Twitches, calf aches, abnormal EMG.....opinions please

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Dkurp11

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Hello,

Many thanks to the CALS/PALS who provide insight in this forum. I can only imagine the hardships you endure and my thoughts are with you all.

I am a 40 year old male, firefighter, married with 2 young children. I have had back problems for years and recently got an MRI indicating some disc dessecation in L4/L5 and L5/S1. Mild concentric disc bulge with posterior annular fissure affecting left L5 nerve root. At L5/S1, I have symmetrical disc bulge with right paracentral protrusion with mild right foraminal recess stenosis.

I am here, concerned about ALS due to twitching I noticed in both calves while sitting at work. This began almost 2 months ago. Didn't think much at first, but they picked up and would appear pretty much everywhere including forearms, shoulders, back, and stomach. Shortly after, my right calve began to ache (like the feeling after a cramp). It was intermittent at first, then became a 24/7 thing despite stretching and massaging. Same has now occurred in the left calf. I have read the sticky (many times!!). I do NOT have clinical weakness. I do NOT notice that anything has become noticeably more difficult. I do have some burning in both feet which I now understand points away from ALS. Routine blood work and electrolytes are normal. I do have Reynauds so maybe an ANA might be in order?

I had an NCS and EMG done today and I have attached the results. This was done at kaiser based on my recent back injury (work related). The NCS was totally normal so he decided he wanted to do the EMG and unsolicited he mentioned ALS. This of course freaked me out, but I tried to stay calm. However, I could tell he was finding some things during the EMG. After doing the legs he wanted to test my right arm too. He was making me a little nervous so I asked him what he was seeing. He told me he saw my fasiculations and noted some fibrillations. He said "I was only checking things based on your back injury, but I do not think you have ALS RIGHT NOW. If you develop foot drop or wrist drop we can do another EMG." He was rushed and didn't have time to discuss further. His interpretation is as follows

Impression:
This is an abnormal study with electrophysiological evidence for a right L4-5 radiculopathy. There is no evidence for peripheral Neuropathy or myopathy. Multiple fasciculations seen on this EMG exam are likely benign at this time , but in case of any future focal weakness please consider repeating the EMG test to rule out a motor neuron process.

My question: I have 2+ fibs, few fasc's, and 1+ PSW on both my R tibialis anterior and R gastrocnemius. This is a bit alarming to me. He did not use the words denervation at all. Should I be concerned about this EMG? Does this look "dirty" to you based on your knowledge and experience? Regardless of weakness, should I repeat this in 3-6 months anyway?

I apologize for the length, I was really hoping for a clean EMG.
 

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Nikki J

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The right side of the emg chart is entirely normal and your fibs/ psw correspond to your documented back issues. Mentioning ALS in advance of the emg given no weakness is a bit odd quite honestly and saying repeat in you get weakness sounds like he is covering himself rather than truly suspicious. You should of course follow your doctor’s advice. Was he also the ordering clinician? And finally back issues could cause weakness so do not immediately assume ALS should you develop it. It is unfortunate that this doctor planted the thought rather than simply saying he wanted to do an emg and then telling you it showed a couple of abnormalities consistent with your back but if you have more symptoms let us know
 

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I'm wondering if you brought up that you fear you have ALS and this then influenced the comment about repeat if you get weakness? Did you say this was your fear before the EMG?
 

Dkurp11

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Nikki and Affected,

Thank you for your input. He was not the ordering clinician, and though internally I had been anxious about ALS for 6-8 weeks, I had not mentioned anything to the neurologist performing the test. Of course, once he mentioned it, my anxiety exploded. After that, I did ask him directly about his thoughts on ALS in my case. That's when he said "come back and repeat if you develop foot or wrist drop." On his way out the door he said "don't worry about it." Once I saw the report on my health file, it was a bit worrying to see the Fibs/PSWs. Though he was not super reassuring in his approach, he seemed like a solid neuro, even said he works in the ALS clinic at Kaiser and will be involved in a local fundraising walk coming up.

A sincere thanks for taking the time to respond. The EMG table looked confusing to me, so I appreciate your input. I may decide to follow up with my PCP (not through workers comp) and share my results. I did go on Lexapro about 1 month ago and have been to CBT sessions twice so far. I had no previous history of health related anxiety before this episode, but I am trying to address it now before I spiral any further.

My thoughts are with all the CALS/PALS and others impacted by ALS and other MND's. Best wishes to you all.
 

Dkurp11

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So, of course I am anxious and have been trying to understand the fibs and positive sharp waves seen in my recent EMG. They sound pretty ominous. Can anyone explain to me why they are not concerning in my case?

Nikki, you mentioned that the right side of my chart was normal. Do you have anymore insight to what fibs and PSW's are? I wish I had more time to discuss with the neuro.

I have contacted my PCP who agreed to refer me to a neuro outside my workers comp case.

Thanks again
 

Nikki J

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Basically they are a sign of some acute nerve damage. Could absolutely happen with your back. In contrast als shows acute and chronic nerve damage at the same tine in a widespread pattern. You have no chronic signs ( the normal right side report says that) and no widespread pattern. Further the emg changes in ALS need to be unexplained by mri or other tests ( yours are). Finally we often see peopke with emgs like yours here even without a correlating mri. The symptoms never seem to come to anything and the emgs often normalize.
 

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You really need to discuss the EMG results and next steps with your doctor. Make another appointment to go back if you feel it hasn't been fully explained to you.
We can't do much more without examining you I'm afraid. It looks like you have a diagnosis, I'm not sure why you don't want to accept it when the test results all fit your symptoms.
That is another thing best discussed with your doctor rather than trying to speculate on here.
 

Dkurp11

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Thank you both for the input, much appreciated. Like many here, the cramps and fascs have me concerned. Plus the EMG abnormality.

I spoke to a neuro who wants to repeat the EMG herself, and wants to fit me in soon. This makes me a bit nervous but I will ask her more questions. Will provide updates.

Thanks again.
 

Nikki J

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It is not unusual for a doctor to want their own emg. If they didn’t examine you it isn’t as if they saw something to raise clinical suspicion. We have given you answers based on our experience which you are free to disbelieve of course. Now is the time to step back let the doctors do their work and only post back when you have new test results to share
 
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