Polymyalgia rheumatica

Introduction
Symptoms
Causes
Diagnosis
Treatment
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Introduction

Polymyalgia rheumatica is a condition that causes pain and stiffness in the muscles around the shoulders, neck, buttocks and hips because of inflammation.

How common is polymyalgia rheumatica?

Although it's not a common condition, polymyalgia rheumatica isn't classed as rare.

Polymyalgia rheumatica is an age-related condition. It occasionally occurs in people in their 50s but is more common in people over 60, and especially in those in their 70s and 80s.

Polymyalgia rheumatica is two to three times more common in women than in men. It is more widespread among white people, particularly those of Scandinavian descent, and it is much less common in black people.

The cause of polymyalgia rheumatica is unclear. However, it is thought that a combination of genetic and environmental factors is responsible.

Giant cell arteritis

Around one in five people with polymyalgia rheumatica go on to develop a more serious condition called giant cell arteritis, which causes inflammation in the body’s medium and large arteries, resulting in symptoms such as:

persistent headaches with scalp tenderness (scalp is sore to touch)
pain in the jaw muscles when chewing
impaired vision, such as double vision or loss of vision

Unlike polymyalgia rheumatica, giant cell arteritis is regarded as a medical emergency and without prompt treatment it can cause permanent blindness.

The symptoms of giant cell arteritis can develop before, after or at the same time as the symptoms of polymyalgia rheumatica.

See giant cell arteritis for more information.

Outlook

The outlook for polymyalgia rheumatica is very good and the symptoms usually improve quickly if treated with steroid tablets (oral corticosteroids).

Most people with polymyalgia rheumatica will need to take a long-term course of corticosteroids (one to two years) to prevent their symptoms returning.

Read more about the treatment of polymyalgia rheumatica.

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Symptoms

The symptoms of polymyalgia rheumatica usually develop rapidly over the course of a few weeks.

Muscle pain and stiffness are the most common symptoms. The pain and stiffness can range from moderate to severe.

In polymyalgia rheumatica, the muscles in the neck and shoulder are usually affected, and people also experience pain and stiffness in their lower back, hips and thighs. You may also experience tenderness and pain in your upper arms.

The stiffness usually feels worse first thing in the morning after you wake up and starts to improve after 45 to 60 minutes, as you become more active. The painful symptoms you feel are usually more persistent.

Some people with polymyalgia rheumatica will have additional symptoms including:

a mild high temperature (fever) of 37C-38C (98.6F-100.4F)
depression
fatigue (extreme tiredness)
loss of appetite
weight loss

When to seek medical advice

If you have symptoms of pain and stiffness that last longer than a week, you should make an appointment to see your GP. These types of symptoms require further investigation.

When to seek immediate medical advice

You should seek immediate medical advice if you have been diagnosed with polymyalgia rheumatica (or the condition is suspected) and you suddenly develop the following symptoms:

a persistent and severe headache
jaw pain or cramping in your jaw muscles which is worse when you are eating
vision loss or vision disturbances, such as double vision

These symptoms may indicate a more serious condition called giant cell arteritis.

If you have any of the above symptoms, call your GP immediately for advice. If this is not possible, call NHS Direct Wales (0845 46 47) or contact your local out-of-hours service.

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Causes

The cause of polymyalgia rheumatica is unknown.

The fact that polymyalgia rheumatica mainly affects white people seems to suggest that genes play a role in the condition.

As well as being born with a genetic mutation, an environmental factor is probably also involved in triggering the symptoms of polymyalgia rheumatica.

This environmental factor could be an infection, but as yet there is little hard evidence to support this and no specific infectious agent has been found to cause it.

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Diagnosis

Diagnosing polymyalgia rheumatica can often be quite a lengthy process that involves several different tests.

This is because it shares many symptoms with more common health conditions, such as rheumatoid arthritis, which will need to be ruled out first.

Tests

It is likely that you will be given a series of blood tests. The results can be used to check a range of factors, including:

whether there is any presence of infection in your blood
the levels of inflammation inside your body
how well some of your organs, such as your kidneys, are working
whether your have an overactive thyroid gland or an underactive thyroid gland (both conditions can cause muscle pain)

You may have a urine test to check how well your liver is functioning. X-rays and ultrasound scans may also be used to assess the condition of your bones and joints.

Symptom checklist

After other possible causes of your symptoms have been ruled out, a checklist can be used to see whether your symptoms match those that are most commonly associated with polymyalgia rheumatica.

A checklist of symptoms is used because there is no test to confirm whether you definitely have polymyalgia rheumatica or not. According to the most widely used checklist, a very confident diagnosis of polymyalgia rheumatica can be made if you meet all of the following criteria:

You are over 50 years old.
You have pain in your shoulders or your hip.
You have stiffness in the morning that lasts longer than 45 minutes.
Your symptoms have lasted longer than two weeks.
A blood test shows raised levels of inflammation inside your body.
Your symptoms improve rapidly after being treated with corticosteroids.

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Treatment

Steroid medication (corticosteroids) is the preferred treatment for polymyalgia rheumatica. A type of corticosteroid called prednisolone is usually prescribed.

Non-steroidal anti-inflammatory drugs (NSAIDs), which are widely used to treat other inflammatory conditions, only have limited effectiveness in treating polymyalgia rheumatica. Therefore, there is currently no effective alternative medication for treating the condition other than steroids.

Prednisolone

Prednisolone works by blocking the effects of certain chemicals that are responsible for kick-starting the process of inflammation inside your body. It is taken orally. Most people will be prescribed several tablets, once a day.

It is likely that you will be prescribed about four 5mg prednisolone tablets initially, and the dosage will be gradually reduced every one to two months.

You may need to take prednisolone for at least two years to prevent the symptoms of polymyalgia rheumatica returning. There should be a marked improvement in symptoms within a few days of starting treatment.

Do not stop taking your steroid medication unless your GP says that it is safe for you to do so. This is because suddenly stopping steroid treatment can make you feel very ill.

Side effects

Side effects of prednisolone include:

increased appetite that often leads to weight gain
thinning of the bones (osteoporosis)
increased blood pressure
increased blood sugar (diabetes)
indigestion
increased risk of infection

These side effects should improve as your dosage of prednisolone is decreased, although osteoporosis can be a persistent problem, particularly if you are over 65. It can put you at increased risk of fracturing a bone.

To reduce the risk of osteoporosis, your GP will usually also prescribe medication (bisphosphonates) and calcium and vitamin D supplements to help compensate for the effects of prednisolone by strengthening your bones. Read more about the treatment of osteoporosis.

You may also be referred for a scan known as a dual energy X-ray absorptiometry (DEXA) scan, which helps assess how strong your bones are (see diagnosing osteoporosis).

Vulnerability to infection

Prednisolone can also make you more vulnerable to infection, particularly to the varicella-zoster virus, which is the virus that causes chickenpox and shingles.

You may become very ill if you develop these viral infections. Therefore, avoid close contact with anyone who has chickenpox or shingles.

Seek immediate medical advice if you think that you have been exposed to one of these infections or if a member of your household develops one of these infections.

Follow-up

Your GP will ask you to attend regular follow-up appointments so that they can check how well you are responding to treatment, whether your dosage of prednisolone needs to be adjusted and how well you are coping with the side effects of the medication.

During these appointments, you will have blood tests to check the levels of inflammation inside your body.

Follow-up appointments are usually recommended every few weeks for the first three months and then at three to six-monthly intervals after this time.

If you experience a return of your symptoms during any part of your treatment, contact your GP because your dosage may need to be adjusted.

Steroid card

If you need to take steroids for more than three weeks, your GP or pharmacist should arrange for you to be issued with a steroid card.

You should carry the steroid card with you at all times because it will explain that you are regularly taking steroids and that your dose should not suddenly be stopped. This information may prove very important for healthcare professionals who need to treat you in the event of a sudden illness, accident or emergency.

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