Polymyalgia Rheumatica Clinical Presentation

Author: Patricia J Papadopoulos, MD; Chief Editor: Herbert S Diamond, MD more...

Updated: Apr 4, 2012

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History
Physical Examination
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History

Patients were often in good health prior to disease onset, which is abrupt in about 50% of patients. In most patients, symptoms appear first in the shoulder girdle. In the remainder, the hip or neck is involved at onset. At presentation, symptoms may be unilateral but they usually become bilateral within a few weeks.

The symptoms include pain and stiffness of the shoulder and hip girdle. The stiffness may be so severe that patients may have great difficulty rising from a chair, turning over in bed, or raising their arms above shoulder height. Muscle weakness is not a feature of polymyalgia rheumatica (PMR), although this can be difficult to assess in the setting of pain, especially if symptoms are protracted and untreated, resulting in disuse atrophy. Stiffness after periods of rest (gel phenomenon) as well as morning stiffness of more than 1 hour typically occurs. The patient may also describe distal peripheral joint swelling or, more rarely, limb edema. Carpal tunnel syndrome can occur in some patients. Most patients report systemic features as listed below. Additionally, patients are always older than 50 years and are usually older than 65 years.

Several diagnostic criteria for PMR exist. One set of diagnostic criteria is as follows^[10]:

Age of onset 50 years or older
Erythrocyte sedimentation rate ≥40 mm/h
Pain persisting for ≥1 month and involving 2 of the following areas: neck, shoulders, and pelvic girdle
Absence of other diseases capable of causing the musculoskeletal symptoms
Morning stiffness lasting ≥1 hour
Rapid response to prednisone (≤20 mg)

In 2012, the European League Against Rheumatism and American College of Rheumatology published new provisional classification criteria for polymyalgia rheumatica in patients aged 50 or older with bilateral shoulder aching and elevated inflammatory markers. These classification criteria are not diagnostic criteria, but rather are designed for enrolling patients in clinical trials of new treatments for PMR. This collaborative initiative resulted in a scoring algorithm based on the following criteria:

Morning stiffness >45 minutes (2 points)
Hip pain/limited range of motion (1 point)
Absence of rheumatoid factor and/or anti-citrullinated protein antibody (anti-CCP) (2 points)
Absence of peripheral joint pain (1 point)

A score of ≥4 points had a 68% sensitivity and 78% specificity for discriminating PMR from other comparison patients. There is also an additional ultrasound criteria (1 point if positive findings), which can add up to a score of ≥5 points that is associated with a 66% sensitivity and 81% specificity for PMR.^[11]

Systemic findings in more than 50% of patients are as follows:

Low-grade fever and weight loss
Malaise, fatigue, and depression
Difficulty rising from bed in the morning
Difficulty getting up from the toilet or out of a chair
Difficulty completing daily life activities
High, spiking fevers (rare, should prompt evaluation for underlying infection, malignancy, or vasculitis)

Musculoskeletal findings are as follows^[12]:

Morning stiffness for ≥1 hour, often more prolonged
Muscle stiffness after prolonged inactivity
Synovitis of proximal joints and periarticular structures
Peripheral arthritis (in 25% of patients)
Carpal tunnel syndrome (in about 15% of patients)
Distal extremity swelling (in approximately 12%)
Possible development of arthralgia and myalgia up to 6 months after onset of systemic symptoms

Physical Examination

Polymyalgia rheumatica is a clinical diagnosis based on the complex of presenting symptoms and exclusion of the other potential diseases. The signs and symptoms of polymyalgia rheumatica are nonspecific, and objective findings on physical examination often are lacking.

General symptoms are as follows:

Fatigued appearance
Low-grade temperature
Distal extremity swelling with pitting edema

Musculoskeletal findings are as follows:

Normal muscle strength; no muscle atrophy typically present at initial presentation
Pain in the shoulder and hip with movement; active range of motion may be decreased because of pain
Transient synovitis of the knee, wrist, and sternoclavicular joints; a more peripheral nonerosive arthritis may be seen in some cases
Tenderness to palpation with decreased active range of motion in the musculature of the proximal hip/leg and/or shoulder/arm girdle

In later stages, disuse muscle atrophy with proximal muscle weakness may occur. Contractures of the shoulder capsule may lead to limitation of passive and active movement.

Proceed to Differential Diagnoses

Contributor Information and Disclosures

Author

Patricia J Papadopoulos, MD Key Clinical Faculty, Rheumatology Service, Department of Medicine, Walter Reed National Military Medical Center; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences

Patricia J Papadopoulos, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and American College of Rheumatology

Disclosure: Merck Ownership interest Own stock

Coauthor(s)

Ehab R Saad, MD, MA, FACP, FASN Assistant Professor, Department of Medicine, Medical College of Wisconsin

Ehab R Saad, MD, MA, FACP, FASN is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Geriatrics Society, American Society of Nephrology, and National Kidney Foundation

Disclosure: Nothing to disclose.

Gloria Fioravanti, DO Clinical Assistant Professor, Program Director, Department of Internal Medicine, St Luke's Hospital of Bethlehem, Temple University School of Medicine

Gloria Fioravanti, DO is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American Osteopathic Association

Disclosure: Nothing to disclose.

Allen Samuels, MD Consulting Staff, Department of Internal Medicine, Division of Rheumatology, St Luke's Hospital, Lehigh Valley Hospital, Pocono Medical Center

Allen Samuels, MD is a member of the following medical societies: American College of Rheumatology

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD Adjunct Professor of Medicine, Division of Rheumatology, University of Pittsburgh School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa

Disclosure: Merck Ownership interest Other; Smith Kline Ownership interest Other; Zimmer Ownership interest Other

Additional Contributors

The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the US Government. Additionally, this publication does not imply the Federal or Department of Defense endorsement of any product.

Past Contributors

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine