Can restless legs syndrome (RLS) be painful?

Restless Legs Syndrome and Pain

Yes, restless legs syndrome (RLS) can be painful, as it is characterized by uncomfortable and unpleasant sensations in the legs that are often described as painful by patients. 1, 2 According to the International Restless Legs Syndrome Study Group diagnostic criteria, RLS involves "an urge to move the legs usually but not always accompanied by or felt to be caused by uncomfortable and unpleasant sensations in the legs."

Characteristics of RLS Sensations

• The sensations experienced in RLS vary in description and intensity:
  • Uncomfortable and unpleasant sensations are a core feature 1
  • These sensations can be described as achy or painful 3
  • The discomfort ranges in severity from mildly annoying to disabling 1
  • Some patients may have the urge to move without accompanying sensations 1

Diagnostic Criteria for RLS

The American Academy of Sleep Medicine established five essential criteria for diagnosing RLS 2:

1. An urge to move the legs usually accompanied by uncomfortable/unpleasant sensations
2. Symptoms begin or worsen during periods of rest or inactivity
3. Symptoms are partially or totally relieved by movement (walking, stretching)
4. Symptoms occur or worsen in the evening or night compared to daytime
5. Symptoms are not solely accounted for by another medical or behavioral condition

Pain vs. Other Sensations in RLS

While pain can be present in RLS, patients may describe their sensations using various terms 4, 5:

• Uncomfortable urge to move
• Unpleasant sensations
• Aching
• Crawling sensation
• Creeping feeling
• Electric-like sensations

Clinical Significance

For RLS to be clinically significant, symptoms must cause 2:

• Significant distress or impairment in functioning
• Impact on sleep, energy levels, daily activities
• Effects on behavior, cognition, or mood

Differentiating RLS Pain from Other Conditions

It's important to distinguish RLS pain from other conditions that can mimic RLS 1, 2:

• Leg cramps (typically more sudden, intense contractions)
• Venous stasis (associated with swelling)
• Arthritis (typically joint-focused pain)
• Peripheral neuropathy (often constant, not relieved by movement)
• Myalgia (muscle pain that doesn't typically follow circadian pattern)

Management Implications

Understanding that RLS can be painful influences treatment approaches:

• For painful RLS symptoms, alpha2-delta calcium channel ligands (gabapentin, pregabalin) may be particularly effective 4
• Dopaminergic agents (first-line therapy) address both the urge to move and uncomfortable sensations 2, 4
• Opioids may be considered for severe, painful RLS unresponsive to other treatments 6

Key Takeaway

The pain in RLS is distinctive in that it:

• Follows a circadian pattern (worse in evening/night)
• Is relieved by movement
• Occurs during periods of rest
• Can significantly impact quality of life and sleep

Understanding that RLS can manifest as painful sensations is crucial for proper diagnosis and effective management of this condition.