polymyositis there is true proximal weakness with high CK.
What is the first-line treatment of polymyalgia rheumatica?
Low-dose oral glucocorticoids, tapered slowly, with bone protection.
Related conditions
- Giant cell arteritis
- Rheumatoid arthritis
- Inflammatory myopathies (dermatomyositis, polymyositis)
- Osteoporosis
- Hypothyroidism
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Polymyalgia rheumatica (MedlinePlus (U.S. National Library of Medicine), 2025).
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