I thought I was just hyperactive or had adult attention deficit disorder of my legs. Perhaps because of all that restlessness, I now have two total hips, pretibial edema, and an ingrown big toe nail secondary to hallux valgus. (Getting old ain’t for sissies!)


Published 3/1/2013
S. Terry Canale, MD

Are you pulling my (restless) leg?

Boy, is my leg restless today! My legs have been restless since the 1995 AAOS Summer Institute where Kenneth J. Koval, MD; Peter G. Trafton, MD; E. Greer Richardson, MD, and James A. Nunley II, MD, lectured and demonstrated leg operations, while Judy Sherr (who was then an AAOS staff member) cheered them on. It didn’t seem that I needed any of those operations, but my legs just wouldn’t quit moving. I looked like “Mambo Man!”

S. Terry Canale, MD

Now I discover I may have something called “restless leg syndrome” (RLS). I thought it was an orthopaedic undercover name for those who are restless and can’t sleep at night. I don’t sleep well—no sleep maintenance, unrefreshing sleep, and nightmares. I do toss and turn, but I didn’t know it was due to RLS. I tried a bar of soap under my sheets as suggested by author and health advice columnist Peter H. Gott, MD, for leg cramps and RLS—no help for my legs, but I smell good.

RLS occurs secondary to uremia, iron deficiency (anemia), and pregnancy. That last one I ruled out pretty easily, and my hematocrit, blood urea nitrogen, and creatine levels are borderline normal. I guess I will live with it. For an old man like me to have restless legs and a wandering eye may not be all bad!!

Dealing with RLS patients
If RLS is not an orthopaedic problem, why do I bring it up? Well, I have had several patients in the last 6 months give me a chief complaint of RLS, which they identified based on a series of television commercials they had seen. I gave them a “deer-in-the-headlights” response and, leaving my ego at the door, informed them that I am not sure what the “restless leg syndrome” is, but I’ll look it up on the Internet and get back to them.

Also, because RLS is a “leg in motion” and the AAOS is promoting a “nation in motion,” the public expects orthopaedists to know something about all forms of motion in the leg.

I did a Medline search and here’s the deal: RLS is a real entity, very common in the neurology literature, with hundreds of citations noted. The problem is that anyone whose leg shakes too much is told that he or she has RLS. Patients are happy to find out what is wrong, finally have an answer, and now know why they don’t sleep well.

The symptoms are bizarre and different for each patient. Some patients feel like something is scratching or crawling on their legs, others describe pins-and-needles sensations (paresthesias), and still others describe a sensation of the legs jumping at night and awakening them.

Treatment seems to consist of the following techniques:

  • Reassurance that there is nothing seriously wrong and no real nerve deficit is present
  • L-dopamine prescriptions, although this drug has many side effects
  • Ropinirole (Requip) or pramipexole (Mirapex), which can cause drowsiness or narcolepsy (falling asleep during the day)
  • Bar of soap under the bottom sheet at night (Dr. Gott)

My preference would be #1. Patients need to be reassured that they don’t have this very specific entity; they are just restless. (I’m beginning to wonder what restless means.) Lab studies can show they are not anemic, uremic, or pregnant, and they don’t need ­L-dopamine.

If that didn’t satisfy them, I would refer them to a neurologist. As they leave, I might mention the soap under the sheet, but I would make them swear to never reveal that I suggested it!

What’s the point?
The point of this editorial is not to teach you about RLS in depth (I hope you will see only two or three cases in your career), but to encourage you to look into a situation before forming an opinion. I once saw a bumper sticker that read “Avoid contempt prior to investigation,” which I think should be applied all the time—particularly in medical and orthopaedic situations.

Many things in medicine, if investigated, can be explained and don’t deserve your contempt. Consider, for example, the following three examples. They are all situations in which orthopaedists might benefit from a little judicious investigation.

  • Being contemptuous of a diagnosis or treatment given in the emergency department (ED) for a patient who is referred to your office. The ED staff may not have access to someone with your experience, and that’s why they sent the patient to you as a specialist.
  • Being critical of treatment recommended by another physician or orthopaedist that differs from your method of treatment without knowing the treatment rationale.
  • Relying on only the patient’s information or story about another physician and what that physician said to the patient. ­Patients are notorious for misinterpreting and getting information wrong.

When I first heard of RLS, I was skeptical and immediately had contempt for the patient, the referring physician, and whatever led to this diagnosis. But then I looked at the subject from 30,000 feet and realized I had not investigated it at all. After reviewing the literature, I see that much has been written about it. Just because we can’t explain a condition anatomically, physiologically, or objectively doesn’t mean it doesn’t exist. It just means that we have not been able to explain it on a scientific basis as yet.

So avoid contempt prior to investigation and don’t judge a man with restless leg syndrome until you’ve walked a mile in his shoes. If you still have contempt—well, you’re a mile away and you’ve got his shoes! Now that will really give him something to be restless about.

S. Terry Canale, MD, is editor-in-chief of AAOS Now. He can be reached at aaoscomm@aaos.org

Editor’s note: Perhaps the best place to conduct some serious orthopaedic investigations is at the AAOS Annual Meeting, which kicks off on March 19. Although I realize that not everyone reading this column can attend the meeting, the Academy and AAOS Now are going to do our best to bring you the best.

Next month’s issue of AAOS Now will focus almost exclusively on hot topics from the meeting. Even if you’re not in Chicago, for example, you can check out the electronic posters and scientific exhibits (see “Technology Enhances Education at Annual Meeting.”) or download and listen to symposia on a wide range of topics (see “AAOS Brings Annual Meeting to You,” AAOS Now, February 2013).

Every day during the meeting, AAOS Headline News Now will bring you summaries of the research being presented, and the electronic version of The Annual Meeting Daily Edition of AAOS Now will be live every day with reports on what’s happening at the meeting.

For those planning to be in Chicago, we’ve even done research in advance on the best places to eat, best sights to see, and hottest night spots. (See “Sweet Home Chicago.”) Some of these venues sound so good, I plan to get my restless legs in motion and head over to them!