Painful legs and moving toes syndrome with stimulus-sensitive startle myoclonus

Painful legs and moving toes (PLMT) syndrome is a rare movement disorder characterised by chronic lower limb pain associated with involuntary toe movements. We describe a 56-year-old woman referred for evaluation of suspected myoclonus who presented with an 18-month history of bilateral lower limb dysaesthetic pain associated with intermittent jerking movements predominantly affecting the left quadriceps. Symptoms were worse at night and accompanied by longstanding abnormal toe movements and episodic leg spasms. She had exaggerated stimulus-sensitive jerks triggered by tactile and auditory stimuli, consistent with startle myoclonus. Home video recordings showed slow irregular abduction–adduction toe movements occurring at approximately 1–2 Hz, consistent with PLMT phenomenology. MR scan of brain and spine and nerve conduction studies were unremarkable apart from mild degenerative spinal changes. Her symptoms partially improved with clonazepam. This case expands the recognised phenotypic spectrum of PLMT and highlights a possible association with broader central sensorimotor hyperexcitability.