Working Diagnosis:
Painful legs and moving toes syndrome

Treatment:
Trials of nortriptyline and gabapentin were not tolerated.
She had some modest improvement of pain with Pregabalin (up to 75 mg three times daily.
Botulinum toxin (50 units) was injected into the flexor digitorum brevis under electromyogram guidance.

Outcome:
Movement and pain began decreasing two months later over winter break.
She is currently participating fully in her sport with no residual symptoms at 5 months.

Author's Comments:
PLMT is a rare syndrome, particularly in the young adult population.
It is rarer still for the movement disorder to predate the pain syndrome.
Etiology is typically local trauma, lumbar radiculopathy, or idiopathic.
Symptoms typically last days to years.
Treatment is difficult with poor pharmacologic responses.
Case reports exist to support use of botulinum toxin to reduce movement and improve pain.

Editor's Comments:
Painful legs and moving toes syndrome (PLMT) is a rare disorder, and the incidence, prevalence and exact etiology are unknown. It may develop in the setting of trauma and underlying radiculopathy or peripheral neuropathy, however in many cases, the cause is unknown. Symptoms may be unilateral or bilateral, and pain usually precedes the movement disorder. Clinical presentation involves pain of the lower legs and involuntary movement of the feet/toes. It is important to differentiate from restless leg syndrome. Diagnosis is primarily clinical. EMG and NCS may be helpful. On review of literature, multiple treatments have been tried with little success. GABAergic medications (Gabapentin, Pregabalin) have been effective in some patients. PLMT can be a debilitating condition, therefore Neurology consultation is recommended.

References:
Liu R, Moizuddin M, Hung S. Painful legs and moving toes - Case report and Review of literature. BJMP 2011;4(3):a431.

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