Dear Dr. Roach: I think my 75-year-old husband has polymyalgia rheumatica, and I understand it has no definitive cause. He gets severe unbearable pain alternating between his neck and hips every few weeks. It seems that the only treatment is prednisone, but he does not want to take it. What else can we do?
C.W.
Polymyalgia rheumatica (PMR) is an inflammatory disease of an unknown cause that causes aching and stiffness, especially in the neck and shoulders. It is usually worse in the mornings and has an abrupt onset; people with months or years of gradually worsening pain and stiffness are unlikely to have PMR. People with morning symptoms may develop pain and stiffness later in the day (after a car ride, for example), but morning stiffness is necessary for the diagnosis.
Blood tests are almost always markedly abnormal with those who have PMR. The C-reactive protein, which is a measure of inflammation, is abnormal 99% of the time and usually very high. Both the symptoms and the lab findings are necessary to make a diagnosis of PMR.
Steroids like prednisone sometimes have an almost-miraculous effect on the symptoms of PMR, although some people respond more slowly. If a person doesn’t respond to prednisone, it’s worth reconsidering the diagnosis.
For your husband, I’d want to be sure of the diagnosis of PMR based on his symptoms and test results. Once it’s confirmed, a trial of prednisone would be likely to have such a dramatic effect on him that he would change his mind about taking it. The course is long, and prednisone has very serious long-term side effects. So, the diagnosis really ought to be as certain as possible.
There are many conditions that cause pain between the hips and neck, so if his story isn’t consistent with a PMR diagnosis, looking for other causes — such as osteoarthritis — is appropriate. When uncertain, a rheumatologist is the correct expert to consult.
Dear Dr. Roach: I’m a 74-year-old man in good health. When I lay down, my toes tingle. If I put the covers over them, I don’t feel them tingling. When I sit at my desk with my feet on the floor, there’s no tingling.
I read that this is a sign of diabetes. My annual physicals show that my glucose level has been normal the past three years, all within the range of 71-99 mg/dL. Any idea what could be causing this?
B.M.
Tingling or burning sensations are highly characteristic of pain coming from an irritated or damaged nerve (called neuropathic pain). When this occurs in both feet, a diabetic neuropathy is a very likely diagnosis — but only if you have diabetes.
On average, a person has diabetes for at least seven years before getting a diabetic neuropathy, and it is much more likely to occur when the diabetes has been poorly controlled. It is extremely unlikely that you have a diabetic neuropathy. Furthermore, the fact that the symptoms change depending on your position is not consistent with a diabetic neuropathy.
What I am the most concerned about is the pressure on the nerves to your legs. The fact that the symptoms are happening in both feet means that you either have two separate problems (unlikely) or compression at the level of the spinal cord. This is most likely spinal stenosis. However, most people find that standing is when the symptoms are worse, and they get better when laying down or leaning over.
Neurologists are the experts at making diagnoses of neuropathies. Imaging studies or a nerve test (EMG) might be needed to make a diagnosis. However, other conditions, such as a vitamin B12 deficiency, can sometimes cause this symptom.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
