{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T00:57:03Z","timestamp":1760057823115,"version":"build-2065373602"},"reference-count":29,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2025,3,3]],"date-time":"2025-03-03T00:00:00Z","timestamp":1740960000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Intramural Research Program of the National Institutes of Health Clinical Center"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Toxins"],"abstract":"<jats:p>Background: Runner\u2019s dystonia (RD), a rare task-specific lower-limb dystonia affecting high-mileage runners, presents as abnormal lower-extremity muscle contractions during running. Treatment of RD is challenging and often confounded by significant diagnostic delays due to overlapping symptomatology with other conditions. This case series examines the relationship between stiff knee gait RD and musculoskeletal (MSK) knee pathology. Methods: Eight RD cases, evaluated at the NIH Movement Disorders Clinic since 2018, were retrospectively reviewed. Patients underwent neurological, biomechanical, and MSK evaluations, including 3D motion analysis, surface electromyography, and knee ultrasound. Therapeutic interventions, including botulinum neurotoxin (BoNT) injections, were assessed. Results: Seven patients demonstrated stiff knee gait subtypes, with all having ipsilateral and\/or contralateral knee effusions or tendinopathies. Three patients who received MSK interventions (e.g., aspiration, corticosteroid injections) combined with BoNT therapy experienced significant symptom improvement. One patient with isolated foot dystonia displayed different biomechanical patterns without knee pathology. Conclusions: RD patients with stiff knee gait often exhibit knee pathology, most likely due to altered biomechanics and running history. Addressing both issues is essential for optimizing treatment outcomes, reducing pain, and improving function, especially since pain can trigger dystonia. Future research should determine the ideal sequence of interventions for RD patients with MSK issues to develop effective, personalized treatment algorithms.<\/jats:p>","DOI":"10.3390\/toxins17030121","type":"journal-article","created":{"date-parts":[[2025,3,3]],"date-time":"2025-03-03T05:52:16Z","timestamp":1740981136000},"page":"121","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The Relationship Between Stiff Knee Gait Runner\u2019s Dystonia and Musculoskeletal Knee Pathology: A Case Series"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9741-3239","authenticated-orcid":false,"given":"Jared A.","family":"Stowers","sequence":"first","affiliation":[{"name":"MedStar Georgetown National Rehabilitation Hospital, Washington, DC 20010, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-0741-268X","authenticated-orcid":false,"given":"Derek S.","family":"Day","sequence":"additional","affiliation":[{"name":"Department of Physical Medicine and Rehabilitation, University of Utah Health, Salt Lake City, UT 84132, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Steven","family":"Jow","sequence":"additional","affiliation":[{"name":"Holmdel Sports and Spine, Holmdel, NJ 07733, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarah","family":"Heins","sequence":"additional","affiliation":[{"name":"Department of Undergraduate Medical Education, Georgetown University School of Medicine, Washington, DC 20007, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Euan","family":"Forrest","sequence":"additional","affiliation":[{"name":"The Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, MD 20892, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yonathan M.","family":"Assefa","sequence":"additional","affiliation":[{"name":"The Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, MD 20892, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Paige M.","family":"Lind","sequence":"additional","affiliation":[{"name":"The Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, MD 20892, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-2367-3378","authenticated-orcid":false,"given":"Afreen","family":"Mushtaheed","sequence":"additional","affiliation":[{"name":"The Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, MD 20892, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Frances T.","family":"Sheehan","sequence":"additional","affiliation":[{"name":"The Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, MD 20892, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5405-2143","authenticated-orcid":false,"given":"Katharine E.","family":"Alter","sequence":"additional","affiliation":[{"name":"The Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, MD 20892, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,3,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1016\/j.parkreldis.2016.03.013","article-title":"Repetitive exercise dystonia: A difficult to treat hazard of runner and non-runner athletes","volume":"27","author":"Ahlskog","year":"2016","journal-title":"Park. Relat. Disord."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"242","DOI":"10.1111\/j.1468-1331.2009.02781.x","article-title":"Lower limb involvement in adult-onset primary dystonia: Frequency and clinical features","volume":"17","author":"Martino","year":"2010","journal-title":"Eur. J. Neurol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"688","DOI":"10.2519\/jospt.2012.3892","article-title":"Diagnosis of primary task-specific lower extremity dystonia in a runner","volume":"42","author":"McClinton","year":"2012","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Ahmad, O.F., Ghosh, P., Stanley, C., Karp, B., Hallett, M., Lungu, C., and Alter, K. (2018). Electromyographic and joint kinematic patterns in runner\u2019s dystonia. Toxins, 10.","DOI":"10.3390\/toxins10040166"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1016\/j.jns.2006.09.003","article-title":"Runner\u2019s dystonia","volume":"251","author":"Wu","year":"2006","journal-title":"J. Neurol. Sci."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Shetty, A.S., Bhatia, K.P., and Lang, A.E. (2019). Dystonia and parkinson\u2019s disease: What is the relationship?. Neurobiol. Dis., 132.","DOI":"10.1016\/j.nbd.2019.05.001"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"4646","DOI":"10.1007\/s00415-022-11200-0","article-title":"Movement disorders and neuropathies: Overlaps and mimics in clinical practice","volume":"269","author":"Gentile","year":"2022","journal-title":"J. Neurol."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Ramdhani, R.A., and Frucht, S.J. (2013). Adult-onset idiopathic focal lower extremity dystonia: A rare task-specific dystonia. Tremor Other Hyperkinet. Mov., 3.","DOI":"10.5334\/tohm.135"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"454","DOI":"10.1080\/00222895.1987.10735424","article-title":"Task-dependent compensatory responses to perturbations applied during rhythmic movements in humans","volume":"19","author":"Patla","year":"1987","journal-title":"J. Mot. Behav."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"689","DOI":"10.1016\/j.jbiomech.2005.01.015","article-title":"Kinematic and kinetic factors that correlate with improved knee flexion following treatment for stiff-knee gait","volume":"39","author":"Goldberg","year":"2006","journal-title":"J. Biomech."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1016\/j.gaitpost.2013.05.003","article-title":"A method to differentiate the causes of stiff-knee gait in stroke patients","volume":"38","author":"Campanini","year":"2013","journal-title":"Gait Posture"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"586","DOI":"10.1016\/j.gaitpost.2014.12.019","article-title":"Sagittal gait patterns in cerebral palsy: The plantarflexor-knee extension couple index","volume":"41","author":"Sangeux","year":"2015","journal-title":"Gait Posture"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1016\/j.parkreldis.2018.04.030","article-title":"Pain in focal dystonias\u2014A focused review to address an important component of the disease","volume":"54","author":"Avenali","year":"2018","journal-title":"Park. Relat. Disord."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"156","DOI":"10.1002\/mdc3.13390","article-title":"Movement disorders and musculoskeletal system: A reciprocal relationship","volume":"9","author":"Pandey","year":"2022","journal-title":"Mov. Disord. Clin. Pract."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"100","DOI":"10.1016\/S1474-4422(13)70213-8","article-title":"Sensory aspects of movement disorders","volume":"13","author":"Patel","year":"2014","journal-title":"Lancet Neurol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"3023","DOI":"10.1177\/0363546518793657","article-title":"Is there a pathological gait associated with common soft tissue running injuries?","volume":"46","author":"Bramah","year":"2018","journal-title":"Am. J. Sports Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1016\/j.jshs.2017.08.003","article-title":"Classification of higher- and lower-mileage runners based on running kinematics","volume":"8","author":"Clermont","year":"2019","journal-title":"J. Sport. Health Sci."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"S249","DOI":"10.21037\/atm.2019.04.08","article-title":"Evidence based treatment options for common knee injuries in runners","volume":"7","author":"Mellinger","year":"2019","journal-title":"Ann. Transl. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1033","DOI":"10.1016\/j.parkreldis.2013.07.013","article-title":"Focal task-specific lower extremity dystonia associated with intense repetitive exercise: A case series","volume":"19","author":"Katz","year":"2013","journal-title":"Park. Relat. Disord."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"467","DOI":"10.1097\/JSM.0b013e3181845f35","article-title":"Case report: Action-induced focal dystonia in long distance runners","volume":"18","author":"Leveille","year":"2008","journal-title":"Clin. J. Sport. Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"613","DOI":"10.1016\/j.parkreldis.2008.01.012","article-title":"The spectrum of disorders presenting as adult-onset focal lower extremity dystonia","volume":"14","author":"McKeon","year":"2008","journal-title":"Park. Relat. Disord."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Ogasawara, I., Hattori, N., Revankar, G.S., Konda, S., Uno, Y., Nakano, T., Kajiyama, Y., Mochizuki, H., and Nakata, K. (2021). Symptom locus and symptom origin incongruity in runner\u2019s dystonia\u2014Case study of an elite female runner. Front. Hum. Neurosci., 15.","DOI":"10.3389\/fnhum.2021.809544"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1177\/8756479309336240","article-title":"Accuracy and cost comparison of ultrasound versus alternative imaging modalities, including ct, mr, pet, and angiography","volume":"25","author":"Bierig","year":"2009","journal-title":"J. Diagn. Med. Sonogr."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1390","DOI":"10.2214\/AJR.21.25606","article-title":"The evolving roles of mri and ultrasound in first-line imaging of rotator cuff injuries","volume":"217","author":"Zoga","year":"2021","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_25","unstructured":"Alter, K.E., and Wilson, N.A. (2015). Botulinum Neurotoxin Injection Manual, Demos Medical Publishing, LLC."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Alter, K.E., and Wilson, N.A. (2021). Botulinum Toxin Dosing Manual, Demos Medical Publishing. [1st ed.].","DOI":"10.1891\/9780826147660"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Karp, B.I., and Alter, K. (2017). Muscle selection for focal limb dystonia. Toxins, 10.","DOI":"10.3390\/toxins10010020"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"511","DOI":"10.3349\/ymj.2023.0124","article-title":"Intramuscular neural distribution of the gastrocnemius for botulinum neurotoxin injection: Application to cosmetic calf shaping","volume":"64","author":"Yi","year":"2023","journal-title":"Yonsei Med. J."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1","DOI":"10.26603\/001c.68184","article-title":"MSK Ultrasound\u2014An IJSPT Perspective","volume":"18","author":"Page","year":"2023","journal-title":"Int. J. Sports Phys. Ther."}],"container-title":["Toxins"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6651\/17\/3\/121\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T16:45:59Z","timestamp":1760028359000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6651\/17\/3\/121"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,3,3]]},"references-count":29,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2025,3]]}},"alternative-id":["toxins17030121"],"URL":"https:\/\/doi.org\/10.3390\/toxins17030121","relation":{},"ISSN":["2072-6651"],"issn-type":[{"type":"electronic","value":"2072-6651"}],"subject":[],"published":{"date-parts":[[2025,3,3]]}}}