A previously healthy and active 72-year-old woman presents to your office with a complaint of stiffness and pain in her neck and shoulders. The symptoms are much worse in the morning and improve throughout the day. The pain affects the soft tissues and does not appear localized to the shoulder or hip joints. She denies headache or jaw claudication. Physical examination is unrevealing; there is no inflammatory synovitis, muscle tenderness, or skin rash. Muscle strength is normal in the deltoid and iliopsoas muscle groups. She has normal range of motion of the shoulder and hip joints. Laboratory studies reveal an elevated ESR of 92 mm/h and a mild normocytic anemia. Which of the following is the best next step in management of this patient?
The patient has PMR. A relatively common disease of the elderly, PMR presents as morning stiffness and pain in the shoulders, neck, and hip girdle. Diagnosis is mainly clinical; improvement of symptoms throughout the day and an absence of joint findings on physical examination provide clues to the diagnosis. Most patients have a markedly elevated ESR. PMR overlaps with giant cell (temporal) arteritis, so it is worthwhile to ask about symptoms of headache or jaw claudication. In the absence of symptoms or signs of temporal arteritis, no additional testing is indicated, and the diagnosis is presumptively confirmed by prompt response to moderate dose steroids (10-20 mg prednisone per day). Patients with occult temporal arteritis will not usually respond to modest doses of prednisone. Caution must be taken in tapering the steroids as patients with PMR frequently relapse upon discontinuation of treatment. A graded exercise regimen (answer b) would be an appropriate treatment option for fibromyalgia, but fibromyalgia rarely begins at age 72 and does not cause elevation of the ESR. MRI of the upper torso may show inflammation of the bursa and shoulder joint synovium, but this patient does not have localized tenderness in these structures. Muscle biopsy (answer d) is indicated in polymyositis or inclusion body myositis, but this patient does not have muscle weakness. Temporal artery biopsy (answer e) should be performed in patients suspected of having giant cell arteritis. Our patient, however, denies symptoms consistent with arterial involvement. If the patient does not respond to treatment with modest dose steroids, stronger consideration should be given to "blind" temporal artery biopsy.
Empiric trial of prednisone 15 mg daily
Graded exercise regimen
MRI of bilateral shoulders
Trapezius muscle biopsy
Immunology and Rheumatology