1226 - A New Diagnosis of Polymyalgia Rheumatica by Physiatry

An 84-year-old female with acquired hemophilia, CAD, COPD, PAD, and low back pain was discharged after treatment for an LAD blockage requiring stents. During initial admission, she reported bilateral shoulder pain, yet no diagnostic workup was performed. She was readmitted with worsening shoulder and new hip pain. MRI revealed insertional tendinosis of the supraspinatus, infraspinatus, and subscapularis. Pain persisted despite NSAIDs, neuropathic agents, and opioids.  

PM&R was consulted for rehabilitation and pain management, recommending measurement of CRP (normal), ESR (elevated), CPK (low), and LDH (low). The combination of history, physical exam, elevated inflammatory markers, normal muscle enzymes, and a negative infectious workup suggested a systemic inflammatory process (versus myopathy or infection), indicating polymyalgia rheumatica (PMR). Prednisone was started (15 mg daily) yielding significant pain relief. After 1 week in inpatient rehabilitation, patient improved from minimal-assist to supervision. She was discharged home with a 12-week prednisone taper and a rheumatology referral. 


Discussions: This case highlights the physiatrist’s essential role in uncovering a missed diagnosis. The patient’s advanced age and comorbidities contributed to diagnostic complexity, obscuring a systemic cause of pain. While the initial consultation centered on pain management and discharge planning, the physiatrist’s perspective—emphasizing functional status and broad differentials—ultimately led to the correct diagnosis. By applying a systems-based approach, the physiatrist identified a condition that would otherwise have resulted in significant disability, poor rehabilitation outcomes, and diminished quality of life.  

Conclusions:

A physiatrist’s expertise in musculoskeletal and rheumatologic conditions that cause dysfunction lends a unique perspective in the evaluation of patients presenting with pain. Early physiatry consultation can help prevent missed diagnoses and reduce the risk of unsafe discharges.