Polymyalgia rheumatica
Polymyalgia rheumatica is an inflammatory condition that causes pain and stiffness in the muscles around the shoulders, neck and hips.
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Medicines commonly prescribed for Polymyalgia rheumatica
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 400 mgActive substance: ibuprofenManufacturer: Pharmaclan S.R.O.Prescription not requiredDosage form: ORAL SOLUTION/SUSPENSION, 20 mg/mlActive substance: ibuprofenManufacturer: Reckitt Benckiser Healthcare S.A.Prescription not requiredDosage form: ORAL SOLUTION/SUSPENSION, 4 mg/mlActive substance: prednisoloneManufacturer: Laboratorio Aldo Union S.L.Prescription required
Polymyalgia rheumatica is an inflammatory condition that causes pain and stiffness in the muscles around the shoulders, neck and hips. It starts quickly, often over a few days: someone who had no complaints the day before cannot lift their arms, get up from a chair or turn over in bed. It responds very well to treatment, and improvement is usually felt within the first few days. Something else matters more: in some people it goes together with inflammation of the arteries in the head, which can take away sight and needs to be acted on immediately.
What it feels like
The most telling feature is not so much the pain as the morning stiffness. People wake up almost unable to move: to sit up in bed they have to use their arms and rock themselves. The stiffness lasts more than forty-five minutes, often two or three hours, and only eases once the body gets going. Evenings are easier, and after sitting for a while it all comes back.
The pain is dull and aching, mostly in the shoulders and upper arms, the neck, the buttocks and the thighs. It nearly always affects both sides about equally, and it wakes people at night when they roll onto a sore shoulder. Hence the very recognisable everyday difficulties: brushing your hair, putting on a coat, reaching something off a high shelf, getting out of a low armchair or out of a car.
General symptoms are common too: tiredness that rest does not fix, loss of appetite and weight, night sweats, a slightly raised temperature, low mood. Sometimes it is these, rather than the pain, that bring someone to the doctor.
One important detail: in polymyalgia rheumatica the muscles do not truly lose power. Moving is hard because of pain, but if you help someone lift their arm, the strength in it is normal. Genuine weakness points to a different illness.
Who it affects and why it happens
Polymyalgia rheumatica begins in the second half of life. It is virtually unseen before the age of fifty, and most people diagnosed with it are past seventy. It is about twice as common in women as in men, and more common in people from northern Europe.
The cause is unknown: an inherited susceptibility and some outside trigger, such as a previous infection, both seem to play a part. The immune system starts to inflame the linings of the joints and the bursae around them, and the pain is felt in the muscles. It is not the result of overexertion or a draught, and it is not catching.
Polymyalgia rheumatica by itself does not destroy joints or shorten life. The main danger lies not in it but in the condition that can travel with it.
Temporal arteritis: when waiting is not an option
Around one in five people with polymyalgia rheumatica develops giant cell arteritis, also called temporal arteritis: inflammation of large arteries, most often those running through the temples towards the eyes. It also happens the other way round, with the arteritis first and the muscle pain following later.
See a doctor the same day if you develop:
- a new headache unlike your usual ones, typically in the temple or the back of the head;
- a tender scalp, so that combing your hair, resting your head on a pillow or wearing glasses hurts;
- aching and tiredness in the chewing muscles or the tongue while eating or talking, making you stop;
- brief blurring or dimming of vision in one eye, or double vision;
- a hardened, tender artery at the temple with no pulse in it.
Call an ambulance — 112 is the single emergency number across much of Europe — if sight in one eye is suddenly lost or sharply worse, or if an arm and leg suddenly become weak or speech is disturbed.
The reason for the hurry is simple: sight lost to arteritis does not come back, whereas treatment started in time almost always preserves it. That is why, once the suspicion is well founded, treatment begins at once, without waiting for test results.
What looks like polymyalgia rheumatica
The diagnosis is rarely made straight away, precisely because many conditions resemble it and no specific test exists. The usual ones to tell apart are:
- rheumatoid arthritis, where the small joints of the hands and feet swell and hurt rather than the shoulder muscles;
- shoulder problems — rotator cuff injury, frozen shoulder, osteoarthritis — usually on one side and without feeling unwell in general;
- an underactive thyroid, which causes muscle aches, sensitivity to cold, puffiness and fatigue;
- muscle damage from medicines, above all cholesterol-lowering ones, and inflammatory muscle diseases: there the weakness is real and the enzyme creatine kinase is raised;
- fibromyalgia, with pain all over the body and poor sleep but normal inflammatory markers;
- Parkinson's disease, which causes stiffness without inflammation;
- infections and cancers. Prolonged fever, night sweats, marked weight loss, bone pain or an abnormal blood count can point to infection of the heart valves, myeloma or another malignancy. A complete lack of response to treatment raises the same question.
How the diagnosis is reached
There is no test that names polymyalgia rheumatica. The diagnosis is built from the typical picture, signs of inflammation in the blood, exclusion of lookalike conditions and a rapid response to treatment.
The usual investigations are:
- ESR and C-reactive protein, the markers of inflammation; they are generally raised, but in some people one of the two stays normal, so both are checked;
- a full blood count, which may show anaemia and a raised platelet count;
- creatine kinase, which is normal in this condition: if it is high, the trail leads to muscle diseases;
- thyroid hormones;
- rheumatoid factor and anti-CCP antibodies, to separate off rheumatoid arthritis;
- liver and kidney blood tests, protein electrophoresis and a urine test;
- an ultrasound scan of the shoulders and hips, which shows the inflammation of bursae and tendons typical of this condition.
Examination and x-rays on their own confirm nothing: a shoulder x-ray in polymyalgia rheumatica can be entirely normal. If temporal arteritis is suspected, an ultrasound scan of the temporal arteries is added and sometimes a small piece of the artery is taken for testing.
The diagnosis is supported by this combination: age over fifty, pain in both shoulders or the pelvic girdle, morning stiffness lasting more than forty-five minutes, symptoms present for more than two weeks, raised inflammatory markers, and rapid improvement on treatment.
Treatment
The mainstay of treatment is steroid tablets, usually prednisolone. Painkillers and anti-inflammatories such as ibuprofen barely help in this condition and are poorly tolerated in later life, so they are not the basis of treatment.
Treatment starts at a moderate dose chosen by the doctor. The response is usually striking: pain and stiffness drop markedly within two or three days, and after a week people feel almost as they did before. That reaction is part of the diagnosis. If nothing changes in a week, the diagnosis is reconsidered.
The dose is then reduced slowly, in steps several weeks apart, guided by how you feel and by blood tests. Most people need between one and two years of treatment, some longer. Rushing this stage is the commonest reason for symptoms coming back.
Steroids must never be stopped abruptly. During long treatment the adrenal glands stop making their own hormone in the usual amounts, and a sudden withdrawal can cause a serious state with weakness, vomiting and a fall in blood pressure. The dose comes down only to the doctor's plan. For the same reason, carry a card stating that you take steroids: ambulance staff, surgeons and dentists all need to know.
If the dose cannot be reduced or the illness keeps relapsing, medicines that allow a lower steroid dose are added — methotrexate, or drugs that block interleukin-6. That decision is made by a rheumatologist.
Side effects and what to arrange in advance
Steroids work fast, but over a long course they carry a cost that is better known from the outset, because much of it can be headed off.
- Bones. Steroids speed up osteoporosis. From the start it is worth discussing enough calcium and vitamin D and, where needed, bone-strengthening medicines and a bone density scan.
- Blood sugar and blood pressure. Both often rise and should be checked regularly, and more often if you already have diabetes.
- Stomach. Upper abdominal pain and ulcers can occur, particularly alongside painkillers. If there is heartburn or pain, the doctor adds stomach protection. Black stools or vomiting blood mean calling an ambulance.
- Infections. Steroids mask them and make them worse. With a temperature, a cough or stinging when passing urine, seek advice sooner than you otherwise would.
- Chickenpox and shingles. If you have never had chickenpox and have been in contact with someone who has it, tell your doctor the same day. Vaccination is worth discussing early: live vaccines are not given on high steroid doses, while the others are actively advisable.
- Mood and sleep. Insomnia, irritability, anxiety and swings in mood are common. If low mood, confusion or thoughts of not wanting to live appear, contact your doctor immediately, and if there is an immediate risk to life, call an ambulance.
- Other effects: increased appetite and weight gain, thin skin and bruising, a puffy face, cataracts and raised pressure in the eye.
As the dose comes down, the risk of these effects falls with it.
Follow-up and living with it
In the first months appointments are frequent, roughly every three to four weeks, then further apart, though not less than every three months during the first year. Each visit looks at how you are, checks blood pressure, inflammatory markers, blood sugar and, where relevant, bone health.
Symptoms returning as the dose is reduced happens to many people and does not mean treatment has failed: going back to the previous step is usually enough. What matters is not to raise or lower the dose yourself but to tell your doctor.
What you do yourself helps as well: keep moving, do gentle range-of-movement exercises for shoulders and hips every day, start the morning with a warm shower, watch your weight, eat enough protein, calcium and vitamin D, and stop smoking. Complete rest in this condition only makes the stiffness worse.
In most people the illness eventually settles and treatment can be stopped altogether. It can return even years later, and then the same path is followed from the beginning.
Online consultation
Shoulder pain with morning stiffness in an adult is one of those situations where weeks should not be lost to creams and painkillers. In an online consultation a doctor will ask how it all began, look at the tests already done, say which investigations are still missing for a diagnosis and explain which specialist to see. It is also a convenient way to handle the next steps: how the treatment is being tolerated, what to do if pain returns on a reduced dose, which checks are needed during long steroid treatment. But with a new headache, pain on chewing or any change in vision, waiting for an online appointment is not safe — that needs to be seen in person the same day, and sudden loss of sight needs an ambulance.
This material is for information only and does not replace medical advice.
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