Commentary.

In this case report by Gupta et al.,[1] a patient presents with symptoms of restlessness in the right arm without symptoms in the legs and is diagnosed with restless legs syndrome (RLS). Typically, RLS presents in the legs and may also affect the arms of patients later in disease progression. RLS is characterized by an urge to move the legs that starts or worsens during rest or inactivity. The symptoms are worse in the evening hours and are relieved by movement.[2] Several case reports have been published previously that describe restlessness of the arms as initial presentation of RLS, however, in these cases, both arms were affected.[3-5]

The patient in this case was also diagnosed with depression and bilateral cervical ribs. The symptoms of depression were not determined to be a cause of the RLS symptoms due to temporal association. Cervical ribs may cause thoracic outlet syndrome (TOS),[6] which was also part of the differential diagnosis for this patient. Symptoms of TOS include pain and tingling in the arm and/or neck, which may be exacerbated by deliberate movements such as heavy lifting.[7] The upper extremity pain seen with TOS is generally ipsilateral as with the present case.[8] The symptoms are often nocturnal and can be troublesome enough to awaken patients while sleeping. Although there are some similarities in symptoms among the two conditions, a diagnosis of RLS was ultimately selected, as the patient did not have a positive result for four separate clinical tests that were given to test for TOS.

Dopamine agonists such as pramipexole or ropinirole are commonly used as first-line treatment for RLS.[9] Treatment with pramipexole resulted in an improvement of symptoms in the patient presented in this case, which further supported the original diagnosis.