Exploring Causes of Progressive Leg Weakness: A Guide for Patients

Weakness in the calf extending to the foot?

Dear Dr.
Yeh,
My mother is 58 years old, 158 cm tall, and weighs 48 kg.
She has had a long-standing issue with kyphosis and has undergone cardiovascular stenting.
Her regular medication includes anticoagulants, and she drinks 150 cc of rice wine before bedtime to aid sleep.
I would like to seek guidance on her condition, as her main complaint is progressive weakness in her calves that has spread to her feet (both legs).
Over the past year, she has consulted the following specialties without finding a solution:
1.
Orthopedics (X-rays taken) - Diagnosed with bone spurs causing nerve compression; continued medication and rehabilitation have not improved her condition.
2.
Neurology (nerve conduction studies and blood tests performed) - The doctor found no issues and did not prescribe medication.
3.
Internal Medicine (no examinations conducted) - The physician prescribed tendon medication, colchicine, prednisolone, and gastric medication, but there has been no improvement.
According to my mother, she feels relatively fine in the morning, but her weakness worsens throughout the day.
She even changes her shoes for comfort and support.
She describes a sensation of walking on cotton and an indescribable strange feeling in her calves, and now she also feels weakness in her feet.
There is a family history of hyperthyroidism, and follow-up examinations in cardiology have been satisfactory.

Currently, I have observed that my mother has a patch of scalp psoriasis (or seborrheic dermatitis, uncertain) that has not healed, and she exhibits spoon-shaped nails.
I am unsure if the aforementioned examinations have ruled out the possibilities of myasthenia gravis, endocrine issues, peripheral vascular obstruction, or anemia, which leaves me uncertain about what direction to take for her medical consultations.
I would appreciate your advice on this matter.
Thank you.

Ms. Zhang, 30~39 year old female. Ask Date: 2022/08/21

Dr. Ye Qianyu reply Family Medicine

Hello! Clinical issues are often the result of multiple contributing factors.
Based on the information you provided regarding the causes of intermittent claudication in your mother, here are some analytical suggestions:
1.
X-ray shows bone spurs causing nerve compression: This is a confirmed issue.
Please consult with a physician to determine if it affects motor nerves.
Given that your mother has had a long-standing hunchback issue, her spinal stability is compromised.
Although rehabilitation may not seem effective, it can help delay spinal slippage and reduce compression, preventing symptom exacerbation.
The appropriate use of supportive devices may also improve her symptoms.
2.
Hyperthyroidism is a common comorbid condition associated with muscle weakness.
Blood tests and nerve conduction studies have been conducted, which seem to indicate a lower likelihood of this being an issue.
However, please confirm the blood test results and thyroid function with a neurologist or endocrinologist.
3.
Lower extremity peripheral vascular occlusion: This requires an assessment of the ankle-brachial index (ABI) through upper and lower limb blood pressure measurements.
You may want to consult an endocrinologist to see if further testing is necessary.
4.
Anemia: Blood tests are needed to check hemoglobin levels.
If anemia is present, and considering your mother is postmenopausal, further investigation into the cause of the anemia, such as gastrointestinal bleeding, is warranted.
5.
Daily alcohol consumption of 150cc of rice wine: Women should limit alcohol intake to no more than 10 grams per day.
Since the type of alcohol is uncertain, please refer to the conversion chart (http://yundrivingschool.com/webpage/pic/pdf/alcohol-taiwan.pdf) for guidance.
If there are already issues with nerve conduction, excessive alcohol consumption is not recommended.

Reply Date: 2022/08/21

More Info

Progressive leg weakness can be a concerning symptom, especially when it affects both legs and has been persistent over a year. Given your mother's medical history and the various specialists she has consulted, it is essential to consider a comprehensive approach to identify the underlying cause of her symptoms.
Firstly, it is important to note that progressive weakness in the legs can arise from a variety of conditions, including neurological disorders, vascular issues, metabolic disorders, and musculoskeletal problems. Since your mother has already seen an orthopedic doctor and a neurologist without significant findings, we should explore other potential causes.

1. Neuromuscular Disorders: Conditions such as myasthenia gravis or muscular dystrophies can lead to progressive weakness. These disorders may not always show up in standard neurological examinations or nerve conduction studies. A referral to a neuromuscular specialist may be warranted for further evaluation, including specific blood tests (like acetylcholine receptor antibodies) or electromyography (EMG).

2. Endocrine Issues: Given the family history of thyroid problems, it may be worthwhile to check her thyroid function tests (TSH, T3, T4) again, as thyroid dysfunction can lead to muscle weakness. Additionally, adrenal insufficiency or other hormonal imbalances could contribute to her symptoms.

3. Vascular Concerns: Peripheral artery disease (PAD) could cause weakness and discomfort in the legs, especially if there is a history of cardiovascular issues. A vascular specialist could perform Doppler ultrasound studies to assess blood flow in the legs.

4. Anemia: Low hemoglobin levels can lead to fatigue and weakness. A complete blood count (CBC) should be performed to rule out anemia, which can be caused by chronic diseases, nutritional deficiencies, or other underlying conditions.

5. Autoimmune Conditions: Conditions like lupus or rheumatoid arthritis can also present with muscle weakness and systemic symptoms. Given the skin condition on her scalp and the spoon-shaped nails (koilonychia), it may be beneficial to consult a rheumatologist to evaluate for any underlying autoimmune disorders.

6. Medication Side Effects: Review all medications your mother is taking, including anticoagulants and any other prescribed drugs. Some medications can lead to muscle weakness or fatigue as side effects.

7. Lifestyle Factors: The use of alcohol, even in moderate amounts, can affect muscle function and overall health. Discussing her alcohol consumption with her healthcare provider may be beneficial.

8. Physical Therapy: Engaging in a structured physical therapy program may help improve her strength and mobility. A physical therapist can tailor exercises to her specific needs and monitor her progress.

In summary, it would be advisable to seek a multidisciplinary approach, potentially involving a neuromuscular specialist, an endocrinologist, a vascular surgeon, and a rheumatologist. Each of these specialists can provide insights into different aspects of her health that may be contributing to her symptoms. Additionally, ensure that all relevant tests are performed, and consider lifestyle modifications that may improve her overall well-being. It is crucial to continue advocating for her health and seeking answers until a clear diagnosis is established.

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