Working Diagnosis:
Runner's Dystonia

Treatment:
The patient was referred back to the movement disorder clinic. The initial plan of care was to target the focal dystonia with botulinum toxin injections into the left tibialis posterior, gastrocnemius, and soleus. She was also sent to physical therapy for targeted therapy. Other systemic options, including carbidopa levodopa, carbamazepine, or trihexyphenidyl, were discussed for the future

Outcome:
A follow up gait evaluation was planned for 3 to 4 weeks after the injections. Her outcome was still to be determined.

Author's Comments:
Runner's dystonia is a rarely reported form of adult-onset dystonia that most commonly affects long distance runners. The etiology is poorly understood. It is often misdiagnosed, resulting in delayed management. It is characterized by its gradual and progressive onset, involuntary muscle contractions causing abnormal posturing, reproduction on fatigue, and resolution at rest. Patients often mimic relief by adapting motor tricks like alternative gate-type, cadence, and focusing on heel-toe mechanics

Editor's Comments:
As the author pointed out, Runner's Dystonia is a rare muscular disorder, often difficult to diagnose unless one is familiar with the condition. The management and treatment of dystonia is varied. Botulinum injections in the appropriate muscle groups, anticholinergic medication, dopamine agonists, or anticonvulsants to prevent spasms have all been proposed as possible treatment options. Thus far, many of these treatments fail to yield complete resolution of the symptoms. In the diagnosis and workup of abnormalities caused or exacerbated by fatigue, a post-exercise assessment and gait analysis are key in making the diagnosis

References:
Cifu, D., & Eapen, B. (2021). Braddom's Physical Medicine and Rehabilitation.
Cutsforth-Gregory, Jeremy K, Ahlskog, J. Eric, McKeon, Andrew, Burnett, Melinda S, Matsumoto, Joseph Y, Hassan, Anhar, & Bower, James H. (2016). Repetitive exercise dystonia: A difficult to treat hazard of runner and non-runner athletes. Parkinsonism & Related Disorders, 27, 74-80.
McClinton, Shane, & Heiderscheit, Bryan. (2012). Diagnosis of Primary Task-Specific Lower Extremity Dystonia in a Runner. The Journal of Orthopaedic and Sports Physical Therapy, 42(8), 688-697.
Wu LJ, Jankovic J. Runner's dystonia. J Neurol Sci. 2006 Dec 21;251(1-2):73-6. doi: 10.1016/j.jns.2006.09.003. Epub 2006 Nov 9. PMID: 17097111.
Leveille, L., & Clement, D. (2008). Action-Induced Focal Dystonia in Long Distance Runners. Clinical Journal of Sport Medicine.18(5):467-468.

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