How Doctors Diagnose PMR: History, Exam, Labs, and Imaging

Doctors diagnose polymyalgia rheumatica (PMR) by putting several clues together: your story (both-shoulder and/or hip aching with morning stiffness ≥ 45 minutes in adults ≥ 50), a focused exam, inflammation blood tests (ESR/CRP), and sometimes ultrasound.

A “quick steroid test” alone is not enough to prove PMR—your whole picture matters. If new headache, scalp tenderness, jaw pain when chewing, or any vision change appear, that’s a same-day emergency check for giant cell arteritis (GCA).

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Step 1: Your Story (History)

Doctors listen for a pattern that fits PMR:

• Pain and stiffness on both sides of the shoulders (often neck/upper arms) and often both hips/thighs
• Morning stiffness that lasts 45 minutes or more, improves as you move
• Symptoms start after age 50
• Feeling “flu-ish,” tired, low appetite can happen too

This constellation is the backbone of PMR — and it’s why your words about where, when, and how it hurts are so important.

What raises or lowers suspicion?

• Raises: Both shoulders ± hips, marked morning stiffness, trouble doing overhead tasks (coat, hair), getting out of a chair because of stiffness
• Lowers: Pain on one side only, numbness/tingling (nerve issue), true muscle weakness (not just stiffness), or symptoms focused in hands/feet (think other arthritis)

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Step 2: Focused Physical Exam

Your clinician checks:

• Range of motion at shoulders and hips—often limited by pain/stiffness, not true weakness
• Tender areas around bursae and tendon sheaths (around the shoulders/hips)
• Peripheral joints (hands, wrists, knees). Swelling or tenderness there may suggest elderly-onset rheumatoid arthritis rather than PMR.

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Step 3: Blood Tests (What They Show—and Don’t)

There is no single blood test that proves PMR. We look for inflammation and rule out look-alikes:

• ESR and CRP: Usually elevated in PMR—but not always. Studies show a minority have normal values, especially ESR; CRP may still be high. A very small fraction have both normal at diagnosis. Your story and exam still matter.
• CBC/CMP, CK, TSH: Help exclude anemia, infection clues, kidney/liver issues, muscle disease (CK high), or thyroid problems that can mimic PMR.

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Step 4: Imaging (When We Use It)

Imaging supports the diagnosis or rules out other problems:

• Musculoskeletal ultrasound (often first): can show a PMR-type pattern—bilateral subacromial-subdeltoid (SASD) bursitis and biceps-tendon sheath inflammation around the shoulders (and hip-girdle bursitis/synovitis). It’s quick, safe, and helpful when the story fits. A normal ultrasound doesn’t rule PMR out.
• MRI: Adds detail or helps when symptoms are atypical or one-sided, or when we need to separate PMR from rotator cuff tears, frozen shoulder, spine or hip osteoarthritis.
• PET/CT: Rarely needed for typical PMR; may be used in unclear cases or when we’re also assessing for large-vessel inflammation. (For suspected GCA, vascular ultrasound is now recommended first-line where expertise exists.)

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Step 5: How Doctors Use the 2012 EULAR/ACR Classification Criteria (Plain Language)

To keep thinking structured—and in research—doctors may refer to the 2012 EULAR/ACR criteria. They are not a pass/fail diagnostic test, but a helpful framework:

Start with age ≥ 50, bilateral shoulder pain, and raised ESR/CRP. Then score:

• Morning stiffness > 45 min (2 points)
• Hip pain/limited motion (1 point)
• No rheumatoid factor/anti-CCP (RF/ACPA) (2 points)
• No peripheral joint pain (1 point)

A score of 4 or higher supports PMR. If ultrasound is included, a score of 5 or higher supports PMR with better accuracy. (Again, it supports — it doesn’t replace your doctor’s judgment.)

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Step 6: Response to Treatment: Helpful, But Not the Whole Story

Historically, a fast response to low-to-moderate-dose prednisone was treated as “diagnostic.” We now know that’s not specific—other conditions can briefly improve with steroids. Modern guidelines emphasize that response helps, but must be interpreted with the whole picture.

What’s typical if it really is PMR?

• Many people report clear relief within days to ~1–2 weeks once the right dose is started (often 12.5–25 mg/day prednisone equivalent, tailored to the person), then a slow taper over months. If little or no improvement by 7–10 days, the team re-checks the diagnosis and dose.

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When the Picture Is Atypical (and What Happens Next)

Doctors take a second look if any of these occur:

• One-sided pain, true weakness, numbness/tingling, or symptoms centered in hands/feet
• Normal ESR/CRP and an unusual story
• Poor or no response to adequate steroid dosing
• Frequent relapses very early in tapering

Next steps can include repeat history/exam, medication review (e.g., statins can cause muscle symptoms), targeted ultrasound/MRI, or specialist referral. Recent early-referral recommendations also outline practical triggers for involving a rheumatologist sooner.

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Common Look-Alikes Your Clinician Will Consider

• Elderly-onset rheumatoid arthritis (peripheral joints involved; RF/ACPA sometimes positive)
• Rotator cuff disease / frozen shoulder (often one-sided or mechanical)
• Cervical/lumbar spine issues with referred pain
• Hip osteoarthritis (groin pain, weight-bearing pain)
• Inflammatory myopathies (true muscle weakness, high CK)
• Thyroid disease, statin-related muscle symptoms, infection, or malignancy depending on the story
  Guidelines and reviews stress ruling these out systematically.

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A Special Link: Watch for Giant Cell Arteritis (GCA)

Because PMR and GCA are “sister” conditions, doctors screen for GCA every visit, especially early on. Red flags that need same-day care:

• New/different headache (temples), scalp tenderness
• Jaw pain with chewing (jaw claudication)
• Any vision change: blurred/double vision, “shade” over one eye

Imaging has evolved: vascular ultrasound is now recommended as first-line for suspected GCA where expertise exists, and treatment should not wait if vision is at risk.

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What Patients Can Track (Helps Diagnosis & Follow-up)

• Morning stiffness minutes (time until you “loosen up”)
• Pain scores (0–10) morning and evening
• Function checkpoints: lifting arms overhead, putting on a coat, getting up from a chair
• New symptoms: headache, scalp tenderness, jaw pain, or vision changes (urgent)
  This diary helps your team judge progress and plan a safe taper.

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What to Expect After Diagnosis

• Personalized steroid plan following 2015 EULAR/ACR guidance (start with the lowest effective dose, taper slowly, adjust for relapses/side effects)
• Consider methotrexate if you’re at higher risk for relapse or steroid side effects
• Regular checks of symptoms + ESR/CRP, plus bone, blood pressure, blood sugar, and eye health as needed
  These principles are stable and widely used internationally.

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