Author: Derek Stokes, MD
Co Author #1: Adele Meron, MD
Senior Editor: Jessalynn Adam, MD
Editor: Chenai Nettey, MD

Patient Presentation:
40 year old female presented via referral to the PM&R clinic for evaluation of activity related gait abnormality involving the left lower extremity.

History:
The patient presents for 3 years of non-specific left lower extremity weakness. She has difficulty with walking due to tightness, tingling, and numbness at the lateral aspect of the calf (adjacent to the fibular head) and the lateral aspect of the foot. She feels the need to walk on her toes and has the sensation of instability of the extremity resulting in lateral ankle rolling. At times, she feels like she has a limb length discrepancy. These symptoms are notably worsened when she is fatigued, especially with short term physical activity and at the end of the day. She has tried to alter her cadence and change to a heel-toe gait. The symptoms resolve with rest.

The patient denies any history of trauma or injury. She has an unremarkable past medical and family medical history. Prior to her presentation she had already been evaluated by sports medicine, neurology/movement disorder clinic, a multidisciplinary peripheral nerve clinic, and an orthopedic surgery limb lengthening clinic. Imaging and testing by these specialists showed abnormal fibular nerve conduction near the fibular head that later resolved, negative lumbar spine xray and MRI, negative brain MRI, and no limb length discrepancy. She was previously managed with multivitamin injections for neural health, trials of ankle supports and CAM boots, relative rest, and physical therapy.

Physical Exam:
Full and symmetric 5 out of 5 strength of the bilateral lower extremities, intact and equal deep tendon reflexes, no sensory abnormalities, Normal posture, Back with full range of motion, Hip range of motion was full and non-painful. Gait demonstrates subtle trendelenburg versus hip hike, no abnormalities with backward walking/heel walking/toe walking

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