Drop foot and quad fasciculations

[dav76]

Hi all,
I am a 48-year-and-10-month-old male, and for the last 2 years I have been cycling very intensely, training 10+ hours a week, after a few years of more sedentary life. Last May, when I was recovering from a fracture in my right leg (cycling accident), I noticed that my left foot was not lifting correctly while pedaling. I did not pay much attention to this and I thought it was just because I had not been cycling for a while when I was bedridden.
Then I resumed cycling regularly and started a strength training program in October. Shortly after starting strength training, I noticed some fasciculations in my left quad while falling asleep. A few weeks after starting strength training, I started noticing that I was limping because of my left leg. This was at the beginning of December 2024. At about the same time, in the week of December 9, 2024, I noticed that my left leg was getting tired earlier than my right leg when doing single-leg leg-press and leg-extension machines. But then, on December 16, I got worried when I tripped over while standing up from a restaurant table.
I saw my doctor and he ordered a knee x-ray and a lumbar MRI which came out normal with only

"minimal posterior medial disc protrusion with no root contact. No significant posterior articular osteoarthritis. The foramen are free. Conclusion: No vertebral anomalies. Lumbar canal of normal dimensions. Minimal non-conflicting medial disc protrusion at L5-S1."

Then I had a Spinal Cord MRI and brain MRI which also came out clean except for

"At the L4-L5 level: minimal overall disc protrusion. Integrity of the zygapophyseal joints.
L5-S1: normal disc. Incipient bilateral degenerative zygapophyseal arthropathy."

With conclusion:

"No myelopathy. Minimal degenerative disc disease L4-L5 without disco-radicular impingement and bilateral zygapophyseal osteoarthritis beginning at L5-S1."

Finally, I had an electromyography, which concluded:

No motor deficit, 4+/5 in left front lower leg.

No sensory deficit
Vivid ROT
RCP indifferent
No epileptoid tremor, Hofiman neg
No tongue fasciculations left quadriceps fasciculations +.

Lower limbs
The sensory amplitudes of the sural and musculocutaneous nerves are normal and symmetrical.
Sensory conduction velocities are normal.
Motor responses of the SPI nerves are normal.
Motor amplitude asymmetry of the SPE nerve at the expense of the left al in pedal collection. The amplitude is recovered in the JA collection.
Absence of F wave on the G EPS.
Distal motor latencies are normal.

Detection :
Accelerated poor tracing in the vastus lateralis and left anterior hamstring. Interferential pattern in the right vastus lateralis.
Intermediate pattern in the medial twins.
Fasciculations in the forelegs and left vastus lateralis.
Upper limbs:

Sensory amplitudes of the median and ulnar nerves are normal.
Moderate decrease in sensory conduction velocity of the left median nerve.
The motor responses of the median and ulnar nerves are normal, with a slowing of the motor conduction velocity at the left elbow.
Distal motor latencies are normal.
F wave latencies are within norms.
Detection:
Intermediate tracing in the right deltoid, and common extensors of the right fingers, first dorsal left interosseous.
Interferential pattern in the long supinators and right first dorsal interosseous muscle.
Fasciculations in the left first dorsal interosseous muscle.

Overall:
Examination showed multiple radicular lesions predominating in L4 and L5 with motor axonal damage.
Motor neuron disease cannot be ruled out in view of the staged denervation tracings and resting activities.
Further work-up with MRI of the cervical spine, MRI of the brain and spinal cord and follow-up EMG in 2 months.
Mild left carpal tunnel syndrome and ulnar compression in the left elbow.

So according to the neurologist, I need to redo the EMG at the beginning of March, he wrote 2 months but told me orally 6 to 8 weeks. So I picked an appointment at 7 weeks.

I am concerned this may be the early symptoms of ALS, particularly because I had an uncle (my father's brother) who died of ALS at 67 years old in 2002. At the time, there were no routine genetic tests, so we have no idea whether his variant was familial.
I am attaching an anonymized version of my EMG results with graphs.
What do you all think?

forgot one symptom, which also appeared in December. Sometimes, particularly after exercising, when I contract my left quad, it will lock in a painless cramp, and I need to apply pressure with my other leg to bend my leg. I've been taking magnesium supplement for the last month, and it has helped a lot with cramps, but fasciculations have been constantly higher than in December since early January.

 

[Nikki J]

It is certainly not a slam dunk for MND. Obviously if it were you would be diagnosed. Not having examined you I don’t know if there is real cause for concern or if your doctor is being cautious

Seven weeks no doubt seems forever but is really not that long

For family history you of course know if there is a genetic connection your father would have to be a carrier. What happened to him?

 

[dav76]

Thanks for your reply.
Unfortunately, my father died in a car accident when he was 53. So, it is hard to tell if he was a carrier.

 

[dav76]

Quick update. I had an elbow ultrasound that showed an enlarged left ulnar nerve and a wrist ultrasound that showed no abnormalities.
In the meantime, over the last few days, I've been experiencing random twitches in both my arms and chest.
I hope this is just the anxiety leading to my next EMG appointment in 10 days.

 

[dav76]

Hi all,
I had my follow-up EMG yesterday, which showed no progression after 7 weeks. This should be relatively reassuring, but my neurologist recommended I do further checks and, in particular, an MEP (motor evoked potential) test to determine if there is any upper-motor neuron involvement.

My primary care physician seems to say it is impossible that this is a pinched nerve or root, but he wouldn't tell me the odds or other possibilities. So, I am left wondering if this is ASL, even with a relatively reassuring second EMG.

I am attaching my anonymized EMG (in French) and posting below its automatic translation by ChatGPT.

Observation​

Follow-up EMG for weakness and fasciculations in the left quadriceps.
Assessment for possible motor neuron disease.

---

Conclusion​

Lower Limbs​

• Sensory nerve amplitudes (sural and musculocutaneous nerves) are normal and symmetrical.
• Sensory conduction velocities are normal.
• Motor responses of the tibial nerve (SPI) are normal.
• Asymmetry in the motor amplitude of the deep peroneal nerve (SPE), lower on the left when recorded at the foot. However, the amplitude is recovered when recorded at the tibialis anterior (JA).
• Prolonged F-wave latency in the left deep peroneal nerve (SPE).
• Distal motor latencies are normal.

Needle EMG Findings (Muscle Activity Analysis)​

• Accelerated intermediate pattern in the left vastus externus and reduced pattern in the left tibialis anterior.
• Interferential pattern in the right vastus externus (normal recruitment).
• Interferential pattern in the gastrocnemius (calf muscles) (normal recruitment).
• Fasciculations in the left tibialis anterior and left vastus externus.
• Fibrillations in the left gastrocnemius (medial head).

---

Upper Limbs​

• Sensory nerve amplitudes of the median and ulnar nerves are normal.
• Moderate slowing of sensory conduction in the left median nerve.
• Motor responses of the median and ulnar nerves are normal, but there is a slowing of motor conduction in the left ulnar nerve at the elbow.
• Distal motor latencies are normal.
• F-wave latencies are within normal limits.

Needle EMG Findings (Muscle Activity Analysis)​

• Interferential patterns in the deltoids, brachioradialis (long supinator), finger extensors, and first dorsal interosseous muscles (both hands) → Normal recruitment.
• Interferential pattern in the chin (left side).

---

Summary of Findings​

• Stable findings compared to January 2025.
• Severe radiculopathy at L4-L5 (left side) with axonal motor involvement.
• No additional signs of denervation observed today, but there is spontaneous resting activity in the right vastus externus.
• Motor neuron disease cannot be excluded at this stage.
• Compression of the left ulnar nerve at the elbow, with asymmetry in motor responses.
• Further testing recommended at a specialized neuromuscular center, including another EMG and Motor Evoked Potentials (PEM).

Note that the spontaneous activity in the right vastus externus might be a typo, as he recorded fasciculations in the left vastus externus but not on the right one as far as I know.

Do you have any thoughts?

 

[Nikki J]

I agree it looks like there was a typo when I look at the original chart there is no notation on the right

It seems like your neurologist is exceptionally cautious so try not to worry too much as you wait for further testing

 

[dav76]

Thanks Nikky!

 

[dav76]

hi, @Nikki J, all,
I asked my neurologist about my right leg fasciculation, and he said he wrote that because I indeed had some fasciculation in the right quad.

I do not think I said it, but since December, my left quad has been fasciculating constantly at a high rate, while I feel more random twitches in my right quad, right shoulder, and left tricep and sometimes in my abdomen.

I also asked if radiculopathy remains an option. As I said, my PCP said it's basically impossible, while my neurologist said: "Finally, a radicular involvement remains possible (L4 and L5), but it is true that the MRI is not very suggestive (which remains possible nonetheless)."

He also added, regarding my idea of doing the MEP more quickly at a private clinic, "I prefer that you do everything at the referral center to centralize the exams and have more in-depth expertise right away.". have sent several emails to referral centers in my city and in a 4h-train radius, but no answer yet.

Also, he wrote that I did not lose any muscle, but I have the impression my left quad is a bit smaller than before, and at least I am sure that there is a part of it, near my knee, that I am unable to contract like I used to.

I also have no conduction blocks: so no MMN.

What do you think? What do you see as the most likely explanations for my symptoms?
thanks

 

[lgelb]

The MRI and EMG don't necessarily sync up, nor the MRI and your clinical picture. I think the odds against ALS are still well in your favor, so I would continue with the diagnostic process.

 

[dav76]

What do you mean that they do not sync up?
I am definitely continuing the diagnostic process. No reason to do otherwise. I just hope I can get an appointment soon!

 

[lgelb]

I didn't mean that you were questioning the process, just encouraging you that you're on the right track.

These are 3 different types of data. They measure different things in different ways.

 

[dav76]

My neurologist asked the main hospital in France that does ALS research to look into my case, and I have an appointment next week. But apparently, the doctor I am seeing won't be doing any exams next week. The secretary asked them if it was possible to do the EMP at this time, but the doctor said it was unnecessary. I am confused.

 

[Nikki J]

You have an appointment with a doctor who won’t be there? Or do you mean you will only have a consult and a clinical exam but no separate testing? The latter is often the case The consultant wishes to see and examine the person and determine for themselves what tests if any they want. Depending on the place and the circumstances then the tests might happen quickly

 

[dav76]

Hi Nikki,
sorry I wasn't clear. My neurologist asked for an MEP, but the doctor scheduled only a consult with her and apparently stated that the MEP was not necessary at this time. I know it's common for doctors to want to see patients themselves before scheduling follow-up exams, but I do not understand why she wouldn't accept her colleague's suggestion for an MEP. I will know more in a week.

 

[Nikki J]

If you are a consultant and the go to person for a specific condition you get many referrals and suggestions to order this or that test. If they did then a certain percentage would be getting tests the consultant on exam wouldn’t have ordered themselves.