1.09 Polymyalgia Rheumatica
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agk's Library of Common Simple Emergencies



Presentation
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An elderly patient (more commonly female) 
complains of a week or two of morning stiff- 
ness, which may interfere with her ability to 
rise from bed, but improves during the day. She 
may ascribe her problem to muscle weakness or 
joint pains, but physical examination discloses 
that symmetrical pain and tenderness of neck, 
shoulder, and hip muscles are the actual source 
of any "weakness." There may be some mild 
arthritis of several peripheral joints, but the 
rest of the physical examination is negative.

What to do:
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- Perform a complete history and physical exam- 
   ination, particularly of the cervical and 
   lumbar spines and nerve roots (strength, 
   sensation, and deep tendon reflexes in the 
   distal limbs should be intact with PMR). 
   Confirm the diagnosis of PMR by palpating 
   tender shoulder muscles (perhaps also hips, 
   and, less commonly, neck).
- Confirm the diagnosis by obtaining an erythr- 
   ocyte sedimentation rate, which should be in 
   the 30-l00mm/hour range. (An especially high 
   ESR, over 100/hour suggests more severe 
   autoimmune disease or malignancy.)
- Mild and borderline cases may respond with 
   nonsteroidal anti-inflammatory medications 
   (ibuprofen, naproxen). More severe cases 
   will respond to prednisone 20-60mg qd within 
   a week or two, after which the dose should 
   be tapered. Failure to respond to cortico- 
   steroid therapy suggests some other 
   diagnosis.
- Explain the syndrome to the patient and 
   arrange for followup.

What not to do:
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- Do not miss temporal arteritis, a common 
   component of the polymyalgia rheumatica 
   syndrome, and a clue to the existence of 
   ophthalmic and cerebral arteritis, which can 
   have dire neurological consequences. Palpate 
   the temporal arteries for tenderness, 
   swelling, or induration, and ask about 
   transient neurological signs.
- Do not postpone diagnosis or treatment of 
   temporal arteritis pending results of a 
   temporal artery biopsy showing giant cell 
   arteritis. The lesion typically skips areas, 
   making biopsy an insensitive diagnostic 
   procedure.

Discussion
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Stiffness, pain, and weakness are common 
complaints in older patients, but polymyalgia 
rheumatica may respond dramatically to 
treatment. Rheumatoid arthritis produces 
morning stiffness, but is usually present in 
more peripheral joints, and without muscle 
tenderness. Polymyositis is usually character- 
ized by increased serum muscle enzymes with a 
normal ESR, and may include a skin rash 
(dermatomyositis). Often, a therapeutic trial 
of prednisone helps make the diagnosis.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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