title: Repetitive exercise dystonia: A difficult to treat hazard of runner and non-runner athletes.
abstract: Runner's dystonia has previously been described in small series or case reports as a lower limb, task-specific dystonia. We have occasionally encountered this disorder and recognized the same phenomenon in non-runners regularly engaging in lower limb exercise. We wished to characterize the syndrome further, including outcomes, treatment, and the diagnostic usefulness of electrophysiology.
  
  
  
  We conducted a retrospective review and follow-up survey of adults seen at Mayo Clinic (1996-2015) with task-specific dystonia arising after prolonged repetitive lower limb exercise. The findings were compared to all 21 previously reported cases of runner's dystonia.
  
  
  
  We identified 20 patients with this condition, 13 runners and seven non-runner athletes. Median age at dystonia onset was in mid-adulthood. Correct diagnosis was delayed by a median of 3.5 years in runners and 1.6 years in non-runners, by which time more than one-third of patients had undergone unsuccessful invasive procedures. Most patients had dystonia onset in the distal lower limb. Dystonia was task-specific with exercise at onset but progressed to affect walking in most. Sensory tricks were reported in some. Surface EMG was consistent with task-specific dystonia in nine patients. Botulinum toxin, levodopa, clonazepam, trihexyphenidyl, and physical therapy provided modest benefit to some, but all patients remained substantially symptomatic at last follow up.
  
  
  
  Repetitive exercise dystonia is task-specific, confined to the lower limb and occasionally trunk musculature. It tends to be treatment-refractory and limits ability to exercise. Diagnosis is typically delayed, and unnecessary surgical procedures are common. Surface EMG may aid the diagnosis.
authors.affiliation: Department of Neurology, Mayo Clinic, Rochester, MN, USA. Electronic address: cutsforthgregory.jeremy@mayo.edu.
authors.forename: Jeremy K
authors.initials: JK
authors.lastname: Cutsforth-Gregory
authors.affiliation: Department of Neurology, Mayo Clinic, Rochester, MN, USA. Electronic address: eahlskog@mayo.edu.
authors.forename: J Eric
authors.initials: JE
authors.lastname: Ahlskog
authors.affiliation: Department of Neurology, Mayo Clinic, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA. Electronic address: mckeon.andrew@mayo.edu.
authors.forename: Andrew
authors.initials: A
authors.lastname: McKeon
authors.affiliation: Department of Neurology, Mayo Clinic, Rochester, MN, USA. Electronic address: burnett.melinda@gmail.com.
authors.forename: Melinda S
authors.initials: MS
authors.lastname: Burnett
authors.affiliation: Department of Neurology, Mayo Clinic, Rochester, MN, USA. Electronic address: jmatsumoto@mayo.edu.
authors.forename: Joseph Y
authors.initials: JY
authors.lastname: Matsumoto
authors.affiliation: Department of Neurology, Mayo Clinic, Rochester, MN, USA. Electronic address: hassan.anhar@mayo.edu.
authors.forename: Anhar
authors.initials: A
authors.lastname: Hassan
authors.affiliation: Department of Neurology, Mayo Clinic, Rochester, MN, USA. Electronic address: bower.james@mayo.edu.
authors.forename: James H
authors.initials: JH
authors.lastname: Bower
mesh_terms: D000328:Adult; D000368:Aged; D056352:Athletes; D001905:Botulinum Toxins / Q000008:administration & dosage; D020821:Dystonic Disorders / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy*; D004576:Electromyography / Q000379:methods; D015444:Exercise / Q000502:physiology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D026741:Physical Therapy Modalities; D012189:Retrospective Studies; D012420:Running / Q000502:physiology*
chemical_list: D001905:Botulinum Toxins
keywords: Dystonia; Exercise; Focal dystonia; Movement disorders; Task-specific dystonia