Joseph Magnant, MD, FACS, RPVI
Restless Leg Syndrome (RLS) or Willis-Eckbom Disease is a neurological disorder in which the person who suffers from it has a constant urge to move their legs. RLS most strongly affects people during times of inactivity, and can make it extremely difficult for a person to relax, rest, or sleep. While RLS can appear in a person at any age, it is considered both a progressive disease and a spectrum disease. RLS symptoms can either become worse over time or better, depending on the patient, and the severity of symptoms also varies strongly from patient to patient.
What is RLS?
In order for patients to be officially diagnosed with restless legs syndrome, they must meet the criteria described in the four bullets:
• Patients have a strong urge to move their legs, which they may not be able to resist.
• RLS symptoms start or become worse when a patient is resting.
• RLS symptoms get better when patients move their legs. Relief persists as long as the motor activity continues.
• RLS symptoms are worse in the evening, especially when lying down.
Many cases have shown that RLS occurs as a result of and is associated with venous reflux disease or venous insufficiency.
Veins are blood vessels that are specially designed to pump blood back toward the heart, against the force of gravity. Inside the veins are a series of one-way valves that open and close with the rhythm of muscle contractions. Healthy valves close tightly, keeping blood moving upward toward the heart. With vein disease or venous insufficiency, the valves do not close properly, causing symptoms.
Venous insufficiency has many signs and symptoms and they go beyond the visible varicose veins. They include swollen, achy and heavy legs, skin discoloration and ulceration. Vein disease can be a contributing factor in the development of RLS.
With venous insufficiency, the valves of the deep and/or superficial veins of the lower extremities are either stuck or scarred in the open position or, more often, are floppy and continue to open, or prolapse, beyond the closed position. This results in reflux, or backward blood flow in the veins, which produces increased hydrostatic pressure in the downstream venous system.
Typically, the normal pressure in healthy veins, veins in which the valves are closing properly, is approximately ten millimeters of mercury at the level of the ankle when a patient is standing. If the valves are leaking from the groin all the way down to the ankle, by the end of the day the pressure could be as high as fifty or sixty millimeters of mercury. All of that extra pressure causes fluid to leak out of the veins into the skin, fat and muscle, causing pain and swelling.
It is thought that the return of this fluid, which contains water and protein, from the muscles back into the lymph vessels at night, when the legs are elevated, can trigger a cellular electrolyte imbalance and the symptoms of RLS. Thus, RLS symptoms often go hand-in-hand with venous insufficiency. However, not everyone with RLS has venous insufficiency, and not everyone with venous insufficiency has RLS.
We recommend that, before patients start taking prescription medication for restless legs syndrome, they request a consult by a qualified vein specialist. He or she will likely perform ultrasound evaluation to identify whether there is significant underlying venous insufficiency that might be causing or contributing to their problem.
There is no downside to getting an ultrasound; there is no radiation involved, no needles, no pain and it is a physiologic test that reveals which veins are leaking and how much they are leaking. Venous ultrasound for insufficiency is conservative and noninvasive, and it accurately identifies which patients are most likely to benefit from treatment.
Clearly, other causes of RLS exist, however, we encourage patients to consider venous insufficiency as a contributing factor and to request a venous insufficiency evaluation by an experienced vein specialist prior to undergoing a million-dollar workup for other diagnoses or initiating medical therapy for RLS.
One such treatment for varicose veins is endovenous ablation therapy, a procedure that uses heat in either lasers or radio frequencies to seal off and close affected veins. Many patients report immediate relief in their symptoms, and, because the procedure is minimally invasive and relatively painless, most patients are able to resume their normal activities almost immediately and experience no interruption in their work or home life as a result.
If you are experiencing RLS, seeing a physician who specializes in vein disorders could be the most important step you take towards alleviating your discomfort. Before you consider medical therapy or medication for RLS, consider a venous insufficiency evaluation.