Shoulder and Hip Girdle Pain in a 72-Year-Old Woman
A 72-year-old woman has 5 weeks of bilateral shoulder and hip girdle aching and stiffness, worst in the morning and lasting about 90 minutes. She struggles to rise from a chair and to lift her arms overhead, and has had to stop gardening. She denies headache, jaw claudication, scalp tenderness, or visual change. On exam, there is painful restriction of shoulder abduction without true weakness, and no synovitis. ESR 88 mm/h, CRP 61 mg/L, hemoglobin 10.8 g/dL with MCV 86 fL, platelets 410,000/µL, CK 110 U/L, creatinine 0.9 mg/dL, RF and anti-CCP negative. She asks whether this is just arthritis and whether she needs physical therapy.
1. What is the diagnosis, what treatment would you start today, and what response do you expect?
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This is polymyalgia rheumatica: age over 50, bilateral shoulder and hip girdle pain, prominent morning stiffness over 45 minutes, no true weakness, markedly elevated inflammatory markers with a normal CK, and negative rheumatoid serology. The normal CK and the absence of objective weakness argue against a myopathy; the absence of synovitis argues against rheumatoid arthritis (and RF/CCP are negative).
Start prednisone 15–20 mg daily today. No confirmatory test exists, so the diagnosis is supported by the response: stiffness and pain should improve substantially within days to 2 weeks, and inflammatory markers should fall. Do not start low-dose prednisone (5 mg) - that dose is used for maintenance, not induction - and do not wait for imaging.
Also address at initiation: baseline bone density and calcium/vitamin D with an antiresorptive plan (she is over 65 and starting glucocorticoids), glucose monitoring, blood pressure, and counseling about tapering rather than stopping abruptly. Arrange a follow-up in 2–4 weeks to assess response and taper to the lowest effective dose, generally over months.
Physical therapy is an adjunct, not the treatment. Without glucocorticoids she will not improve, and delay risks unnecessary disability.
2. At the 3-week visit she reports only minimal improvement. What would you reconsider, and how would you work it up?
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Failure to respond to 15–20 mg of prednisone within 2–3 weeks should make you doubt the diagnosis. Consider:
- Late-onset rheumatoid arthritis - reexamine for synovitis in the wrists, MCPs, and knees; repeat RF and anti-CCP (seronegative RA exists).
- Inflammatory myopathy - recheck CK, consider aldolase and EMG; proximal weakness rather than pain points this way.
- Hypothyroidism and hypercalcemia - both cause proximal aching; check TSH and calcium.
- Malignancy and infection - multiple myeloma (check SPEP/free light chains with the anemia), endocarditis, and occult solid tumors can mimic PMR. Weight loss, night sweats, or focal bone pain should prompt imaging.
- Large-vessel vasculitis without cranial symptoms - ask again specifically about claudication of the jaw and limbs, polymyalgia symptoms of the legs, and any limb claudication; FDG-PET can show aortitis and large-vessel uptake.
- Fibromyalgia and depression - expected inflammatory marker elevation makes these less likely but not impossible.
- Adrenal insufficiency if she has been on steroids long enough to suppress the axis and then stopped.
Also verify adherence, that she is actually taking the dose prescribed, and that no enzyme inducer or rifampin is accelerating steroid metabolism.
3. She calls the next morning reporting jaw pain with chewing and a transient curtain over her right eye lasting 5 minutes. What do you do?
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This is a vision-threatening emergency - treat for giant cell arteritis immediately, before any confirmatory testing. Jaw claudication with amaurosis fugax is high-risk disease, and the fellow eye can be lost within hours to days.
Same day:
- Prednisone 40–60 mg daily (1 mg/kg), started now - do not wait for an ultrasound, a biopsy, or an ESR result. If there is established visual loss, many experts give intravenous methylprednisolone 500–1000 mg daily for 1–3 days, though the evidence for rescue of established loss is weak; the goal is protecting the other eye.
- Immediate ophthalmology evaluation the same day.
- Diagnostic confirmation without delaying treatment: temporal artery ultrasound (halo sign) is the preferred noninvasive test where available; temporal artery biopsy remains an option and stays informative for up to about 2 weeks after starting steroids. A negative biopsy does not exclude the diagnosis - skip lesions occur - and does not justify stopping steroids.
- Consider large-vessel involvement with FDG-PET or CT angiography if there is limb claudication, bruits, or unexplained fever.
Ongoing: high-dose steroids for weeks before tapering, bone and glucose protection, and Pneumocystis prophylaxis if the dose and duration are substantial or other immunosuppressants are added. Tocilizumab is steroid-sparing in relapsing or refractory disease.