Imagine going to bed feeling fine and waking up the next morning feeling as if you have aged a decade overnight. You are gripped by a profound, debilitating stiffness and aching pain in your shoulders and hips, making the simple act of getting out of bed, raising your arms to comb your hair, or getting up from a chair an excruciating effort. This sudden and dramatic onset of symptoms is the classic story for someone developing Polymyalgia Rheumatica (PMR). PMR is a common inflammatory disorder that primarily affects older adults. While its symptoms can be disabling and frightening, it is crucial to understand that PMR is a highly treatable condition. With a proper diagnosis and a course of low-dose corticosteroids, most individuals experience a rapid and dramatic relief from their symptoms, allowing them to regain their mobility and quality of life.

To understand this condition, it is helpful to break down its name, which comes from Greek:

• Poly- means “many.”
• -myo- refers to muscle.
• -algia means “pain.”
• Rheumatica refers to rheumatic diseases affecting joints and connective tissues.

So, the name literally means “pain in many muscles.” However, this is slightly misleading. Polymyalgia rheumatica is not a disease of the muscles themselves. It is an inflammatory condition that primarily affects the joints and the tissues surrounding the joints, particularly the large “girdles” of the shoulders and hips. The inflammation targets the synovium (the lining of the joints) and the bursae (small, fluid-filled sacs that cushion the joints).

A helpful analogy is to think of your shoulder and hip joints as complex, high-traffic intersections.

• In a healthy state, all the moving parts,the hinges, bearings, and shock absorbers (the joints, tendons, and bursae) are well-lubricated and move smoothly.
• In PMR, it is as if a sudden, intense inflammatory “rust” has seized up the machinery in the intersections on both sides of your body.
• The inflamed and swollen tissues make any movement a painful, stiff, and difficult process. You feel the pain and weakness in your large muscles because they are struggling to move these “rusted” and inflamed joints.

In my experience, patients often come in thinking they’re just “getting old” because of morning stiffness and fatigue. But polymyalgia rheumatica is a distinct, treatable condition.

The exact cause of polymyalgia rheumatica is unknown. It is considered an inflammatory disorder that likely results from a combination of genetic and environmental factors.

The leading theory is that in a genetically susceptible older individual, an environmental trigger most likely a viral infection sets off an abnormal and overactive inflammatory response from the immune system. This theory is supported by the fact that new cases of PMR often appear in cyclical, seasonal patterns, similar to the circulation of common respiratory viruses. The immune system, perhaps after fighting off a virus, fails to shut down properly and instead begins to cause widespread inflammation in the susceptible joint linings and bursae of the shoulder and hip girdles.

In my experience, patients are often surprised to learn that PMR is not caused by physical strain, it’s a systemic inflammatory condition, not just a musculoskeletal issue.

PMR is not contagious. You cannot catch it from another person. It is a condition that develops, usually quite suddenly, due to a combination of risk factors that a person cannot control.

The primary risk factors for developing PMR are:

• Age: PMR almost exclusively affects older adults. It is extremely rare in people under the age of 50, and the risk increases significantly with each passing decade. The average age of onset is around 70 to 75.
• Gender: The condition is about two to three times more common in women than men.
• Ancestry: It is most common in people of Northern European descent, particularly those from Scandinavia. However, it can and does affect people of all races and ethnic backgrounds.

In my experience, PMR tends to develop gradually in older adults, and many first notice it as stiffness that’s worse in the morning but improves throughout the day.

The onset of PMR symptoms is typically abrupt, developing over a period of just a few days to a couple of weeks.

The hallmark symptoms of the condition are:

• Symmetrical Pain and Stiffness: The pain and stiffness affect both sides of the body, centered on the major joint girdles:
  • The shoulders and neck.
  • The hips, lower back, and thighs.
• Profound Morning Stiffness: This is a classic and defining feature. The stiffness is most severe upon waking in the morning and typically lasts for at least 45 minutes. This morning stiffness can be so debilitating that it makes it extremely difficult to get out of bed, lift the arms to get dressed, or stand up from a chair.

In addition to the pain and stiffness, many people with PMR also experience constitutional symptoms that make them feel generally unwell. These include:

• Profound fatigue and a lack of energy.
• A general feeling of malaise, similar to having the flu.
• A low-grade fever.
• Unintended weight loss and loss of appetite.

Clinically, I also look for systemic signs like low-grade fever, fatigue, and weight loss. Some patients may even have trouble getting dressed due to stiffness.

The Critical Link to Giant Cell Arteritis (GCA)

It is absolutely vital for anyone with symptoms of PMR to be aware of its close association with a more serious condition called Giant Cell Arteritis (GCA).

• GCA is an inflammatory disease of major blood vessels, especially arteries in the head and temples.
• Approximately 15-20% of people with PMR will also develop GCA. About 50% of people with GCA also have PMR symptoms.
• GCA is a medical emergency because if the inflammation affects the arteries supplying the eyes, it can cause sudden, permanent blindness.
• Seek immediate medical care if you have symptoms of PMR and develop any of the following “red flag” symptoms of GCA:
  • A new, severe, and persistent headache, typically at the temples.
  • Scalp tenderness (e.g., pain when brushing your hair).
  • Pain in your jaw when chewing.
  • Sudden blurred vision, double vision, or loss of vision in one eye.

There is no single blood test or imaging scan that can definitively diagnose PMR. It is a clinical diagnosis made by a doctor, usually a rheumatologist, based on a careful evaluation of a patient’s age, their characteristic pattern of symptoms, and the results of blood tests that measure inflammation.

The diagnostic process involves three key components:

• Clinical Criteria: The doctor will listen for the classic story of a person over 50 with a recent, abrupt onset of symmetrical shoulder and hip pain, accompanied by significant morning stiffness.
• Blood Tests for Inflammation: While there is no test for PMR itself, blood tests will show very high levels of inflammatory markers.
  • Erythrocyte Sedimentation Rate (ESR or “sed rate”)
  • C-Reactive Protein (CRP)
  • The presence of very high ESR and CRP levels in a patient with the classic symptoms is a strong indicator of PMR.
• A Dramatic Response to Steroids: This is a key diagnostic feature of the disease. When a patient with PMR is given a low dose of corticosteroids, they typically experience a rapid and dramatic improvement in their pain and stiffness, often within just one to three days. This near-miraculous response is highly characteristic of PMR and helps confirm the diagnosis.

A doctor will also perform other blood tests, such as for rheumatoid factor (RF) and anti-CCP antibodies, to rule out other inflammatory conditions like rheumatoid arthritis that can sometimes cause similar symptoms.

Clinically, I rely on a combination of history, physical exam, and elevated inflammatory markers like ESR and CRP, though imaging may be needed to rule out other causes.

While PMR symptoms can be debilitating, the good news is that it is a highly treatable condition. The goal of treatment is to reduce the pain and stiffness, restore function, and improve quality of life.

1. Low-Dose Corticosteroids

The cornerstone and primary treatment for PMR is a low dose of an oral corticosteroid, most commonly prednisone.

• A starting dose of around 12.5 to 25 mg of prednisone per day is typically prescribed.
• The response is usually very fast and dramatic. Most patients feel a significant, almost miraculous, improvement in their pain and stiffness within the first few days of starting the medication.

2. The Tapering Process

Once the symptoms are well-controlled, the most important and challenging part of management begins: the taper.

• The doctor will guide the patient through a very slow and gradual reduction of the prednisone dose over a long period.
• This tapering process is highly individualized and can often take one to two years, or even longer.
• Tapering the dose too quickly can cause the symptoms to flare up again, requiring the dose to be increased. The process requires patience and a close partnership between the patient and their doctor.

3. Managing the Side Effects of Steroids

Even at low doses, long-term use of corticosteroids can have side effects. These can include weight gain, an increased risk of high blood pressure and diabetes, cataracts, and bone loss (osteoporosis). To mitigate the risk of osteoporosis, a doctor will almost always recommend that patients taking long-term steroids also take calcium and vitamin D supplements. They may also order a bone density scan to monitor bone health.

4. Steroid-Sparing Agents

For patients who have difficulty tapering off prednisone, who experience a relapse, or who are at high risk for steroid side effects, a doctor may add a “steroid-sparing” agent to the treatment plan. A medication like methotrexate can help control the underlying inflammation, allowing a lower dose of prednisone to be used.

Clinically, I monitor closely to taper steroids slowly over months, as relapse is common. I also watch for side effects like osteoporosis or glucose intolerance.

Polymyalgia Rheumatica is a common inflammatory condition that brings a sudden and disabling onset of severe pain and stiffness to the shoulders and hips of older adults. The experience can be frightening, making a person feel as if they have aged years in a matter of days. It is essential for individuals with these symptoms to seek a prompt medical evaluation to confirm the diagnosis and, crucially, to rule out the related medical emergency of Giant Cell Arteritis. The most reassuring aspect of PMR is that it is an eminently treatable disease. The response to a low dose of corticosteroid medication is typically rapid and profound, quickly relieving the debilitating symptoms. Clinically, I’ve seen that early diagnosis and careful tapering of steroids offer excellent outcomes, especially when supported by regular follow-ups and patient education.

1. American College of Rheumatology. (2023). Polymyalgia Rheumatica. Retrieved from https://rheumatology.org/patients/polymyalgia-rheumatica
2. The Mayo Clinic. (2024). Polymyalgia rheumatica. Retrieved from https://www.mayoclinic.org/diseases-conditions/polymyalgia-rheumatica/symptoms-causes/syc-20376539
3. National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), NIH. (2020). Polymyalgia Rheumatica and Giant Cell Arteritis. Retrieved from https://www.niams.nih.gov/health-topics/polymyalgia-rheumatica-and-giant-cell-arteritis