Polymyalgia rheumatica causes stiffness and aching across both shoulders and hips in people over 50, and it responds quickly to a modest dose of steroid, typically starting around 15mg of prednisolone. The treatment is effective and it has a cost: prolonged glucocorticoid use causes proximal muscle weakness and accelerated bone loss. Resistance training is the main defence against both, and it is the part of the plan most often left out entirely.
Bone and balance matter more than usual on long-term steroids, and the work that genuinely reduces falls is set out in PhysioHub’s guide to falls prevention.
Ranked by how much each protects against the specific costs of long-term steroid treatment.
| Priority | What it defends against | Frequency | When to start |
|---|---|---|---|
| 1. Resistance training | Steroid-induced proximal muscle weakness | 2 to 3 times weekly | Once symptoms settle, usually within weeks |
| 2. Weight-bearing exercise | Accelerated bone loss | Most days | Immediately, at whatever level is possible |
| 3. Balance and falls prevention | Fracture, which is where the two above combine | 2 to 3 times weekly | Early, and it matters most later |
| 4. Protein intake | Muscle loss, and it limits the benefit of item one | Every meal | Immediately |
| 5. Coordinating with the medical team | Confusing a taper flare with deconditioning | At each review | Throughout |
The connection running through the list is fracture. Steroids weaken the muscles that keep you upright and thin the bones that break when you are not, so strength, bone and balance are three defences against one outcome.
This is a documentary review of published guidance and trial evidence rather than a treatment plan. Five priorities were selected on how directly each addresses a known consequence of long-term glucocorticoid treatment, and ranked by the size of that consequence.
The sources read were the British Society for Rheumatology guideline scope for the treatment of polymyalgia rheumatica, which notes that the last full BSR guideline dates from 2009 and sets out the case for updating it; a randomised trial of a resistance exercise programme in patients with rheumatological disease receiving high-dose glucocorticoids; and evidence on the effects of low-dose corticosteroids on bone density in polymyalgia rheumatica. Evidence checked in August 2026.
Two honest limits. There is very little randomised evidence on exercise in polymyalgia rheumatica specifically, so most of what follows is reasoned from the wider glucocorticoid literature and from general principles of strength and bone health in older adults. And medication decisions, including the starting dose and the taper, belong entirely to your GP or rheumatology team. Nothing here is a reason to change a dose.
Separate disease from deconditioning. Polymyalgia rheumatica causes stiffness and pain rather than true muscle weakness at the outset. Weakness that appears months into treatment is more likely to be the steroid or the inactivity than the disease returning.
Note whether it is symmetrical and girdle-based. Both shoulders and both hips is the pattern. One shoulder is a different problem.
Track function, not just symptoms. How many times you can stand from a chair in 30 seconds is a better measure of where you are than how stiff you felt this morning, and it responds to the training.
Know the emergency. New headache, tenderness of the scalp or temples, jaw pain when chewing, or any change in vision needs same-day medical attention, because giant cell arteritis is associated with this condition and can cause irreversible sight loss.
Expect the taper to be bumpy. Symptoms returning as the dose reduces is common and is a conversation with the prescriber rather than a reason to stop exercising.
What it is
Progressive strengthening work targeting the same muscle groups the condition and the treatment both affect: the shoulders, upper back, hips and thighs.
Who it suits
Everyone on glucocorticoids for polymyalgia rheumatica, started once symptoms have settled enough to move comfortably, which is usually within a few weeks of beginning treatment.
What it involves
Two to three sessions a week. Sit-to-stands, step-ups, and any hip and thigh work you can load. For the shoulders, resistance band work and light overhead pressing. Start light and progress the load gradually. Eight to twelve repetitions where the last two feel genuinely effortful.
What the evidence supports
Glucocorticoid-induced myopathy characteristically produces slowly progressive weakness in the proximal muscles, particularly the legs, which is precisely the pattern resistance training addresses. A randomised trial of resistance exercise in people with rheumatological disease on high-dose glucocorticoids examined muscle strength, functional performance and quality of life in this context. EULAR guidance on glucocorticoid use recommends an individualised exercise programme aimed at maintaining muscle strength and function and preventing falls, particularly in older people.
Limits and cautions
Do not start during the acute painful phase before the steroid has taken effect. Progress by load rather than by repetitions, and expect this to take months rather than weeks.
Why it ranks first
It directly counters the most predictable side effect of the treatment, and it is the priority most often absent from the plan entirely.
What it is
Activity performed on your feet, so that bone is loaded through the skeleton: walking, stair climbing, and where appropriate light impact work.
Who it suits
Everyone on glucocorticoids, from the first week, at whatever level is currently possible.
What it involves
Walking most days, building duration gradually. Stairs where you can manage them. For those already doing resistance training, loaded standing exercises count twice, because they load bone and muscle in the same movement.
What the evidence supports
Bone loss on glucocorticoids is fastest in the first six to twelve months of treatment, and research in polymyalgia rheumatica specifically has documented the deleterious effects of low-dose corticosteroids on bone density. Guidance on glucocorticoid-induced osteoporosis includes regular weight-bearing or resistance exercise among its recommendations, alongside assessment of fracture risk and, where indicated, bone-protective medication.
Limits and cautions
Exercise supports bone protection rather than replacing it. Anyone on prolonged steroids should have their fracture risk assessed, and calcium, vitamin D and bone-sparing medication are medical decisions to raise with your GP.
Why it ranks second
Bone loss on steroids is rapid and silent, and the window in which it happens fastest is the window in which people are least active.
What it is
Specific training of standing balance and the ability to recover from a stumble, rather than general activity.
Who it suits
Everyone over 65 on this treatment, and anyone of any age who has noticed unsteadiness or has had a near-fall.
What it involves
Progressive balance challenges: standing feet together, then heel to toe, then on one leg, then with head turns, working near a support you are not holding. Programmes such as Otago combine this with strengthening and have been designed specifically for falls reduction. Two to three sessions a week.
What the evidence supports
Strength and balance training reduces falls in older adults, and the effect is specific: general activity such as walking does not reduce falls in the same way that targeted balance work does. On steroids the case is stronger still, because weakened proximal muscles reduce the ability to recover from a stumble at the same time as bone becomes more fragile.
Limits and cautions
Balance work must be genuinely challenging to produce change, which means it must be done safely, near a solid support, and ideally supervised at first.
Why it ranks third
It addresses the event that turns the two problems above into a serious outcome, and it does nothing about the underlying muscle and bone loss on its own.
What it is
Eating enough protein, distributed across the day, to support the muscle you are trying to keep.
Who it suits
Everyone in this situation, and particularly anyone over 70, in whom appetite and protein intake commonly fall at exactly the point they matter most.
What it involves
Protein at every meal rather than concentrated in the evening, since older adults use it more effectively when it is spread out. The full numbers are set out in how much protein you actually need.
What the evidence supports
Glucocorticoids increase protein breakdown in muscle, and older adults have a reduced anabolic response to a given amount of dietary protein. Both point the same way: resistance training on an inadequate protein intake produces a fraction of the result it should.
Limits and cautions
Anyone with kidney disease should take advice before increasing protein substantially. Steroids also stimulate appetite, so this sits alongside a weight conversation rather than instead of one.
Why it ranks fourth
It changes nothing on its own, and it determines how much the training at number one actually delivers.
What it is
Keeping the exercise plan and the medical plan in the same conversation, particularly during dose reductions.
Who it suits
Everyone, and it matters most for anyone whose treatment extends beyond a year, which is common.
What it involves
Reporting returning stiffness during a taper promptly, so the prescriber can distinguish a genuine flare from the ordinary aches of a training programme. Asking about fracture risk assessment and bone protection. Asking whether your dose and duration put you in the group needing bone-sparing medication.
What the evidence supports
Bone protection is generally considered for people on ongoing prednisolone, and treatment for polymyalgia rheumatica frequently continues for a year or longer, which is well past the point where cumulative dose matters. The British Society for Rheumatology has set out the case for updated guidance in this area, noting the age of the existing recommendations.
Limits and cautions
Never adjust a steroid dose yourself. Long-term glucocorticoids suppress the body’s own cortisol production, and stopping abruptly is dangerous.
Why it ranks fifth
It is not something you do so much as something you keep track of, and without it the other four can be undermined by a taper nobody adjusted for.
| Priority | Protects muscle | Protects bone | Reduces fall risk | Needs equipment | Start when |
|---|---|---|---|---|---|
| Resistance training | Yes, directly | Yes | Yes | Bands or weights | Once symptoms settle |
| Weight-bearing exercise | Somewhat | Yes | Somewhat | No | Immediately |
| Balance work | No | No | Yes, directly | No | Early |
| Protein intake | Enables it | Supports it | No | No | Immediately |
| Medical coordination | Indirectly | Yes, via bone protection | Indirectly | No | Throughout |
Only one row protects muscle, bone and balance at once, which is why resistance training sits at the top despite being the hardest to start. Two of the five cost nothing and can begin the day you are diagnosed.
If you have just started steroids and feel dramatically better, this is the moment to start walking daily and to plan the strength work. The first six to twelve months is when bone loss is fastest.
If you have been on steroids for months and feel weaker than when you started, that is the recognised pattern of glucocorticoid myopathy rather than the disease returning, and resistance training is the response to it.
If you are over 65, add specific balance training rather than relying on walking, because walking alone does not reduce falls in the way targeted balance work does.
If your appetite has increased on steroids, direct some of that towards protein at each meal instead of concentrating it in the evening.
If stiffness returns as your dose reduces, tell your prescriber promptly rather than pushing through, and keep exercising at a reduced level meanwhile.
If you develop a new headache, scalp tenderness, jaw pain on chewing or any visual change, seek same-day medical care. That combination is an emergency.
Locally, the most useful thing about this condition is that the supporting infrastructure already exists and is rarely connected to it. Age UK East Sussex runs strength and balance classes and Otago programmes across the county, designed precisely for the combination of reduced proximal strength and raised fracture risk that a year on prednisolone produces. They are usually offered to people after a fall rather than to someone who has just been prescribed steroids, which is the wrong end of the sequence.
The clinical point is that the timing is entirely predictable here. Unlike most conditions, this one comes with a known trajectory: the steroid works quickly, the symptoms recede, and muscle and bone are lost quietly over the following months while the person feels comparatively well. That gap between feeling better and being weaker is when the training should start, and it is exactly when nobody thinks to.
Where building strength safely on long-term steroids is the priority, that is what one-to-one rehab and strength training is for.
Can you exercise with polymyalgia rheumatica?
Yes, and it is important that you do. Once steroids have settled the acute symptoms, resistance training two to three times a week protects against the proximal muscle weakness that long-term glucocorticoids cause, and weight-bearing exercise protects bone. The exception is the acute painful phase before treatment takes effect.
Do steroids cause muscle weakness in polymyalgia rheumatica?
Yes. Glucocorticoid-induced myopathy is a recognised side effect, producing slowly progressive weakness in the proximal muscles, particularly the thighs and shoulders. It is often mistaken for the condition returning, and resistance training is the main way to limit it.
How do steroids affect bone density?
They accelerate bone loss, most rapidly in the first six to twelve months of treatment, and research in polymyalgia rheumatica specifically has documented reduced bone density even at low doses. Anyone on prolonged steroid treatment should have fracture risk assessed and discuss calcium, vitamin D and bone-sparing medication with their GP.
What exercises are best for polymyalgia rheumatica?
Resistance work for the hip and shoulder girdles, since those are the areas both the condition and the treatment affect: sit-to-stands, step-ups, band work for the shoulders and light overhead pressing. Add daily walking for bone and specific balance training to reduce fall risk.
How long does polymyalgia rheumatica last?
Treatment commonly continues for a year or more, with the steroid dose tapered gradually, and some people need low-dose treatment for considerably longer. That duration is exactly why muscle and bone protection matters, since the cumulative dose is what drives the side effects.
Is polymyalgia rheumatica the same as fibromyalgia?
No. Polymyalgia rheumatica is an inflammatory condition affecting people over 50, with raised inflammatory markers, symmetrical shoulder and hip girdle stiffness, and a rapid response to steroids. Fibromyalgia involves widespread pain with normal inflammatory markers and does not respond to steroids.
When is polymyalgia rheumatica an emergency?
If you develop a new headache, tenderness of the scalp or temples, jaw pain when chewing, or any change in vision, seek same-day medical care. These suggest giant cell arteritis, which is associated with polymyalgia rheumatica and can cause irreversible sight loss without urgent treatment.
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