Author: Gary Allen, DO, ATC
Co Author #1: Bryan Prine, MD
Editor: Christine Persaud, MD
Senior Editor: Christine Persaud, MD
Editor: Marc Hilgers, MD, PhD, FAMSSM
A 42-year-old male presented with 1-year history of left lower leg weakness and left ankle pain.
Patient first noticed muscle wasting in his left calf and difficulty with heel raising after beginning an exercise regimen to lose weight. Was seen by multiple Orthopedic and PM&R physicians who evaluated and treated with multiple ankle corticosteroid injections, but pain and weakness persisted despite periods of rest, exercise, and treatments. Patient reported history of normal physical performance including high school football, but was found to have elevated CK levels with inconclusive muscle biopsy results in his college years. Additionally, patient has chronic left shoulder pain which was also treated with a sub-acromial corticosteroid injection upon presentation to sports medicine clinic.
Inspection: marked muscle atrophy of medial and lateral compartments of left calf.
Palpation: Tenderness to the left lateral malleolus.
ROM/Strength: Left ankle plantarflexion 3/5. Left knee extension, knee flexion, hip flexion, and ankle dorsiflexion all 4/5. Right LE strength all 5/5. Shoulder exam without significant deficits in strength or ROM.
Neuro: Left ankle Achilles reflex diminished to 0 compared to 2+ on the right.
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