Case Scenario: Polymyalgia Rheumatica (PMR)

Summary:

The case discussion focused on differentiating osteoarthritis from polymyalgia rheumatica (PMR). The feedback emphasized recognizing key clinical features, the importance of structured questioning, and effective management.

Key Points:

Clinical Features and Diagnosis:

• Autoimmune vs. Mechanical Conditions:

  • Morning stiffness that improves with activity suggests an autoimmune condition (e.g., PMR, rheumatoid arthritis, ankylosing spondylitis).

  • Osteoarthritis (OA) worsens with activity due to wear and tear.

• Typical Signs of PMR:

  • Elderly patients (usually >50 years).

  • Proximal muscle stiffness and pain (shoulders, hips).

  • Difficulty standing without support or raising hands above shoulders (distinguishing feature).

  • No peripheral joint involvement (rheumatoid arthritis affects smaller joints).

• Differential Diagnosis:

  • Rheumatoid arthritis – Involves smaller joints, associated with nodules (Bouchard’s & Heberden’s).

  • Osteoarthritis – Affects weight-bearing joints, worsens with activity.

  • Giant cell arteritis (GCA) – PMR is strongly linked; always ask about headaches, jaw claudication, and vision issues to rule out GCA.

Diagnostic Approach:

• Key History Questions:

  • Pattern of stiffness and pain – Worse in morning? Improves over the day?

  • Bilateral vs. unilateral involvement (PMR is typically bilateral).

  • Any associated symptoms? (headache, jaw pain – suggest GCA).

  • Impact on daily activities (difficulty lifting arms, standing up).

  • Other systemic symptoms? (fever, weight loss – rule out malignancy/infection).

• Examinations to Perform:

  • Functional assessment: Check for difficulty in raising arms, standing from a chair.

  • Joint examination: Look for swelling, tenderness (PMR does not cause joint deformities).

• Investigations to Confirm Diagnosis:

  • Inflammatory markers:

    • ESR and CRP → Markedly elevated in PMR.

  • Autoimmune markers:

    • Rheumatoid factor (RF) and ANA → Negative in PMR (helps rule out RA/SLE).

  • FBC, LFTs → Rule out infection, malignancy.

Management:

• First-Line Treatment:

  • Low-dose corticosteroids (Prednisolone 15mg daily) → Rapid symptom improvement confirms diagnosis.

  • Tapering schedule required to prevent relapse.

• Supportive Management:

  • Gastroprotection: If patient is on steroids, prescribe Omeprazole for gastric protection.

  • Bone Protection: Calcium, Vitamin D, and consider bisphosphonates to prevent osteoporosis.

  • Smoking cessation advice (smoking can worsen inflammatory conditions).

• Monitoring:

  • Regular ESR/CRP monitoring to guide steroid tapering.

  • Watch for steroid side effects (weight gain, osteoporosis, diabetes).

• Red Flags & Safety Netting:

  • Sudden vision loss or severe headache → Suggests giant cell arteritis (GCA) → Urgent referral, high-dose steroids immediately.

  • Advise to return if symptoms worsen or fail to improve with treatment.

Communication Skills:

• Explain PMR simply:

  • “This is an autoimmune condition that causes inflammation in your muscles, leading to stiffness and pain, especially in the morning.”

• Discuss steroid therapy risks & need for tapering.

• Use clear, structured questioning to ensure a thorough history.

Ethical Considerations:

• Informed consent for long-term steroid use.

• Discuss lifestyle modifications to prevent complications (diet, exercise).

Additional Resources:

• NICE Guidelines on PMR management.

• GMC Good Medical Practice on patient-centered care and safety netting​.

• PLAB 2 Examiner Tips on structured consultation​.