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Painful legs and moving toes syndrome is a rare medical picture characterized by involuntary movements of the toes or the whole foot and pain in lower limbs. However, this must be kept in mind due to its association with other diseases and its possibility of being the first symptom. Spinal cord and cauda equina diseases, neuropathies, radiculopathies, drugs and other systemic diseases are the main cause of this syndrome although many cases are still idiopathic. Its diagnosis is essentially clinical and its treatment is complex, including different combinations of drugs and invasive techniques, and generally with a bad response.
Painful Legs and Moving Toes Syndrome:
Unusual condition that presents with acute onset (usually) of a constant, deep, throbbing and severe burning/aching pain of one affected leg and/or foot with spontaneous involuntary foot movements (mainly the toes --> flexion-extension and abduction-adduction). Can be painful. Movements tend to persist during sleep --> may cause insomnia. Patient can usually stop the movements voluntarily for up to a minute. Can vary from a mild to severe affect on patients daily activities. Case has been reported of the initial symptoms mimicking Morton’s interdigital neuroma .
Usually have no sensory loss. EMG shows two different patterns:
1) Rhythmic bursts of high amplitude complex motor discharges
2) Erratic continuous low amplitude activity
May be linked to impairment of spinal serotonin and GABA functions as some patients have been reported as responding to clonazepam and baclofen. Adenosine deficiency in blood has been reported in two cases . Ephaptic transmission in damaged nerve roots or peripheral nerves with central reorganisation has also been suggested as the underlying mechanism of the syndrome
May have history of lumbosacral radiculopathy or other lesion of the spinal cord, peripheral neuropathy or bony/soft tissue injury to the feet.
Treatment:
Generally responds poorly to pharmacological intervention; anticonvulsant medication (eg dilantin) may help some – also baclofen (possibly in combination with clonazepam); brace at night to limit foot plantarflexion (may help sleep); use of TENS with vibratory stimulation has also been suggested ; sympathetic and epidural nerve blocks have helped some
__________________ Craig Payne
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any idea's a foot with involentary movement of great toe joint involing distal/phangeal sections, on side of body that has had a stroke.this happens during walking and when not moving action is of a dorsiflexion of toe
Case series of painful legs and moving toes: Clinical and electrophysiologic observations.
Alvarez MV, Driver-Dunckley EE, Caviness JN, Adler CH, Evidente VG. Mov Disord. 2008 Aug 29. [Epub ahead of print]
Quote:
We present a retrospective review of cases of painful legs and moving toes (PLMT) syndrome. Out of 4,780 database patients with movement disorders diagnosed at Mayo Clinic Arizona from 1996 to 2006, we identified 14 cases of PLMT and its variants (6 men, 8 women). Ages ranged from 25 to 84 years (mean, 69 years). Movements were bilateral in 12 and unilateral in 2. Pain preceding the movements was most commonly burning; movements consisted of flexion/extension, abduction/adduction, fanning, or clawing of toes, fingers, and sometimes the foot or hand. The most common predisposing factors were neuropathy and radiculopathy. Surface electromyography showed movements suggestive of both chorea and dystonia. Movements were partially suppressible and were diminished but still apparent during light sleep. GABAergic agents were most effective in controlling the pain and the movements
Has anyone dealt with a patient with dystonia? I have a client who was diagnosed with dystonia about a year ago, just shortly after having back surgery. She gets extreme pain and discomfort throughout her whole left foot, as well as burning feeling of her bilateral feet. I have made her a pair of semi-rigid custom orthoses to help provide stability and decrease some of the stresses present along her spine. However, she is only able to wear the orthoses for about 2 hours before having to take them off due to intense pain throughout her feet and severe burning. I've adjusted the orthoses a few times already, by decreasing the support along the medial longitudinal arches and removing the metatarsal domes.
Any suggestions?
__________________
C Shantz
BSc, C Ped Tech (C), C Ped (C)
Painful legs and moving toes is a rare syndrome characterized by spontaneous neuropathic pain in the lower limbs associated with peculiar involuntary movements of the lower extremities, especially the toes and feet. Although its origin is unknown, it is associated to some pathologies. With regard to the painless variant, very few patients have been reported and most of them are idiopathic. We report a patient with involuntary movements of the toes similar to those seen in painful legs and moving toes syndrome, but without any associated pain and due to a spinal compression. We conclude that spinal lesions may produce the painless variant as it has been reported with the painful form.
Painful legs and moving toes syndrome associated with lumbar radiculopathy
[Article in French]
El Otmani H, Moutaouakil F, Fadel H, Slassi I. Rev Neurol (Paris). 2009 Nov;165(11):980-3.
Quote:
INTRODUCTION: Painful legs and moving toes (PLMT) is a rare syndrome characterized by spontaneous neuropathic pain in the lower limbs associated with peculiar involuntary movements of the toes. It has been associated with a variety of peripheral and central nervous system diseases. Pathophysiology is unclear and treatment approaches remain largely empirical.
CLINICAL CASE: We report a case of a 42-year-old women with typical presentation of PLMT syndrome, associated with lumbar (L5) disc prolapse. Oxcarbazepine gave a partial improvement.
CONCLUSION: Clinical presentations and etiological aspects of the PLMT syndrome are described and pathophysiological mechanisms and therapeutic possibilities discussed.
The syndrome of painful legs-moving toes (PLMT) is an adult-onset, rare disorder characterized by pain, typically of a neuropathic quality, in the feet or legs, associated with writhing movements of one or more toes. It is the pain which usually brings the patient to medical attention. The syndrome may be unilateral or bilateral. Identical toe movements may occur without pain, referred to as: "painless legs-moving toes," and a similar condition affects the upper limbs: "painful arms-moving fingers." The pathophysiology of PLMT and its variants is not known but most reports suggest an association with a peripheral lesion, usually at the level of the root or nerve, though in many cases no cause is found. It has been suggested that a peripheral lesion causes aberrant input leading to "central reorganization," probably at the level of the spinal cord, and that the latter is responsible for the pain and movement. Treatment is often unsatisfactory and many drugs commonly used for neuropathic pain have been reported anecdotally to help (e.g., gabapentin). Other anecdotal therapies include spinal blocks, spinal cord stimulation, and local injection of botulinum toxin.
Painless legs and moving toes: symptom reduction during pregnancy.
Diaz NL, Hanspal EK, Mazzoni P. Mov Disord. 2012 Feb;27(2):328-9
(no abstract available)
Painless legs and moving toes from parasagittal meningioma.
Yabe I, Kano T, Sakushima K, Terasaka S, Sasaki H. Mov Disord. 2012 Apr;27(4):586-7.
(no abstract available)
Painful legs and moving toes syndrome: a 76-patient case series.
Hassan A, Mateen FJ, Coon EA, Ahlskog JE. Arch Neurol. 2012 Aug;69(8):1032-8.
Quote:
OBJECTIVE:
To better characterize the clinical features, electrophysiologic features, and treatment outcomes of painful legs and moving toes (PLMT) syndrome.
DESIGN:
Large case series.
SETTING:
Neurology outpatient clinic at a tertiary referral center, 1983-2011.
PATIENTS:
All cases of PLMT seen at our institution during an 18-year period were identified using our medical record linkage system.
MAIN OUTCOME MEASURES:
Key demographic, clinical, imaging, and electrophysiologic features of PLMT. Treatment outcomes and long-term follow-up are also reported.
RESULTS:
Of 76 cases identified (including 50 women [66%]), the mean age at onset was 58 years (range, 24-86 years) and at neurologic evaluation was 63 years (range, 26-88 years). Pure lower limb involvement was most common (69 patients [91%]), and 44 cases (58%) were bilateral. The most frequently diagnosed causes were peripheral neuropathy (21 cases [28%]), previous trauma (8 [11%]), and radiculopathy (7 [9%]); 32 cases (42%) were cryptogenic. Electromyography consistently showed irregular 50-millisecond to 1-second bursts of normal motor unit potential firing at 2 to 200 Hz accompanying the movements. Pain occurred first in nearly all cases and was more distressing to patients than the movements. Both components were difficult to treat, with no consistent benefit from a variety of drugs and therapeutic modalities. The syndrome persisted in most patients (83%) during the mean follow-up of 4.6 years, suggesting low likelihood of spontaneous resolution.
CONCLUSIONS:
Painful legs and moving toes syndrome is a debilitating clinical syndrome, not because of the movements but rather because of the pain, which often is refractory to treatment. Segmental lower limb involvement is most common, and neurophysiologic findings support a pathophysiologic process localizing to a central generator at the spinal cord or brainstem level.
Painful legs and moving toes syndrome
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