Polymyalgia rheumatica.
Polymyalgia rheumatica (PMR) is an inflammatory disease of the shoulder and hip girdle that primarily affects adults over 50. It causes prominent morning stiffness, pain, and an elevated ESR/CRP. PMR responds dramatically to low-dose prednisone (15–20 mg) — a treatment response that's almost diagnostic. About 15–20% of PMR patients also have giant cell arteritis (GCA), which requires urgent recognition. Most patients can taper off steroids over 1–2 years, though some have a longer course. Methotrexate and tocilizumab are steroid-sparing options.
The mechanism, the inflammation that is almost too obvious.
PMR is one of the most characteristic inflammatory diseases in rheumatology — pattern, age, and treatment response all align. Four mechanisms drive what patients experience:
Bursitis and synovitis
Inflammation of the shoulder and hip girdle bursae (subacromial, subdeltoid, trochanteric) and shoulder and hip joint synovium. Ultrasound or MRI confirms the inflammation in atypical cases.
Age-related immune dysregulation
PMR almost exclusively affects adults over 50, peaking in the 70s. The mechanism appears to involve age-related immune dysregulation and shared pathways with giant cell arteritis.
GCA overlap
15–20% of PMR patients have concurrent or subsequent GCA. Every PMR patient needs to be screened for GCA symptoms (headache, jaw claudication, scalp tenderness, vision changes) at every visit. Missing GCA loses vision permanently.
IL-6 driven
Like GCA, PMR is heavily IL-6 driven. This is why ESR and CRP are reliably elevated and why tocilizumab (an IL-6 receptor antagonist) works as a steroid-sparing agent.
The 4-step plan, applied to PMR.
Get the right diagnosis
Clinical pattern (bilateral shoulder and hip girdle pain and stiffness, prominent morning stiffness, age over 50) plus elevated ESR/CRP. Rule out RA with anti-CCP and RF. Imaging (ultrasound or MRI) is helpful in atypical presentations. The dramatic response to low-dose prednisone (15–20 mg) within days is part of the diagnostic picture.
Learn more about labs →Clean up your food
Adequate protein (1.2 g/kg/day) and calcium with vitamin D during steroid courses to preserve muscle and bone. Mediterranean pattern reduces inflammation. Limit alcohol on steroids (osteoporosis risk).
PMR & diet →Detox your daily life
Bone health matters during steroid courses — bisphosphonate or calcium plus vitamin D as appropriate. Manage stress; stress amplifies pain perception.
PMR & environment →Build a stronger body
Daily mobility work to prevent steroid-induced muscle loss and the disuse atrophy that comes from limited activity during active disease. Resistance training is essential — sarcopenia is the long-term risk in PMR.
PMR & exercise →
Go deeper.
Common misconceptions.
"PMR is just old-age aches and pains."
PMR is a specific inflammatory disease with characteristic features, elevated inflammatory markers, and a dramatic response to low-dose steroids. Calling it 'just aging' delays diagnosis and treatment — and misses the 15–20% of patients who also develop GCA.
"I'll be on steroids forever."
Most PMR patients taper off prednisone over 1–2 years. Some have a longer course. Methotrexate and tocilizumab are effective steroid-sparing options when needed. The 'forever on steroids' picture is often a treatment plan problem, not a disease feature.
"PMR is the same as rheumatoid arthritis."
They're very different. PMR affects the shoulder and hip girdle (proximal), not the small joints. Anti-CCP and RF are negative. The treatment is different (low-dose prednisone for PMR, DMARDs and biologics for RA). And PMR can co-occur with GCA — a feature RA doesn't have.
When to see a rheumatologist.
See a rheumatologist if you have:
- Bilateral shoulder and hip girdle pain and stiffness lasting more than 2 weeks
- Morning stiffness lasting more than 45 minutes
- Age over 50 (PMR is rare before 50)
- Elevated ESR or CRP on a routine lab
- Difficulty getting out of bed or out of a chair due to stiffness
- Any new headache, vision change, or jaw claudication (GCA red flag — urgent)
Every PMR patient should be screened for GCA at every visit. New headache, jaw claudication, scalp tenderness, or vision change requires same-day evaluation and high-dose steroids — do not wait.
- Dasgupta B, et al. 2012 provisional classification criteria for polymyalgia rheumatica. Ann Rheum Dis, 2012. PubMed 22454398
- Dejaco C, et al. 2015 EULAR/ACR recommendations for the management of PMR. Ann Rheum Dis, 2015. PubMed 26385445
- Devauchelle-Pensec V, et al. Tocilizumab in PMR. Ann Rheum Dis.
- Buttgereit F, et al. Polymyalgia rheumatica and giant cell arteritis: a systematic review. JAMA, 2016. PubMed 27923089