A 62 Year Old Man Complains Of Worsening fatigue And Pain In His Back, Shoulders And Neck

A 62 year old man who has been a known case of hypertension for several years while on a followup with his general physician complains of worsening fatigue and aching in his back, shoulders and neck. He has been taking acetaminophen for about last 3 months with no improvement. On further asking the patient says he experiences neck and shoulder stiffness every morning for about 30 minutes. He occasionally has difficulty getting out of bed.
On examination Vital signs were normal. There is no evidence of synovitis of hands wrists and elbows. Active range of motion in the hands, neck and shoulder are slow but full, There was no tenderness on palpation of the neck, shoulder and back and there was no apparent muscle atrophy. The areas where the patient felt the pain is shown below:

Study Questions with Answers related to the above presented Case scenario:


1. What diagnosis is this patient's presentation consistent with?

Answer: Polymyalgia rheumatica.
This patient’s presentation is consistent with the diagnosis of polymyalgia rheumatica (PMR).It is an inflammatory disorder that usually affects patients older than 6o years of age and causes muscle pain and stiffness in the shoulders, neck, upper arms and hips.

2. What is the next step to help in the diagnosis?

Answer; Obtain an ESR and CRP. An elevated ESR and CRP suggests an underlying inflammatory disorders and hence favors the diagnosis of polymyalgia rheumatica.

3. What other vasculitis disorder should be considered ?
Answer: Patients should be observed for signs and symptoms that may suggest the onset of giant cell temporal arteriitis. Patients are told to see the doctor immediately if any of the following develops:

• New unusual or persistent headaches
• Jaw pain or tenderness
• Blurred, double vision or vision loss
• Scalp tenderness

4. What is the treatment for polymyalgia rhuematica?

Answer: Treatment can take an year or more but most patients begin to feel better after the course of the treatment is started. Polymyalgia rheumatica is usually treated with a low dose of an oral corticosteroid.The daily dose at the beginning is 10-20 milligrams a day. Releif from pain and stiffness should occur within the first 2 or 3 days. if no improvement other diagnosis should be considered. After 2 to 3 weeks the dose may be increased epending upon the response and the ESR and CRP values. After a year or two the medication may be slowly tapered but some patients may go into relapse. Other treatment options include methotrexate and anti TNF drugs. 

Also it is recommended to get physical therapy and calcium and vitamin D supplements.