Restless Legs Syndrome: The Daily PANCE Blueprint
A 58-year-old woman reports a year of trouble falling asleep because of an uncomfortable "creepy-crawly" feeling deep in both legs that comes on in the evening when she sits or lies down. She has an irresistible urge to move her legs, and walking relieves it right away, but it returns as soon as she lies back down. Her husband says her legs jerk during sleep. Her neurologic exam and pedal pulses are normal. Which is the most likely diagnosis?
A. Peripheral artery disease
B. Restless legs syndrome
C. Diabetic peripheral neuropathy
D. Nocturnal leg cramps
E. Akathisia
Answer and topic summary
The answer is B. Restless legs syndrome
Restless legs syndrome (Willis-Ekbom disease) is a clinical diagnosis built on four features: an urge to move the legs, usually with unpleasant sensations, that begins or worsens at rest, is relieved by movement, and is worse in the evening or at night. Most patients also have periodic limb movements of sleep, the leg jerks that someone sharing the bed may notice. The next step is a serum ferritin with iron studies, because iron deficiency is the most important reversible cause; iron is replaced when ferritin is 75 ng/mL or lower or transferrin saturation is below 20%. Other associations are pregnancy, chronic kidney disease, neuropathy, and medications such as antihistamines, antidopaminergic drugs, and SSRIs. Peripheral artery disease causes calf pain with walking that eases with rest, the opposite pattern. Neuropathy causes burning or numbness that moving does not relieve. Leg cramps are painful, palpable muscle contractions. Akathisia is a whole-body inner restlessness after starting an antipsychotic, without the evening pattern. For ongoing symptoms, the American Academy of Sleep Medicine now favors gabapentin or pregabalin over dopamine agonists, which can cause augmentation (symptoms that start earlier and spread).
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