Painless legs and moving toes: symptom reduction during pregnancy.

Painless legs and moving toes is a rare variant of painful legs and moving toes, itself a very rare movement disorder. Both conditions cause semicontinuous movements of the toes, and sometimes of fingers, jaw, and tongue. We describe a woman with painless legs and moving toes, whose symptoms dramatically varied in relation to her menstrual cycle, oral hormone use, and pregnancy. The patient developed, at age 26 years, small involuntary movements of her toes and fingers without associated limb pain. She also had childhood tics involving face and shoulders, previous minor dance-related foot injuries, a right lateral meniscus tear, and bilateral carpal tunnel syndrome (onset age 27 years). Examination revealed small, multidirectional, nearly continuous, involuntary movements of the toes (Video), and less frequent similar finger movements. The movements were not accompanied by a preceding urge or subsequent relief, and they were only briefly suppressible. They worsened for a few days before menses and during use of oral progesterone. During the course of 2 pregnancies, the toe movements considerably decreased in frequency and amplitude (Video). They remained nearly absent throughout each pregnancy and postpartum amenorrheic lactation period, after which they returned to their original severity (Video). Serum studies, including complete blood count, electrolytes, blood urea nitrogen, creatine, glucose, creatine kinase, thyroid function tests, liver function tests, erythrocyte sedimentation rate, and rheumatoid factor, were within normal limits. Antinuclear antibodies were absent. Electromyography and nerve conduction studies revealed only mild bilateral carpal tunnel syndrome. There was no conduction abnormality or evidence of denervation in the lower extremities. Polysomnography with surface electromyography revealed that the toe movements persisted through all stages of sleep. Magnetic resonance imaging of the brain and cervical spine were normal. Fluctuation of symptom severity has not been previously described for painless legs and moving toes. Our patient’s movements nearly disappeared during 2 pregnancies and subsequent lactation periods, and worsened during her menstrual cycle and Table 1. Clinical data in 4 patients with confirmed diagnosis of MSA