Polymyalgia Rheumatica (PMR) - when a diagnosis is missed.
Polymyalgia rheumatica (PMR) is an inflammatory condition affecting adults over 50. It typically presents with bilateral shoulder and hip pain, marked morning stiffness and raised inflammatory markers such as CRP and ESR. Unlike mechanical back or joint pain, PMR is systemic. It is not caused by disc degeneration, rotator cuff tears or “wear and tear”. It is driven by inflammation.
In most cases, PMR is identified in primary care and managed promptly with corticosteroids, often with rapid and dramatic improvement. It is not something we commonly diagnose first in osteopathic practice.
However, occasionally the pattern is missed.
A Patient I Knew Well
This patient had been known to me for nearly ten years, on and off. He is typically robust, direct and physically capable.
When he came into clinic recently, he looked profoundly unwell.
Over the preceding two months he had lost around a stone in weight unintentionally. His skin tone was grey. His posture was flexed and guarded. He appeared to be in constant discomfort. He was unable to drive himself to the appointment because his legs were too painful.
He described eight weeks of bilateral shoulder pain, hip pain and diffuse leg discomfort. His hamstrings were tender even when sitting. Mornings were extremely difficult. He struggled to get out of bed. The stiffness was severe and prolonged.
This was not behaving like a localised mechanical issue.
The Investigation Pathway
Before attending clinic, he had consulted privately. Because he had a past history of disc-related pain, a lumbar MRI scan was recommended to exclude nerve root impingement. The scan was clear.
Blood tests through his GP were reported as satisfactory. Inflammatory markers were within normal limits.
A further recommendation was made for bilateral shoulder X-rays, at a significant additional private cost of around £1,500.
At this stage, he was in escalating pain, financially burdened and without a clear diagnosis.
When the Pattern Speaks Louder Than the Tests
On assessment, several red flags stood out:
• Bilateral shoulder and hip girdle pain
• Profound morning stiffness
• Unintentional weight loss
• Systemic appearance of illness
• Non-mechanical pain behaviour
With his permission, I reviewed his blood results on the NHS app. CRP and ESR were within range. On paper, PMR seemed unlikely.
Clinically, it remained highly suspicious.
Early inflammatory disease does not always follow textbook laboratory patterns. Blood markers can lag behind clinical presentation. A normal result does not automatically exclude pathology when the overall picture is convincing.
I fed back my concerns to his consultant when copied in on an email, outlining why PMR was my first concern. Repeat blood tests were arranged, and these results showed a different picture, inflammatory markers were clearly raised. The diagnosis of PMR was confirmed.
Steroid treatment was commenced. His response was rapid and significant.
The Financial and Emotional Cost of Delay
One of the striking aspects of this case was not simply the missed diagnosis, but the pathway taken to get there.
The patient had undergone expensive private imaging. Further imaging was being considered. He was distressed by ongoing pain and by the financial implications of continued investigation.
PMR, once recognised, is often straightforward to treat. Low-dose corticosteroids frequently provide marked relief within days.
The contrast between the complexity of the investigative pathway and the relative simplicity of the treatment was stark.
My patient is still grumbling about the eye watering cost of the consultant who barely looked up from his computer screen during the consult which lasted according to my patient, 5 minutes. And yet, an Osteopath costing a fraction of this fee, spending much longer engaging with patients are the ones raising the diagnostic eyebrow.
The Osteopathic Perspective
In clinic, we predominantly manage mechanical pain. However, we are trained to assess patterns. Bilateral, symmetrical pain with systemic features should prompt caution. I’m not saying we are specialist consultants by any stretch and of course all clinicians can miss and underlying diagnosis.
Continuity of care matters. I knew this patient’s usual presentation. I knew his baseline energy and posture. I knew that this degree of deterioration was not typical for him. That context supported clinical suspicion even when initial blood results were normal.
As osteopaths, our responsibility is not to diagnose inflammatory disease independently of medical colleagues. It is to recognise when symptoms are not mechanical, identify red flags and ensure appropriate referral or re-referral.
This case reinforces three important principles:
First, not all musculoskeletal pain is mechanical.
Second, laboratory results must be interpreted in clinical context.
Third, listening carefully and observing the whole person can change outcomes - and this is where I found this patients underlying cause of symptoms.
Final Reflection
PMR is not rare, but it can be overlooked, particularly in its early stages. When patients over 50 present with bilateral shoulder and hip pain, significant morning stiffness and systemic change, inflammatory causes must remain on the differential diagnosis list.
This patient is now improving on appropriate medical treatment. The relief has been substantial.
For clinicians, the lesson is clear. When the story does not fit a structural explanation, pause. Reassess. Advocate if necessary.
Sometimes the diagnosis is hiding in plain sight.
If you are struggling with undiagnosed symptoms that you feel are under diagnosed or under treated, speak to one of our team and we’d be happy to help.
The Waterside Practice
10a Mill Green, Warboys, Huntingdon PE28 2SA
01487 209 084 or email reception@thewatersidepractice.co.uk
We have a free no obligation consultation call option bookable here to speak to one of our Osteopaths: https://thewatersidepractice.janeapp.co.uk/