Father in law suspicious case, or is it?

andrewf

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Good morning,

I'm looking for some guidance here. My father-in-law "FIL" (who is happy to get any info he can from a resource like this) has been having mobility issues lately. I need to provide the health history here. 77YO white male, normal weight, 5'10 or so. Avid walker, as in...miles per day. Gradually slowing down past 5 years or so as his toes became worse and worse. He had developed severely deformed toes where they were curved up and over the others. honestly it looked like the second toe was jumping over the big toe trying to make a getaway. He would buy bigger and bigger shoes to be comfortable, but got slower and slower.

Fast forward to this year, in Spring, when he could visit his podiatrist surgeon and schedule surgery for repair, first on his left foot. The podiatrist noticed weakness, a foot-drop, and referred him to a neurologist. Neurologist did full exam....there was no spasticity or hyperreflexivity, in fact, he had lost some reflexes in the foot. Neuro did a MRI of brain, C-spine, and T-spine. Also did a EMG which I would classify as "messy". Impression after EMG was anterior horn cell disease. So, ALS or PMA. As far as upper limbs, no issues, at all. Plays guitar, etc. no neuro issues with contralateral foot.

Something didnt sit right with me about that. FIL was able to walk, do stairs, get around, and actually was able to dorsiflex his foot a bit. Even the neuro gave him a 3/5 on that, I though it was a generous score. We had a videoconference with the neurologist. I basically said "he has weakness but has not lost functionality, he has no UMN signs....oh, and by the way, did you do a L-spine MRI?" Neuro said "uh no, we didnt" and I said "Isnt that where the nerve roots that run the foot come from? Couldn't impingement there do this?" He ordered a L-spine MRI and said that the results from that showed findings that could cause this weakness, and that even if FIL had MND, his presentation was such that he would need his leg to walk on for quite some time anyway and should get the toes fixed.

So FIL got the toes fixed, in June. Foot up for weeks, in a hard cast then soft cast, then back to trying to walk. Now here's the thing. He has not gotten better with walking, he's gotten worse. The foot-drop is a persistent problem, to the point that even with a special brace they fit him with, he is very, very unconfident about this ability to walk places and do things. He says he is doing PT exercises, his PT person says he sees improvement, but he's just not improving.

What we've got here is a clinically-defined neurological deficit, but at the same time as a recovery from a very major surgery correcting his toes. So the overlap complicates figuring out what is going on. I think it leans more toward PMA if it is MND at all, though I'm aware there are forms of ALS that are more LMN-dominant. Its quite possible that at his age there has been atrophy from non-use, combined with nerve impingement, and his dwindling his ability to walk. But what we really need now is more evaluation of him, and neurology seems not to be too interested in seeing him soon. I assume a a followup EMG will tell us if he has 'progressed' or if he is just staying stable neurologically? Then maybe its a confidence issue or just a factor of getting old. 77 ain't 65 after all. I can post his EMG data if anyone cares to look, though in isolation that isn't definitive I realize. Any suggestions on the best diagnostic course to follow?
 

affected

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Posting the EMG would be useful for comments. Thanks for caring about him.
 

andrewf

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Here is his EMG. When grandpa texts screenshots of his ipad, we have to use our mosaic skills....:rolleyes:


image1.jpeg
 

Nikki J

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There are some things in his arm too. I would make an appointment at Hopkins ALS clinic for evaluation. 77 he may be but he deserves a diagnostic work up just like anyone else
 

affected

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Great mosaic work!
I agree, he should be evaluated by a neuromuscular specialist.
We are not saying he has ALS, just saying he should be evaluated by an ALS specialist so you have a clear diagnosis to work from.
 
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andrewf

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So, he had a meeting with his neurologist again before Christmas. I joined by Facetime. Watching his exam and listening to the questions asked the Neuro was thinking the same things I had been. His impression is that it IS a nerve impingement. FIL has marked atrophy in the calf muscle on that side. No UMN symptoms at all though.
I explicitly asked "could this be MND?" and the Neuro said his findings are not consistent with MND right now, and if it is... we would be another year or two even knowing that anyway. Single limb and no progression being the type. Frankly I've stopped being concerned with it. He's getting around decently and is going to do some more PT to hopefully get that nerve to restore. We will see.
 
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