Dystonia in a Runner

NewsBot · Aug 1, 2012

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Diagnosis of Primary Task-Specific Lower Extremity Dystonia in a Runner
Shane McClinton, Bryan C. Heiderscheit
J Orthop Sports Phys Ther 2012;42(8):688-697,

STUDY DESIGN: Resident’s case problem.

BACKGROUND: A 56-year-old man was referred to physical therapy for analysis of unusual gait, first noticed 3 years previously when running. Prior to this evaluation, the patient had seen multiple orthopaedic, sports medicine, and neurological specialists while undergoing repeated and extensive testing. Ten months of testing and treatment, including conservative and surgical management, did not provide an explanation for the gait abnormality or result in improvement of the patient’s condition.

DIAGNOSIS: The patient’s physical examination was relatively unremarkable, considering the severity of the gait abnormality. Distinct abnormalities were apparent with computerized gait analysis and dynamic electromyography, and, when combined with the physical examination findings, led to a suspicion of the task-specific disorder of runner’s dystonia. The patient was referred to a neurologist specializing in movement-related disorders, with a final confirmed diagnosis of primary task-specific dystonia with first onset during running (ie, runner’s dystonia).

DISCUSSION: Idiopathic, task-specific dystonia of the lower extremity is documented as a very rare occurrence, yet increasing trends in running participation may result in a higher incidence of this condition. Improved awareness of runner’s dystonia in the present case might have enhanced the clinical decision-making process and resulted in more timely and effective treatment solutions. Clinical examination findings, including computerized gait analysis and electromyography, in conjunction with imaging, blood, and genetic testing, can aid in the diagnosis of runner’s dystonia
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Admin2 · Aug 1, 2012

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NewsBot · Nov 17, 2012

Difference of Foot Posture in Two Cases of Exercise-Induced Foot Dystonia.
Rana AQ, Boke BN.
Eur Neurol. 2012 Nov 14;69(2):65-66. (free access)
No abstract available.

NewsBot · Mar 2, 2013

Adult-onset Idiopathic Focal Lower Extremity Dystonia: A Rare Task-Specific Dystonia.
Ramdhani RA, Frucht SJ.
Tremor Other Hyperkinet Mov (N Y). 2013;3.

BACKGROUND:
Adult-onset focal lower extremity (LE) dystonia is rare, but there have recently been a number of case series that have reported an idiopathic variant triggered during ambulation.

METHODS:
We describe nine patients with idiopathic, focal task-specific LE dystonia. We conducted a comparative analysis that included our cohort and several recently published case series to further characterize the disorder.

RESULTS:
A total of 48 patients (37 female, 11 male) were compared. The average age of onset was 48 years; 36 patients had distal extremity involvement (75%), 5 proximal (10%), and 7 both proximal and distal (15%). Among 33 patients in which the dystonic side was known, 20 were affected on the left (61%). Inversion of the foot with flexion of one or more toes was the most prevalent pattern in those with distal extremity involvement.

DISCUSSION:
This is a novel task-specific dystonia triggered during ambulation that is often misdiagnosed as an orthopedic or psychogenic issue.
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NewsBot · Apr 1, 2016

Adult onset primary focal dystonia of the foot: an orthopaedic intervention.
Logan L et al
BMJ Case Rep. 2016 Mar 30;2016. pii: bcr2015212072. doi: 10.1136/bcr-2015-212072.

A 54-year-old woman presented to a foot centre with a chief symptom of cramping in her toes, which, she believed, was of a secondary cause originating from a bunion. She was treated conservatively; however, she returned a month later as the symptoms had progressed to painful cramping of toes, toe-curling and instability while walking, due to involuntary movement of her toes. It was believed that the patient presented with a rare case of primary adult onset focal foot dystonia. This case report explains dystonia further in detail and delves into the different treatment and management options available today, including the unique orthopaedic intervention provided for this patient.
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NewsBot · Apr 21, 2018

Electromyographic and Joint Kinematic Patterns in Runner's Dystonia.
Ahmad OF et al
Toxins (Basel). 2018 Apr 20;10(4).

Runner's dystonia (RD) is a task-specific focal dystonia of the lower limbs that occurs when running. In this retrospective case series, we present surface electromyography (EMG) and joint kinematic data from thirteen patients with RD who underwent instrumented gait analysis (IGA) at the Functional and Biomechanics Laboratory at the National Institutes of Health. Four cases of RD are described in greater detail to demonstrate the potential utility of EMG with kinematic studies to identify dystonic muscle groups in RD. In these cases, the methodology for muscle selection for botulinum toxin therapy and the therapeutic response is discussed. Lateral heel whip, a proposed novel presentation of lower-limb dystonia, is also described.
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NewsBot · Dec 16, 2018

Spatiotemporal Gait Analysis and Lower Limb Functioning in Foot Dystonia Treated with Botulinum Toxin.
Datta Gupta A et al
Toxins (Basel). 2018 Dec 12;10(12). pii: E532. doi: 10.3390/toxins10120532.

Foot dystonia (FD) is a disabling condition causing pain, spasm and difficulty in walking. We treated fourteen (14) adult patients experiencing FD with onabotulinum toxin A injection into the dystonic foot muscles. We analyzed the spatiotemporal gait utilizing the GaitRite system pre- and 3 weeks post-botulinum toxin injection along with measuring dystonia by the Fahn⁻Marsden Dystonia Scale (FMDS), pain by the Visual Analog Scale (VAS) and other lower limb functional outcomes such as gait velocity, the Berg Balance Scale (BBS), the Unified Parkinson's Disease Rating Scale⁻Lower Limb Score (UPDRS⁻LL), the Timed Up and Go (TUG) test and the Goal Attainment Scale (GAS). We found that stride length increased significantly in both the affected (p = 0.02) and unaffected leg (p = 0.01) after treatment, and the improvement in stride length was roughly the same in each leg. Similar results were found for step length (p = 0.02) with improvement in the step length differential (p = 0.01). The improvements in the lower limb functional outcomes were also significant-FMDS, VAS, TUG, and UPDRS⁻LL decreased significantly after treatment (all p < 0.001), and BBS (p = 0.001), GAS (p < 0.001) except cadence (p = 0.37). BT injection improved walking in foot dystonia as evidenced through gait analysis, pain and lower limb functional outcomes. Main study limitations were small sample size and lack of control.
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NewsBot · Jun 1, 2021

Functional dystonia in the foot and ankle
Julia Gray et al
Bone Joint J. 2021 Jun;103-B(6):1127-1132

Aims: To assess the characteristic clinical features, management, and outcome of patients who present to orthopaedic surgeons with functional dystonia affecting the foot and ankle.

Methods: We carried out a retrospective search of our records from 2000 to 2019 of patients seen in our adult tertiary referral foot and ankle unit with a diagnosis of functional dystonia.

Results: A total of 29 patients were seen. A majority were female (n = 25) and the mean age of onset of symptoms was 35.3 years (13 to 71). The mean delay between onset and diagnosis was 7.1 years (0.5 to 25.0). Onset was acute in 25 patients and insidious in four. Of the 29 patients, 26 had a fixed dystonia and three had a spasmodic dystonia. Pain was a major symptom in all patients, with a coexisting diagnosis of chronic regional pain syndrome (CRPS) made in nine patients. Of 20 patients treated with Botox, only one had a good response. None of the 12 patients who underwent a surgical intervention at our unit or elsewhere reported a subjective overall improvement. After a mean follow-up of 3.2 years (1 to 12), four patients had improved, 17 had remained the same, and eight reported a deterioration in their condition.

Conclusion: Patients with functional dystonia typically presented with a rapid onset of fixed deformity after a minor injury/event and pain out of proportion to the deformity. Referral to a neurologist to rule out neurological pathology is advocated, and further management should be carried out in a movement disorder clinic. Response to treatment (including Botulinum toxin (Botox) injections) is generally poor. Surgery in this group of patients is not recommended and may worsen the condition. The overall prognosis remains poor.
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NewsBot · Jul 29, 2022

A runner with a movement disorder
David Binyam, Erik van Wensen
Ned Tijdschr Geneeskd. 2022 May 3

A 56-year old female runner is not able to run without tripping over anymore. Only whilst running her right foot repeatedly and involuntary makes an outward twist, which impedes her from continuing. She was diagnosed with Runner's Dystonia based on her presentation and virtually normal physical neurologic examination at rest.
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NewsBot · Aug 9, 2022

Functional dystonia: A pitfall for the foot and ankle surgeon
DishanSingh
Foot and Ankle Surgery Volume 28, Issue 6, August 2022, Pages 691-696

Functional dystonia represents a condition where psychological distress is being expressed as involuntary muscle contractions. In the foot and ankle, it most commonly presents as a sudden onset of a painful fixed ankle/hindfoot deformity in a female patient with a history of trivial trauma or surgery. The “fixed deformity” found on clinical examination is usually correctable under general anesthesia. Less commonly, it can present in the toes or may present as paroxysmal muscle movements rather than a fixed deformity. CRPS may occur concurrently with the dystonia.

Failure to consider the diagnosis leads to a long delay in appropriate diagnosis, patient distress and unnecessary or even harmful surgery. A better approach to this clinical syndrome is to define it as fixed abnormal posturing that is most commonly psychogenic. Early referral to a movement disorder clinic is recommended. The prognosis is generally poor as less than a quarter of patients report subjective long-term improvement even when managed in a movement disorder clinic. Foot and ankle surgeons should, whenever possible, avoid operating on patients with functional dystonia in order to avoid symptomatic deterioration.
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