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Hip and shoulder pain in older adults – PMR

Polymyalgia rheumatica (PMR) is the most common inflammatory rheumatological disorder in older people, and should be considered when assessing an older adult presenting with acute-onset bilateral hip and shoulder pain.

However, diagnosis can be challenging, especially in those with an atypical presentation. The lack of a 'gold standard' diagnostic test means that a thorough and diagnostic work-up is needed to exclude other conditions that commonly present with polymyalgic syndrome.

Learning objectives

This module will help you to:

  • improve your understanding of the diagnosis of musculoskeletal pain in older adults, including polymyalgia rheumatica
  • understand what investigations are appropriate to help with diagnosis
  • recognise 'red flags' which might need further investigation or referral
  • understand initial and long-term treatment strategies and manage potential side-effects of treatment.
Hip pain

Symptoms of PMR

Polymyalgia rheumatica (PMR) is characterised by a rapid onset of bilateral pain and stiffness of the hips and shoulders.

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A therapist helping a patient to stand

Examination for PMR

Patients expect a physical examination and it provides crucial information about the possible causes of pain and stiffness.

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Man having an injection in his arm

Investigations for PMR

Investigations can be helpful in supporting clinical suspicion of polymyalgia rheumatica or in ruling out other possible diagnoses.

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doctor with patient

Diagnosing PMR

In patients over 50, rapid-onset bilateral hip and/or shoulder pain and morning stiffness, with evidence of inflammation, are strongly suggestive of PMR.

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Pills with a bottle

Treatment for PMR

Glucocorticoids are the standard treatment for PMR. Once symptoms are under control the glucocorticoid dose should be gradually tapered to reduce the risk of side-effects.

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A doctor with patient

Reviewing PMR patients

Regular patient reviews – covering response to treatment, possible side-effects and red flag symptoms – are essential in the management of PMR.

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Woman with pain in temples

Diagnosing and treating giant cell arteritis (GCA)

Giant cell arteritis is a 'must not miss' diagnosis and it's important that you and your patient remains vigilant for possible symptoms of GCA.

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Lady having chat with doctor

Referring patients with PMR

PMR can usually be managed entirely in primary care, but patients should be referred if there's uncertainty about the diagnosis or they're not responding to treatment.

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A woman stretching

Summary and further reading

Most patients with PMR can be safely managed in primary care but it's important to continue monitoring for potential side-effects of treatment and for 'red flag' symptoms.

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Man helping lady put her coat on

Case studies

These case studies offer examples to guide through the assessment and management of patients presenting with symptoms suggestive of PMR.

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