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Pain and Spine Medicine

Toe-Tally Confused: When Painful Toes Masquerade as Radicular Back Pain

Friday, October 24, 2025
12:00 PM - 1:30 PM MT
Location: Kiosk 4

    Poster Presenter(s)

  • Andrew Roberts, MD

    Resident Physician
    Medstar Health/Georgetown-National Rehabilitation Hospital PM&R Program
    Washington, District of Columbia

    • Co-Author(s)

  • MD

    Matthew Druckenbrod, MD

    Medical Resident
    Medstar Health/Georgetown-National Rehabilitation Hospital PM&R Program
    Arlington, Virginia

  • AL

    Ann Ly, MD

    Clinical Fellow
    NIH/NINDS
    Redondo Beach, California

Disclosure(s):
Andrew Roberts, MD: No financial relationships to disclose
Case Diagnosis: Painful Limbs Moving Toes Syndrome

Case Description or Program Description: Patient presented with onset of continuous, painless movement of the right fifth toe at rest. Symptoms initially resolved with walking or purposeful ankle movement. Over five years, symptoms progressively spread to all digits with associated throbbing, tightening pain over the dorsum of the right foot and lateral leg. Initial evaluation attributed her worsening pain to known radiculopathy given evidence of gait impairment. She underwent lumbar fusion, which resulted in lower back pain and gait improvements, but involuntary movements in the toes and lower limb pain persisted. Diagnostic workup to rule out other etiologies including EEG, EMG, X-ray, and MRI of right leg/foot were normal. She failed multiple trials of oral medications (GABAergic, dopaminergic, muscle relaxants, and anti-convulsant), acupuncture and physical therapy. Exam findings demonstrated involuntary, continuous, non-rhythmic abduction of the 2nd to 5th digits with occasional flexion of the toes in the right foot. Strength, sensation, deep tendon reflexes and tone were unrevealing.

Setting: Research Institute and Clinical Center

Assessment/Results: Given the phenomenology and clinical history, patient was diagnosed with Painful Limbs Moving Toes (PLMT) syndrome eight years after symptom onset. She underwent ultrasound and EMG-guided botulinum toxin therapy targeted at toe abductors.

Discussion (relevance): PLMT is a rare, adult-onset, treatment-refractory disorder reported to be idiopathic or secondary to neuropathic changes, radiculopathy, or nerve plexus injuries. This is one of the few cases documented of initial painless toe movement with subsequent progressive lower limb pain. Importantly, this case highlights how PLMT may mirror common musculoskeletal conditions, such as radicular pain, resulting in delayed diagnosis.

Conclusions: This case demonstrates how PLMT may mimic, occur simultaneously with, or result from commonly managed musculoskeletal conditions within physiatry. This case emphasizes the need to increase awareness and understanding of this condition amongst physiatrists to improve early detection, functional outcomes, and quality of life.