Quick Summary
Imaging does not diagnose PMR on its own. Instead, it supports the overall picture formed by your symptoms, exam, and blood tests. In many typical cases, no imaging is needed at all. When the story is less clear, ultrasound is usually the first tool to help distinguish PMR from look-alike shoulder or hip problems.
PMR is a condition recognized by its pattern: aching and stiffness in both shoulders — often the hips — with morning stiffness in adults over fifty. Blood tests frequently show inflammation, and the diagnosis is usually made from this combination of history, exam, and labs. Imaging steps in only when the picture needs sharpening: when symptoms are one-sided, when labs are unexpectedly normal, or when other conditions need to be ruled out.
Why Imaging Is Used
Imaging is helpful not because it “proves” PMR, but because it can strengthen or question the working diagnosis. Several shoulder and hip problems mimic PMR, and some systemic conditions behave similarly in early stages. Ultrasound or MRI helps confirm whether the discomfort is coming from inflammation around the joints — which fits PMR — or from mechanical issues such as rotator-cuff tears, frozen shoulder, hip osteoarthritis, or conditions like elderly-onset rheumatoid arthritis.
Ultrasound: The Most Useful First Step
Ultrasound is the imaging test clinicians reach for most often when PMR is uncertain. It can show inflammation around the shoulders and hips, especially in the subacromial–subdeltoid bursa and the biceps tendon sheath. At the hips, it may show synovitis or bursitis. The presence of these findings on both sides supports a PMR-type pattern rather than wear-and-tear causes.
Ultrasound is quick, safe, and radiation-free. In many clinics it can be done during the same visit, which makes it especially valuable when a timely answer is needed. Research over the past decade shows that adding ultrasound findings to the established PMR criteria improves accuracy when the clinical story is already suggestive.
Reports commonly mention phrases like “bilateral SASD bursitis” or “biceps tenosynovitis,” which are common PMR-associated findings. A key point: a normal ultrasound does not rule out PMR if everything else fits.
When the clinical pattern and ultrasound findings match, clinicians often feel confident moving forward without more advanced tests.
MRI: When More Detail Is Needed
MRI becomes useful when the situation is more complicated. Doctors may order it when symptoms are mostly on one side, when the pain involves the neck or lower back, or when the team needs to distinguish PMR from shoulder tears, hip osteoarthritis, or spine-related causes.
MRI can show the same inflammatory features seen on ultrasound but with more detail. It may also pick up interspinous bursitis — a supportive but not universal finding in PMR. While MRI provides deep clarity, most individuals with classic PMR never need one; its strength lies in evaluating mimics rather than confirming PMR itself.
PET/CT: Reserved for Special Situations
PET/CT is not a routine test for PMR. It detects areas of inflammation throughout the body by highlighting regions of increased glucose uptake. In PMR, PET may show increased activity around shoulders, hips, or the spine.
However, these patterns are not specific. Many other inflammatory or systemic illnesses can create similar findings. Because PET involves radiation and is more expensive and less available, clinicians reserve it for cases where the diagnosis remains unclear after standard evaluation, or when investigating possible large-vessel involvement.
Imaging for Giant Cell Arteritis (GCA)
Because PMR is closely linked with giant cell arteritis, clinicians remain alert for symptoms such as new headaches, scalp tenderness, jaw pain while chewing, or changes in vision. When these appear, vascular ultrasound of the temporal and other arteries is recommended as the first-line imaging test where expertise exists. The goal is speed and clarity, because vision can be at risk. Biopsy or other imaging may still be used depending on availability and results.
A Practical Way Imaging Fits Into Care
For many people with a classic PMR pattern and elevated inflammation markers, imaging may not be needed at the first visit. If the features fit neatly, clinicians often start treatment without delay or add an ultrasound for extra confidence.
When the symptoms are less typical — one-sided pain, normal labs, or an unusual exam — ultrasound provides the clearest early insight. If ultrasound raises more questions, MRI may follow, especially if mechanical conditions are on the table. PET tends to step in only when everything else remains inconclusive or when large-vessel disease is a concern.
This tiered approach ensures imaging clarifies rather than complicates the diagnosis.
Pros and Cons at a Glance
Ultrasound offers quick answers without radiation and is excellent for identifying PMR-type bursitis or tenosynovitis. Operator experience matters, and a normal result does not rule PMR out.
MRI provides unmatched detail and is ideal for sorting out shoulder tears, spine problems, or hip disease, though it is more expensive and less available.
PET/CT offers a whole-body view and can identify broader inflammation, but it is used sparingly because findings are not PMR-specific and the test carries higher cost and radiation exposure.
Questions to Discuss With Your Clinician
People often find it helpful to ask whether their ultrasound findings match a PMR pattern, what it means if imaging is normal but symptoms still fit, and how MRI or PET results might change the plan. If GCA is suspected, asking whether vascular ultrasound is available and how quickly results can be obtained may guide next steps.
Final Thoughts
Imaging plays a supporting role in PMR — not a starring one. Its value lies in refining the picture when the story is complicated or when another diagnosis is possible. Ultrasound is usually the most practical and informative first step. MRI helps untangle mimics, and PET is reserved for select scenarios. Together with symptoms, exam findings, and labs, imaging helps clinicians build a diagnosis that is both accurate and safe.
