A Case of an Older Woman Who Cannot Lift Her Right Foot

Elizabeth Walsh · Aug 23, 2008

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Case
Joanne is a 61 year-old woman who comes to your clinic with a complaint of difficulty raising her right foot, which has persisted over the last 3 months. The symptom started slowly and intermittently and then grew worse over time. She has nearly fallen down several times because she cannot dorsiflex her foot during ambulation.

In addition, Joanne has noticed a burning pain in her right foot for the last 2 weeks. She is unsure whether she has experienced any numbness. She has no symptoms in her left foot or hands.

Joanne's medical history is significant only for hyperlipidemia, for which she takes lovastatin nightly. She occasionally uses acetaminophen with diphenhydramine to help her sleep.

A review of systems is positive for mild fatigue and depressed mood. However, Joanne denies significant weight loss, fever, cough, chest pain, shortness of breath, or abdominal symptoms.

On examination, the positive findings include weakness in dorsiflexion more than plantar flexion at the ankle. She has reduced sensation to light touch and 2-point discrimination over the ankle and anterior foot. It is clear that she has right foot drop on gait testing. However, her ankle jerk is intact, and the remainder of her neurologic examination of the rest of the extremities is normal.

You order tests and request an evaluation with neurology. However, the patient misses her appointment with neurology, which was 3 weeks later, because of a family emergency. Instead, Joanne follows up with you 3 months after the initial visit. Her right foot drop has grown worse, and she now notes numbness with occasional sharp pain in her left hand.

On examination, you notice that she has lost 4 kg since her last appointment. Examination of her left hand reveals that it is well-perfused and not edematous. She has decreased sensation over the ulnar side of the left hand and digits 4 and 5. Flexion of these digits is also weaker on the left than on the right. Tinel and Phalen tests are negative. Examination of her right hand is completely normal.

Joanne is concerned that her symptoms seem to be progressing and is worried about the possibility of having had a series of strokes or brain cancer.

What might best explain Joanne's neurologic symptoms?

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David Wedemeyer · Aug 23, 2008

Given the slow progression of symptoms and asymmetric pattern of ascending spinothalamic and descending tracts, I would suggest Syringomyelia vs. upper motor neuron insult due to stroke or neoplasm.

David Wedemeyer · Aug 24, 2008

I reread this today and found that there was a great deal more history and discussion available. I have a family member with Buerger's Disease, it is a horrible condition. There are various vasculitides and they are often difficult to diagnose according to a friend who is a neurologist.

Elizabeth Walsh · Aug 24, 2008

David,

I didn't post the full article as it seemed too long.

Despite not having read the full history of this case,
your diagnosis demonstrated a wealth of knowledge anyway!

It's good to see a chiropractor contributing to the arena.:drinks

Elizabeth

David Wedemeyer · Aug 25, 2008

Hello Elizabeth

Thank you for posting that I enjoy differential dx puzzles. The truth is patients such as that one would be promptly referred out but I do see a variety of neurologic complaints, often as a first contact.

And thank you the compliment and warm welcome.

David

Elizabeth Walsh Active Member

David Wedemeyer Well-Known Member

David Wedemeyer Well-Known Member

Elizabeth Walsh Active Member

David Wedemeyer Well-Known Member

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