PMR/GCA is the most common large-vessel vasculitis in the UK, affecting 1 in 133 women over 50. Delayed diagnosis risks sight loss from GCA. A CK level is critical in proximal weakness — dermatomyositis has an associated malignancy risk of 15–30% and requires urgent cancer screen. Myeloma presents with bone pain and fatigue in over 60% of cases — plasma protein electrophoresis and urine Bence-Jones protein identify the paraprotein. Vasculitis causing haematuria is a renal emergency — ANCA testing and urgent nephrology referral prevents irreversible kidney damage.

Morning stiffness duration is the most discriminating feature between inflammatory and non-inflammatory causes — >45 minutes strongly suggests inflammatory arthritis or PMR, while brief stiffness (<30 min) points toward mechanical or fibromyalgia. Statin-induced myalgia affects 5–10% of users — stopping the statin for 4–6 weeks is both diagnostic and therapeutic. Central sensitisation (fibromyalgia, chronic widespread pain) is driven by maladaptive pain processing and is strongly associated with psychological comorbidity — treating co-existing depression significantly improves pain outcomes.

PMR is the most common inflammatory rheumatological condition in adults over 65 — it responds dramatically to prednisolone 15 mg (70% symptom relief within 48 hours) — failure to respond questions the diagnosis. Vitamin D deficiency affects 1 in 5 UK adults (Public Health England data) and causes musculoskeletal pain that is frequently misdiagnosed as fibromyalgia — a simple blood test and supplementation can be curative. Fibromyalgia and inflammatory arthritis co-exist in 20–30% of patients — both diagnoses must be considered simultaneously.

The chair-rise test is the quickest screen for proximal muscle weakness — inability to rise without arm support is highly sensitive for proximal myopathy. The heliotrope rash (violaceous periorbital discolouration) and Gottron's papules (scaly erythematous papules over knuckles) are pathognomonic of dermatomyositis — this is a medical emergency requiring urgent cancer screen. Psoriasis is present in <2% of the population but occurs in 30% of psoriatic arthritis patients — scalp, umbilical, and nail examination for missed psoriasis is essential in any arthritis presentation.

CK elevation is the most important investigation in proximal myopathy — CK >10× upper limit of normal suggests inflammatory myositis requiring urgent biopsy, while CK 2–5× normal may indicate statin myopathy. Anti-CCP antibodies are 95% specific for RA and are present 5–10 years before clinical disease — they should be checked in any inflammatory arthritis pattern. Requesting ANA in all patients with aches is a common error — it generates false positives (positive ANA in 5–15% of normal population at low titre) and leads to unnecessary anxiety and specialist referrals.

Early DMARD initiation in inflammatory arthritis (within 3 months of symptom onset) significantly reduces joint damage and improves long-term functional outcomes — delay leads to irreversible joint destruction. The 2WW myeloma pathway requires serum protein electrophoresis — not all myeloma is detected on FBC alone, and a normal Hb does not exclude myeloma. PMR that cannot be weaned below prednisolone 7.5 mg at 12 months is considered refractory and requires rheumatology review for steroid-sparing agents (methotrexate, tocilizumab).

The prednisolone response in PMR is both diagnostic and therapeutic — failure to respond within 48–72 hours should prompt reconsideration of diagnosis, especially malignancy. Duloxetine (SNRI) has the strongest evidence base for fibromyalgia (NNT ~7 for 30% pain reduction) and additionally treats co-existing depression. Amitriptyline at low dose specifically improves sleep quality and morning pain stiffness — different mechanism from antidepressant dose. Vitamin D deficiency-related myalgia resolves within 4–8 weeks of adequate supplementation — this is one of the most rewarding and underdiagnosed causes to treat.

NICE NG193 (Chronic Primary Pain, 2021) represents a paradigm shift — it recommends against long-term opioids, paracetamol, and NSAIDs for chronic primary pain, instead prioritising exercise, psychological therapy, and acupuncture. This is because chronic widespread pain involves central sensitisation rather than peripheral nociception — peripherally-acting analgesics have no impact on central pain processing. Exercise is the most evidence-based intervention across all musculoskeletal pain syndromes — even low-intensity exercise reduces inflammatory cytokines and improves central pain modulation.

Up to 30% of PMR patients develop GCA — this risk persists throughout the treatment period. All PMR patients must be educated about GCA symptoms and told to seek same-day review if they develop headache, jaw claudication, scalp tenderness or visual disturbance. Prednisolone-induced osteoporosis causes vertebral fractures in 30–50% of patients on long-term steroids without bone protection — DEXA and bisphosphonate are essential. Statin rechallenge at lower dose or different statin succeeds in 70% of patients who had myalgia — this is preferable to complete abandonment of statin therapy given cardiovascular benefits.