Left Bicep Weakness / Fasciculations but clean EMG

[ikeremix]

I've probably spent 50%+ of my last week surfing this forum.

Below is my situation, please bear with me as i know it's a lot to read, but wanted to lay it all out there. I appreciate you reading and would love to hear any/all thoughts. Of course I'm asking and consulting w/ my neuro but wanted to throw it out on this forum since there seems to be such a wealth of knowledge and experience. If for no other reason, this post helps me vent and put my feelings on paper whether they're valid feelings or misguided ones.

• 39 year old male w/ wife and 7yo daughter
• Pretty athletic - daily 8 mile walks with weightlifting every other day. I've weightlifted consistently in the gym since i was in college until COVID hit, when i moved to at home body weight workouts. I recently returned to the gym in late April where i began lifting heavy again since i had those weights now available to me.
• In the middle of June I noticed a dramatic decrease in strength in my left bicep compared to my right (probably around 80% decrease). It happened suddenly and abruptly. I could curl 50lb dumbbells 12x with both arms, but all of a sudden I was lucky if I could curl a 30lb dumbbell 3x. And weakness seems to be isolated to left bicep only.
• My weakness is only noticed when I'm in the gym lifting weights for my bicep. If it weren't for weight training i wouldn't have noticed the weakness as it doesn't impact any of my daily routines/functions. I know the sticky notes say ALS is a failure to do something (unbutton your shirt, go up stairs, etc..) and not a feeling, but in my mind this is a failure to do something - lift a weight that i've normally done and had no problem with
• No pain or soreness whatsoever. And no dramatic impact to the area
• Labs - all came back clean
• X-rays & MRIs on both my shoulder and neck. All were relatively clean. The doctor that generated the report on my neck MRI noted I had mild/moderate spondylosis in c4 and c5 and it was more prevalent on the left than right. However both my orth doc and neurologist said the MRIs were pretty unremarkable and didn't think it was the cause of my issue.
• Fleeting feelings of very slight restlessness in my left arm and left leg (not necessarily pins and needles, but a slight buzzing sensation if you will). This sensation is not always present but seemed to be more noticeable when laying in bed / resting.
• Atrophy in Left Bicep - Neuro commented on atrophy in left arm/bicep. But I continued to weight train my right arm hard the last 2 months while totally laying off my left arm. So i think that might play a big part in the atrophy that he saw (and my right has always been a little bigger than my left).
• Muscle twitches - I feel like i've always had some muscle twitches over my life, but have noticed an uptick in frequency over the last 2 months. And maybe that's just because I'm looking for them now since i know they're signs of ALS. I would say 60%+ of my twitches are in left arm or left leg, but they are also present in other parts of my body. I only notice the twitches when resting, never when i'm actively moving around or walking.
• EMG / NCS - Had one done last week in my left arm (bicep/forearm/hand) and in my left leg (my neurologist performed both EMGs). Neuro said both limbs looked clean with no signs of weakness. The summary report read "This is a normal study without any evidence of radiculopathy, plexopathy, neuropathy or myopathy". I specifically asked him after the EMG if he thought ALS was a possibility and he said he didn't think this was ALS. And went onto say that when i first came to see him with my symptoms he believed there was a 90% chance I wouldn't end up getting any diagnosis at all (which i thought was kind of odd).
• After EMG - With the EMG good news, my nerves calmed a bit for a couple days which coincidentally (or not) seemed to lessen the frequency of both the twitches and the buzzing sensations in my left limbs (so maybe my anxiety was the source for the increased twitching/buzzing and a mental thing). And i told myself i would stay away from Dr. Google and the Forum (although i do appreciate you guys dearly), but of course i didn't and now am back in my head again - could this EMG have been done too early as i've read a bunch of those posts here? Was 9 weeks a long enough time to wait after weakness/atrophy was noticed to get EMG? I have a lot of the markers for ALS, weakness, twitching, atrophy - so maybe neuro/EMG missed it? I'm back in that dark hole.
• Brain MRI today - so we'll see how that goes. It sounds awful, but i would almost be relived if they saw signs of MS in the brain MRI. That way i'd know for certain it wasn't ALS. Ugh!!

The weakness has remained consistent over the 2+ months since it's onset. I haven't been weight training my left bicep over that time, but would test it every couple weeks to see if there was improvement. And there wasn't (didn't seem to get worse but definitely not better either). But just a couple days ago i tired my doing bicep curls with my left - and while it was still definitively weaker than my right it was at less of a deficit. It was now maybe a 30% difference as opposed to the 70-80% difference i was seeing consistently over the 2mo+ period. So maybe with that and a clean EMG there is hope that whatever is going on is getting fixed inherently.

But i'm still riddled with anxiety due to having so many of the markers for ALS, specifically having real weakness (plus i have all those stories and post about clean EMGs turning into dirty ones later on which has me on edge.

 

[lgelb]

You speak of "weakness" from your own perception, but not, evidently, from the neurologist's. Those are not the same thing.

You don't have any "markers" for ALS. And loss of strength in ALS doesn't improve.

9 weeks past what you noticed is not "too early" for the EMG. If ALS were involved, for strength to have been lost would signify having already lost motor neurons, and they don't show on the EMG in only one muscle.

And the fact that this difference between arms is only appreciated when lifting speaks for itself. Your interpretation of the sticky that translates into everyday activities is incorrect. You won't wake up tomorrow and be unable to lift a milk carton.

When your neuro said that 90% you wouldn't end up diagnosed with anything, he meant that he didn't see anything of concern. What you believe you've seen is improving on its own. You don't have ALS.

You might ask someone in your gym to look at your lifting technique to make sure you're not favoring or babying anything since you've gone back and forth with that arm. And you might want to drop back on weights for both and build back up with more attention to form to rule out overtraining or strain to collateral fibers from coming back to heavy weights in April. But fortunately, you're in the wrong place here.

 

[ikeremix]

lgelb - I appreciate you taking the time to read and providing a comforting response. Based off my limited research the symptoms i show (or at least i perceive that I show them) would fit more into the LMN category (atrophy, twitches, etc.) as opposed to the UMN category - and LMN symptoms would show on EMG. So i do gain comfort in that as well.

And I literally just received my brain MRI results that i had done at 3pm (2hr turnaround!) and it was clean, pfew!!

Would it be correct to assume that if nothing showed in my EMG and nothing showed in my brain MRI that it's heavily pointing away from ALS regardless of LMN/UMN onset? I have my follow-up with my PCP on Friday and call w/ neruo tomorrow to discuss results, but figured i'd ask the question here in the meantime.

I won't keep posting as I know there are many people out there dealing with more concrete evidence of ALS or have been diagnosed. But lgelb, your honest and comforting post was just what i needed in one of the darkest weeks of my life. Thank you

 

[lgelb]

Thank you for the kind words.

The answer to your question is a hard yes.