What is restless legs syndrome?

Evening leg discomfort consistent with restless legs syndrome — **RLS:** discomfort and the urge to move are most characteristic at rest and in the evening. Illustrative image.

Five core diagnostic features

An urge to move the legs, usually with an unpleasant sensation.
Onset or worsening during rest, sitting or lying down.
Partial or complete relief with walking or movement.
Worsening in the evening or at night.
The symptoms are not better explained by cramps, joint pain, oedema, positional discomfort or neuropathy.

Assessment and differential

Diagnosis is mainly clinical and a sleep study is not routinely required. Iron status—including ferritin and transferrin saturation—should be considered together with kidney disease, pregnancy, chronic blood loss, sleep disorders and aggravating medication.

Focal pain, a Tinel sign, tenderness along a nerve, weakness or fixed sensory loss suggests another diagnosis such as nerve entrapment, polyneuropathy or radiculopathy.

Treatment

Aggravating factors such as iron deficiency, caffeine, alcohol, selected medication and untreated sleep apnoea are addressed first. Iron should be given according to blood tests and medical advice.

The 2025 AASM guideline supports α2δ-ligand medication such as gabapentinoids in appropriate patients. Dopamine agonists are no longer recommended as routine long-term treatment for every patient because of augmentation. Conditional non-invasive high-frequency bilateral peroneal nerve stimulation is a neuromodulation option for selected adults; it is not nerve-decompression surgery.

Is there a surgical solution?

There is no established operation for true RLS and no role for peripheral nerve decompression. Surgery becomes relevant only if evaluation identifies a separate focal nerve entrapment that mimics restlessness and explains the symptoms.

Family medicine, neurology or sleep medicine usually coordinates RLS care. Peripheral nerve assessment is useful when the pattern is atypical or focal nerve findings are present.

References

Allen RP, Picchietti DL, Garcia-Borreguero D, et al. Restless legs syndrome/Willis-Ekbom disease diagnostic criteria. Sleep Medicine. 2014;15(8):860–873. doi:10.1016/j.sleep.2014.03.025
Winkelman JW, Berkowski JA, DelRosso LM, et al. Treatment of restless legs syndrome and periodic limb movement disorder: an AASM clinical practice guideline. Journal of Clinical Sleep Medicine. 2025;21(1):137–152. doi:10.5664/jcsm.11390

Restless Legs Syndrome