My husband has dull pain all the time from his hips down to his knees. If he does anything that involves physical activity — getting up or down, riding in a car for a few hours, golfing, mowing, etc. — he is in extreme pain, and can hardly get up or down for a day. He just calls it arthritis, but it is worse than it was several years ago. He is 56 years old. What do you think the possibilities are?
There are of course many kinds of arthritis, including the very common osteoarthritis — also known as degenerative arthritis — which tends to affect the large weight-bearing joints such as the hips and knees. This may turn out to be what the husband of today’s writer has, but some aspects of the symptoms which you describe made me think of another, less well-understood type of arthritis, polymyalgia rheumatica (PMR).
PMR is a clinical syndrome occurring in older people: in women more frequently than men, in whites more frequently than African-Americans or Asians. Its hallmark is the involvement of the joints nearer the center of the body: the shoulders, hips, and neck. Morning stiffness, or stiffness and pain after any period of inactivity such as sitting in a car seat, is typical. Night pain is common, especially in the shoulders, and simply rolling over in bed may be very painful. The pain originates in inflamed joints, therefore it is an arthritis, but it is often felt in nearby muscles such as the thighs and upper arms. It is not a disease of the muscles themselves (the myalgia in polymyalgia means muscle); the name polymyalgia is a misnomer dating back to many years ago, when the condition was not well understood.
PMR may also cause pain, swelling, and stiffness in more distant joints such as the wrists and hands, and carpal tunnel syndrome, in which inflammation in the wrists presses on the nerves running through the carpal canal. Because of the common involvement of the hands and wrists, it is often mistaken for, and treated as, rheumatoid arthritis, and some experts consider it a variant of that type of arthritis. Others, though, consider PMR to be a distinctly separate syndrome, since the painful involvement of the shoulders and hips is not as common in rheumatoid arthritis. Moreover, the feet and ankles are rarely involved in PMR and are more commonly involved in rheumatoid arthritis, and biopsies of affected joints seem to show different pathology.
Rheumatoid arthritis more commonly attacks young people, whereas PMR is rare before age 50. Rheumatoid arthritis is an erosive joint disease, meaning that the joints can be severely damaged, which is not the case in PMR. Rheumatoid factor is commonly (though not always) found in the blood of someone with rheumatoid arthritis, and is never seen in PMR. The sedimentation rate, another blood test, is usually elevated in both conditions, but not in uncomplicated osteoarthritis, and this may be an important differential point for our writer’s husband.
PMR is also associated sometimes with an inflammatory condition of large arteries called giant cell arteritis. The most common manifestation of giant cell arteritis is head pain over the temporal artery which becomes enlarged and tender. There is no association known between giant cell arteritis and rheumatoid arthritis.
Another characteristic of PMR that has important implications for treatment is that the syndrome is extremely responsive to prednisone, a cortisone-type drug, and very low doses are often enough to keep the condition under control. Typically a person with the condition will be started at about 15 milligrams (mg) of prednisone, not a large dose, and the dose is reduced over a few weeks to the lowest dose which controls symptoms. This is often 7.5 mg or less per day, which is important since 7.5 mg of prednisone is usually taken as the threshold for the development of long-term side effects to the drug. Methotrexate, a drug often used to treat rheumatoid arthritis, is also effective in PMR. Hydroxychloroquine (Plaquenil), another commonly used drug for rheumatoid arthritis, does not seem to be effective against PMR.
When your husband sees his doctor, he might ask about the possibility of PMR as a cause of his symptoms, since many physicians are not aware of this syndrome as a common cause of joint pain in older people.