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The possibility that polymyalgia rheumatica (PMR) can be diagnosed when both ESR and CRP are normal at the time of diagnosis and before therapy with glucocorticoids, has been often discussed in the literature. We present a case report of a 100-year-old Caucasian man referred to our outpatient clinic, complaining of chronic pain in the shoulder and hip girdle associated with normal values of both ESR (21 mm/1st hour) and CRP (4 mg/dL). In the previous four months, several anti-inflammatory drugs and painkillers associated with physiotherapy treatments gave no significant improvement in pain and self-care. After an ultrasound (US) and an 18-fluorodeoxyglucose positron emission tomography associated with total body computed tomography (18-FDG PET/CT) examination, PMR was diagnosed and he started therapy with 17.5 mg prednisone, obtaining a fast improvement in pain and self-care. After 10 months of tapering, he stopped prednisone without relapse. During a 3-year follow-up, no alternative diagnosis was done. When a patient complains of chronic bilateral shoulder and hip girdle pain associated with normal inflammatory indices, it is reasonable to think in the first instance that this person is not suffering from PMR. Moreover, the possibility that PMR may onset in a centenarian person, is exceptional. In our patient, when we piece the puzzle together, the diagnosis of PMR was the most possible one.

Background: Discogenic, facet joint, and sacroiliac joint mediated axial low back pain may be associated with overlapping pain referral patterns into the lower limb. Differences between pain referral patterns for these three structures have not been systematically investigated. Objective: To examine the individual and combined relationship of age, hip/girdle pain, leg pain, and thigh pain and the source of internal disc disruption (IDD), facet joint pain (FJP), or sacroiliac joint pain (SIJP) in consecutive chronic low back pain (CLBP) patients. Design: Retrospective chart review. Setting: Community based interventional spine practice. Patients: 378 cases from 358 consecutive patients were reviewed and 157 independent cases from 153 patients who underwent definitive diagnostic injections were analyzed. Methods: Charts of consecutive low back pain patients who underwent definitive diagnostic spinal procedures were retrospectively reviewed. Patients underwent provocation lumbar discography, dual diagnostic medial branch blocks, or intra-articular diagnostic sacroiliac joint injections based on clinical presentation. Some subjects underwent multiple diagnostic injections until the source of their chronic low back pain (CLBP) was identified. Main Outcome Measurements: Based on the results of diagnostic injections, subjects were classified as having IDD, FJP, SIJP, or other. The mean age/standard deviation and the count/percentage of patients reporting hip girdle pain, leg pain, or thigh pain were estimated for each diagnostic group and compared statistically among the IDD, FJP, SIJP, and other source groups. Next, the 4 predictor variables were simultaneously modeled with a single multinomial logistic regression model to explore the adjusted relationship between the predictors and the source of CLBP. Results: The mean age was significantly different among the source groups. IDD cases were significantly younger than FJP, SIJP, and other source groups and FJP cases were significantly younger than other sources. The age by thigh pain interaction effect was statistically significant (P = 0.021), indicating that the effect of age on the source of CLBP depends on thigh pain, and similarly, that the effect of thigh pain on the source of CLBP depends on age. Limitations: Retrospective study design. Conclusions: The presence or absence of thigh pain possesses a significant correlation on the source of CLBP for varying ages, whereas the presence of hip/girdle pain or leg pain did not significantly discriminate among IDD, FJP, or SIJP as the etiology of CLBP. Younger age was predictive of IDD regardless of the presence or absence of thigh pain. Key words: low back pain, intervertebral disc, zygapophyseal joint, sacroiliac joint, pain referral patterns

Evaluation of an athlete's report of "hip pain" is challenging. Many conditions involving the pelvic girdle can present with overlapping pain distributions, and athletes often may have coexisting disorders. Appropriate evaluation requires thorough, systematic consideration of intra-articular hip disease, extra-articular local causes of hip pain, and referred pain from other musculoskeletal or even visceral sources. Although our understanding of intra-articular hip disorders has been greatly enhanced in recent decades through advances in hip arthroscopy, gaps still exist in our understanding of appropriate treatment, including effective nonsurgical protocols and when to consider surgical intervention. For instance, we have a better understanding of hip dysfunction related to structural changes that occur prior to the onset of arthritis, but we are also learning that correction of the structural changes does not always guarantee a correction of dysfunction and pain. Furthermore, athletes need instruction and guidance in retraining appropriate movement patterns after a surgical intervention. Risk stratification regarding which athletes need surgical intervention and what their needs are after specific surgical procedures remain undefined. In this review we will describe the differential diagnosis of hip and pelvic girdle pain in the athlete and then discuss how to use a history, physical examination, and appropriate imaging and diagnostic injections to arrive at a proper diagnosis. Lastly, a brief discussion is included of key concepts and controversies involved in treating some of the most common hip disorders experienced by athletes.

Diplopia may be a sign of giant cell arteritis (GCA). Polymyalgia rheumatica (PMR) is a systemic rheumatic inflammatory disease characterized by shoulder and hip girdle pain, and PMR can be associated in some patients with GCA. The authors report diplopia in two patients with treated PMR and biopsy-proven GCA, and review the literature on diplopia in GCA.

Background Polymyalgia rheumatica (PMR) is an inflammatory disorder of the elderly characterized by girdle pain and stiffness, constitutional symptoms and elevation of inflammatory indexes. Glucocorticoid (GC) treatment is effective but often prolonged, with associated side effects. Data on risk factors of poor prognosis are scanty: in particular it is not known if the pattern of clinical presentation can influence PMR outcome. Objectives To test the hypothesis that clinical presentation of PMR can predict its outcome. Methods 394 patients (251 women, median age 73 yrs, range 47–92 yrs) with PMR diagnosed according to Bird9s criteria, visited between 1990 and 2014 by the same clinician were studied. Median follow up was 13.8 months (range 1–250 months). Clinical features recorded at disease presentation included involvement of: i) the shoulder girdle; ii) the pelvic girdle; iii) the column; vi) two or more of the previous locations; v) with giant cell arteritis (GCA); or vi) with acute onset, defined as completion of full symptoms and signs in ≤72h. PMR outcome was evaluated by considering: i) duration of follow-up; ii) appearance of peripheral arthritis; iii) appearance of GCA; iv) number of exacerbations/ relapses; v) cumulative dosage of GC; vi) use of methotrexate (MTX); and vii) death. Results At multivariate analysis, acute onset predicted a longer follow-up duration (p=0.007) and death (p=0.037); involvement of the spine predicted longer follow up duration (p=0.001) and use of MTX (p=0.018); presentation at the pelvic girdle predicted a high number of exacerbations/relapses (p=0.034) and association therapy with MTX (p=0.009); onset in multiple locations predicted a high number of exacerbations/relapses (p=0.03); presentation with GCA predicted a higher cumulative dosage of GC (p=0.0001) and use of MTX (p=0.027). Conclusions Apart from the obvious association between concomitant GCA and negative prognosis of PMR, other clinical characteristics at disease onset influence outcome. In particular, the initial presentation with multiple locations, including spine and pelvic girdle, resulted in longer follow-up, more relapses, and need of MTX treatment, whereas the classic one with only shoulder girdle involvement was associated with a milder disease. An acute onset was also a negative prognostic factor. Clinicians should consider the pattern of disease presentation when evaluating the burden of PMR. Disclosure of Interest None declared

Background Polymyalgia rheumatica (PMR) is an inflammatory disorder of the elderly characterized by girdle pain and stiffness, constitutional symptoms and elevation of inflammatory indexes. In its classical form, the shoulder girdle is affected, associated or not with pelvic and spinal pain. The latter two locations can occasionally precede shoulder involvement. It is not known if the pattern of clinical presentation is related to disease severity at onset. Objectives In this study, disease severity of PMR has been correlated with clinical characteristics at presentation. Methods 394 patients (251 women, median age 73 yrs, range 47–92 yrs) with PMR diagnosed according to Bird9s criteria, visited between 1990 and 2014 by the same clinician were studied. Clinical features recorded at disease presentation included initial involvement of: i) the shoulder girdle; ii) the pelvic girdle; iii) the column; iv) two or more of the previous locations; v) presence of giant cell arteritis (GCA); vi) acute onset, defined as completion of full symptoms and signs in ≤72h; or vii) peripheral arthritis. Disease severity of PMR was evaluated by considering: i) weight loss; ii) fever; iii) morning stiffness (MS); iv) ESR; v) CRP; and vi) initial dose of prednisone. Results Acute onset and classical involvement of the shoulder girdle were not associated with our indicators of PMR severity. By contrast, onset in the pelvic girdle (p=0.002), simultaneous onset in multiple locations (p=0.006), peripheral arthritis (p=0.045) and GCA (p=0.0004) were associated with a higher initial dose of prednisone; multiple locations onset correlated also with MS (p=0.044). Conclusions The presentation with multiple locations, including column and pelvic girdle, peripheral arthritis, and GCA resulted in a more severe onset at least in the perception of the clinician who used a higher initial dose of prednisone. Clinicians should consider the pattern of disease presentation when evaluating the burden of PMR. Disclosure of Interest None declared

Supraclavicular nerve entrapment syndrome, although rare, should be considered among the causes of anterior shoulder girdle pain. This syndrome is usually related to anatomic variants (involving the bone structures, fibrous bands, or muscles and tendons). Computed tomography is the most useful investigation. Medications used to treat neuropathic pain may provide relief. Otherwise, a local glucocorticoid injection or even surgical decompression should be considered.

A 46-year-old female was admitted complaining of progressive, severe girdle pain consistent with the left Th3 dermatome. Neurological examination on admission revealed dysesthesia and radiating pain in the left Th3 territory. Plain X-rays and tomograms of the thoracic spine revealed a beak-like bony excrescence arising from the lamina and projecting moderately to the Th3/4 intervertebral foramen, suggesting ossification of the thoracic ligamentum flavum (OYL). Myelography showed the dural sac compressed from laterally just below the left Th3 pedicle, which suggested that the Th3 nerve root was compressed by the OYL. After Th3 nerve root decompression through hemilaminectomy and foraminotomy, the girdle pain disappeared. OYL is known to cause thoracic radiculomyelopathy, but presentation with intercostal neuralgia only is very rare. The authors review the literature and stress the importance of myelography for diagnosis.

Polymyalgia rheumatica (PMR) is an inflammatory disease of the elderly characterized by the nonspecific findings of girdle pain and stiffness and constitutional symptoms: as a result its differential diagnosis ranges from rheumatic, to infective and neoplastic diseases. PMR patients also often show peripheral arthritis, which fact further complicates the diagnosis. The main differential diagnosis in patients with suspected PMR is EORA, which also may present with girdle pain and raised inflammation. Both conditions also share a common genetic background and patients with cured PMR can relapse as EORA. Many studies have addressed clinical and laboratory discriminating clues, with only peripheral arthritis being effective. However, peripheral arthritis, being present in up to 40% of PMR patients, has a poor predictive value. In a recent study, US clues for the diagnosis of PMR were the presence of subacromial-subdeltoid bursitis, low frequency of knee menisci chondrocalcinosis and low power Doppler scores at the wrist. Conversely, effusion and synovitis of wrist, metacarpophalangeal joints, metatarsophalangeal joints, and tendinous calcaneal calcifications or Achilles enthesitis were more frequent in patients with diagnoses other than PMR. In a study with 18F-FDG positron emission/computed tomography (PET/CT), PMR patients showed higher uptake of the ischiatic, trochanteric and interspinous bursae compared to EORA patients. Shoulders were not evaluated because of their anatomical complexity and the difficulty of precisely localizing inflammation. In the clinic, follow-up over time is often the only way to help differential diagnosis: if glucocorticoid treatment is effective despite its tapering and peripheral arthritis does not become chronic, the diagnosis of PMR is likely to be correct. Disclosure of Interest None declared

Background Polymyalgia rheumatica (PMR) is an inflammatory disease of the elderly characterized by girdle pain and systemic symptoms. Imaging techniques, such as 18F-fluorodesoxyglucose (FDG)-PET/CT, have demonstrated that inflammation is localized mainly in the joint capsule and in bursae, with occasional large vessel vasculitis. However, the correspondence between FDG uptake and subjective symptoms is unclear. We have recently demonstrated that interspinous bursitis is typical of PMR, although it does not associate with pain. Objectives To test if FDG uptake, which is frequently seen in the girdles of PMR patients, is associated with the clinical experience of pain in the individual patients. Methods Eighty-four patients affected by PMR according to the ACR/EULAR criteria were studied. A standardized clinical examination, including pain at pressure of the long head of the biceps (LHB), the subacromial area (SA), the ischiatic (IB) and trochanteric (TB) bursae, and at mobilization of the shoulder and hip girdles, was performed immediately before PET/CT. After a minimum of six hours fasting, a dose of 4.8-5.2 MBq of FDG per kilogram body weight was injected through a peripheral vein catheter. Data acquisition started between 60 and 90 minutes after tracer administration. Patients underwent simultaneous FDG-PET and CT imaging from the skull base to the knee using an integrated PET/CT scanner (Hirez; Siemens Medical Solutions, Knoxville TN, USA). PET raw data were reconstructed by means of ordered subset expectation maximization and attenuation correction was performed using the CT raw data. The entire CT dataset was fused with the 3-dimensional PET images using an integrated software interface (Syngo Image Fusion; Siemens Erlangen, Germany) to create superimposed anatomical images. Joint uptake was scored relative to liver uptake as 0=no uptake present, 1=lower than liver uptake, 2=similar to liver uptake, 3=higher than liver uptake. Results A history of shoulder pain was present in all patients, whereas that of the pelvic girdle was present in 42/84 (50%). The concordance between pain elicited in the different areas and FDG uptake is shown in the table for the right (R) and left (L) sides. At clinical examination, 11/84 (13.1%) patients reported spontaneous pain or pain on passive motion which was clearly more intense in one shoulder. In these cases, tracer uptake was more intense in the symptomatic side in only 2, whereas in the remaining ones it was symmetrically distributed (bilaterally absent in 1 and bilaterally present in 8). Pelvic pain side was discordant in only 1 patient. The TB and IB were involved more often at PET than clinically. Conclusions The concordance between pain and FDG uptake in the girdles of PMR patients is only modest, except for shoulder capsulitis/synovitis, suggesting that factors other than inflammation visible at PET could contribute to clinical presentation. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3011

Background Polymyalgia rheumatica (PMR) is an inflammatory condition characterized by aching and morning stiffness in the shoulders, hip girdle, and neck. The initial goal of therapy is to rapidly achieve symptomatic control using a relatively low dose of glucocorticoids although most patients require long duration treatment and relapses are common with tapering dosage. Recently musculoskeletal ultrasound (MUS) has been proposed as part of PMR classification criteria. Objectives To assess if a positive MUS pattern of the shoulder (presence of subdeltoid bursitis and/or biceps tenosynovitis) at the diagnosis may represent a predictive marker of response to standard therapy at after 12 months follow-up and may correlate with an higher maintenance dosage of steroid at 6 and 12 months follow-up. Methods 66 consecutive outpatients (51 (77,3%) female) with PMR underwent a shoulder MUS at the time of diagnosis before starting therapy, and after 12 months follow-up. Clinical and laboratory assessment of age, girdle pain, 44 swollen and tender joint count, inflammatory markers was performed. Glucocorticoids at low doses were the mainstay of treatment. Clinical remission was defined as lack of girdle pain and as levels of eritrosedimentation rate (ESR)≤40 mm/h and c-reactive protein (CRP)≤4 mg/l. Results At the study entry, PMR patients had a mean age of 72±6.9 years. All patients presented aching shoulder and 16 (24,2%) had peripheral arthritis. A positive MUS pattern of the shoulder was present in 46 (69,7%) patients of whom 33 (71,8%) patients became negative after 12 months follow-up. 13 (28,2%) patients remains still positive at MUS evaluation after 12 months. All patients rapidly achieve a symptomatic persistent control due to prednisone at the initial mean dosage of 16,29±8,19mg/die of prednisone gradually tapered until a maintenance dose. At 6 months follow-up, 30 (45,5%) patients were treated with prednisone >5 mg/die, of whom 22 (73.3%) had positive MUS pattern and 8 (26.7%) had negative MUS pattern at the study entry. Among the general cohort, after 12 months follow-up, 7 (10,6%) patients were treated with prednisone >5 mg/die, of whom 3 (42.8%) showed positive and 4 (57.2%) a negative MUS pattern at baseline. No significant difference was found for the mean dosage of steroid at 6 and 12 months follow-up (p=0,37 and p=0,35 respectively) comparing PMR patients with positive and negative MUS at the study entry. Moreover no difference was found in the remission rate between patients with positive and negative MUS pattern at the baseline (50,0% of MUS positive patients vs 45,0% of MUS negative patients in disease remission, p=0,46). Conclusions In conclusion in PMR patients, ultrasonographic presence of shoulder bursitis or tenosynovitis at the time of diagnosis is not a predicting marker of higher corticosteroid maintenance dose in the long-term glucocorticoid therapy nor of clinical remission after 12 month of therapy. Normalization of the initial ultrasonographic changes in patients with persistent control of the disease suggests that MUS can add specificity to the diagnosis. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5028

Background Polymyalgia rheumatica (PMR) is a common inflammatory disease of the elderly characterized by girdle pain and cervical and lumbar aching. Interspinous bursitis has been suggested as potential cause of the symptoms at the lumbar spine level in a study performed with MRI (1). In rheumatology, 18F-fluorodeoxyglucose (FDG) positron emission tomography integrated with computed tomography (PET/CT) is used mainly for the demonstration of large-vessel vasculitis. Characteristic uptake patterns are also seen in PMR, where bursal and joint involvement is highlighted in shoulders, hips, column, and ischium (2). Objectives To evaluate the spine structures involved in PMR by FDG-PET/CT in a cohort of consecutive, untreated patients. Methods Sixty-five consecutive patients (44 women, median age 73 years, range 50-87 years), fulfilling Bird’s criteria for PMR were studied. After a standardized physical exam, which included pain and tenderness of the spine, they underwent simultaneous FDG-PET and CT imaging from the skull base to the knee using an integrated PET/CT scanner (Hirez; Siemens Medical Solutions, Knoxville TN, USA), after injection of 4.8-5.2 MBq of F18-FDG per kg body weight. FDG-uptake was scored according to liver uptake as 0=no uptake present, 1=lower than liver uptake, 2=similar to liver uptake, 3=higher than liver uptake. These values were further subdivided into “positive” (scores 2 and 3) and “negative” (scores 0 and 1). Sites of pathological uptake in the column were recorded. Results Table 1 shows the clinical and PET/CT results. FDG uptake was more frequent in the lumbar spine than in the other locations, and in the cervical than in the dorsal spine (p rd and 6 th cervical vertebrae and between the 4 th and 5 th lumbar vertebrae. Spontaneous pain was more frequent in the cervical and lumbar spine than in the dorsal spine (p Conclusions Interspinous bursitis is a frequent finding in the lumbar spine of patients with PMR. It is however not associated with the presence of clinical symptoms and can hardly explain the spinal pain reported by the patients. Cervical pain is more frequent than lumbar pain in PMR patients and might be caused by shoulder girdle involvement. References Salvarani C, Barozzi L, Cantini F, Niccoli L, Boiardi L, Valentini M, et al. Cervical interspinous bursitis in active polymyalgia rheumatica. Ann Rheum Dis 2008;67:758–61. Camellino D, Cimmino MA. Imaging of polymyalgia rheumatica: indications on its pathogenesis, diagnosis and prognosis. Rheumatology (Oxford) 2012; 51: 77-86. Disclosure of Interest : None Declared