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help with diff dx
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help with diff dx - November 16, 2007 10:06:12 PM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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I had a patient today:
- 75 yo male
- some blood pressure issues, otherwise healthy
- no sig past med hx
- no surgeries
- chief complaint is right knee giving way started 3 weeks ago
- now has had several falls
- no pain precipitates the knee giving way
- has been seen extensively by neurology group
- reportedly (by pt) mri of brain and back and leg all negative
- NCV reportedly negative
- Rx says" leg weakness eval and tx"
Eval:
- Isometrics: stong and painfree throughout right LE
- gait: slight decrease stance time on right, no gross abnormalities expected with quad weakness like hyperextension in stance etc
- unable to heel walk easily or for long
- unable to single leg weight bear on right with slight knee flx for more than about 5 secs prior to knee giving way
- full ROM
- moderate resistance for prolonged periods consistant with more of a neurological weakness testing was significant for quick muscle fatigue on right quad
- sensation testing was inconclusive...some loss on the quad and foot of the right but not over a dermatome or significant peripheral pattern
- myotomes were fine
- DTR slight diminish patellar tendon
- back was clear for pain and for increase in any symptoms with repeated flex or ext or palpation testing through the L1-sacrum
- Flexibility of hio flexors and HS, was slightly limited as expected with this age group, but not severe enough to be worried about it and no diff between right and left
SO, here is my opinion and working theory so far:
some sort of peripheral nerve complication most likely a neuropathy. I do not feel this is an actual muscle wekaness since no precipitating factors and no injury and no decline in function etc. I think the neuro would have been more specific if they had some working theory, so I think it clears the spine and brain, and leaves either some weird neuromuscular junction type disease, something related to his heart meds (though I am not sure this would present unilateraly and so focal.
SO...I am going with like a proximal asymmetric neuropathy like a Femoral Mononeuropathy effecting his quad. But then the question is...now what? I am going to try ETPS stim and or NM stim to his quads during SLR or quad sets, some eccentric training, and monitor and see if a need for a KAFO or dynamic knee brace, but not really sure if anyone has any ideas here on poss df or possible tx ideas....other than lumbar or lumbar plexus etiology, and diabietic etiology, and trauma etiology, is there anythign else that can cause this that can be undone by therapy, and that would be missed by a bunch of MRI and NCV?
thanks-
Ben
< Message edited by FLAOrthoPT -- November 16, 2007 10:19:35 PM >
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RE: help with diff dx - November 17, 2007 1:07:37 PM
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Kaden
Posts: 348
Joined: June 17, 2007
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Ben,
Interesting post. Have you given any consideration to drop attacks caused from decreased flow to vertebral artery. I know MRI per patient report is normal but don't think that would r/o a drop attack.
I would have assumed neurologist would have ruled this out but you didn't mention it. Just throwing it out there b/c this would be a much more serious cause of loss of balance.
Otherwise if clear, I would treat as you suggested but if no progress in several visits not be afraid to refer back to MD. Often when you read case studies about scary diff dx type stuff - the harder the PT had to look to come up with a complicated type diagnosis to justify the symptoms - more often than not is was something more serious- like in your case maybe a progressive neurological disease in early state.
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RE: help with diff dx - November 17, 2007 1:13:57 PM
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PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
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Ben: You may be looking at a simple reflexive quad inhibition due to a PF issue, and there does not necessarily need to be pain to cause this "shut down". I have a friend, 81 years of age, with a very similar problem, and it caused on very significant fall for him. There are usual degenerative changes on radiographs for his age,but he does not have good terminal knee extension and cannot "lock out". When we got him in for strengthening (even though no major deficits were found, the extra strength and neuromuscular activation were expected goals), NMES to quad, patellar mobilizations, PF taping, and passive extension, he did great, and no more buckling episodes. This may be the same in your patient. Throw in the muscular tightness which will bother the PF joint mechanics that much more, and you may have the complete picture
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: help with diff dx - November 17, 2007 6:19:40 PM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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yeah I thought this too with the inhibition of quads from swelling etc, but surprising slow, not ,much arthritis going on down there, you'd swear he was 50 years old, young looking and acting. As far as the drop attacks, there is no fainting or syncope, purely knee giving way. I will check the PF a bit closer, but I am pretty sure no prob there, but I will look again and update..
thanks so far!
ben
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RE: help with diff dx - November 17, 2007 9:19:30 PM
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jma
Posts: 2432
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From: NY
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An interesting link and diagnosis to go with it. A knee brace sounds good to prevent any further injury should a bad fall ensue.
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RE: help with diff dx - November 18, 2007 2:11:14 PM
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FLAOrthoPT
Posts: 1011
Joined: May 8, 2004
From: West Palm Beach
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I will keep you updated as to response to PT as I stated in original post..
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RE: help with diff dx - November 18, 2007 4:42:44 PM
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SJBird55
Posts: 2467
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From: Michigan
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When a patient has a peripheral nerve problem, I've always wondered... at what point in time will an EMG be sensitive enough to indicate there is a nerve issue? For example... I know of examples with cervical radiculopathy where prior to attending therapy, the EMG was negative. Really mild symptoms were present - no definite strength deficits though. Then, as strength diminishes more to where there is a noticeable difference between extremities, the EMG does indicate peripheral nerve problems.
I'm not sure what you meant by moderate resistance for prolonged periods... but when I'm not sure what the heck is going on and I know there is weakness but I can't demonstrate it with a manual muscle test, I do 2 things. 1) I do the timed stands test. Often times when there is unilateral involvement, depending on the deficit, that test may not be sensitive enough to pick up anything. What I watch for is the quality of movement and if the velocity changes toward the last few repetitions. I also ask for a subjective report of how the involved extremity feels. I also compare performance to normative data. 2) after a 3 minute break, I then have the patient perform single lower extremity knee extensions on a knee extension machine. I generally use a moderate weight (I guesstimate the resistance with my thoughts of less than 30 reps will occur before fatigue). The uninvolved extremity goes first and I have the patient do as many as possible until fatigue occurs. Fatigue = me telling the patient to stop because the final repetition is about 50% of full motion. I then have the patient perform the same test with the involved lower extremity. Both of those tests are generally helpful in tracking change. Within 4-6 visits, a normal response with physical therapy intervention is for definite change to occur. No, there isn't any published evidence of this.
One thing I would do would be to have a conversation with the referring physician. If the physician was thinking a femoral mononeuropathy, the glaring factor in my mind is why? If the physician didn't rule out the pelvic region, there very well could be "something" in that area causing the symptoms. I'd assume (by the way you generally post) that you already did a medical systems review. I'd double check on responses or ask specific questions targeting the gastrointestinal and the genioturinary systems.
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RE: help with diff dx - November 18, 2007 11:32:29 PM
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bonez
Posts: 239
Joined: August 28, 2007
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The suspision points to femoral nerve neuropathy. with the acute onset and the presence of some pat dtr one should insure ominous causes (Aortic aneurysm) as risk can climb with age. Does fatiguing the limb alter function ie increases in numbness or decreases in reflex If there is true nerve palsy three weeks should show something on the conduction tests
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