Muscle weakness and Gait abnormality

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Differential Diagnosis of Muscle weakness and Gait abnormality

Organ system	Disease	Symptoms												History	Physical Examination	Diagnosis
		Age of onset	Muscle weakness	Fever	Myalgia	Contractures	Gait abnormality	Neuropathy	Atrophy	Stiffness	Myoglobinuria	Other features	Laboratory Findings			Creatine Kinase	Muscle Biopsy	Electromyogram
Medication−induced	Alcohol	Variable	Proximal	−	−	−	+	+/−	−	−	−	Swelling Tender Erythema and induration	Alcohol intoxication	Change in mental status Telangiectasia Peripheral neuropathy	Monspecific and are normal in many patients	Normal or ↑↑	Normal	Normal
Genetic	Becker muscular dystrophy	<13yrs	Proximal	−	−	+	+	−	+	−	−	Milder form of Duchenne	Growth delay Age of onset of symptoms is much delayed than duchenne	Positive Grower sign	Decreased amount of dystrophin.	↑↑	Muscle fibril degeneration, regeneration Isolated fiber hypertrophy Muscle replacement with fat and connective tissue	Myopathic
	Duchenne muscular dystrophy	<13 yrs	Proximal	−	−	+	+	−	+	−	−	Calf psedohypertrophy Cardiomyopathy Kyphoscoliosis Cognitive impairment	Early onset	Positive Grower sign	Errors in the Xp21 gene. Absence of dystrophin.	↑↑
	Limb−girdle muscular dystrophies	<15 yrs	Proximal	−	+	+	+	−	+	−	−	Calf hypertrophy Scapular winging Cardiomyopathy Cardiac arrhythmias Respiratory muscle weakness	Autosomal dominant Deterioration of ability to run/walk	Muscle weakness is generally symmetric	LMNA gene CAV3 gene	↑↑	N/A	Myopathic
	Myotonic dystrophy	<18 years	Proximal & distal	−	−	+	+	−	−	+	−	Myotonia Cataracts Diabetes mellitus Frontal balding Cardiac arrhythmias Cholecystitis Pregnancy Eyelid ptosis	Positive family history	Muscles often contract and are unable to relax	Mutations in the DMPK gene	N/A	N/A	Myopathic
Organ system	Disease	Age of onset	Muscle weakness	Fever	Myalgia	Contractures	Gait abnormality	Neuropathy	Atrophy	Stiffness	Myoglobinuria	Other features	History	Physical Examination	Laboratory Findings	Creatine Kinase	Muscle Biopsy	Electromyogram
Infectious	Lyme disease	Variable	Proximal	+	+	−	+/−	+	−	−	−	Erythema Migrans Flu−like symptoms Lyme arthritis Neurological manifestations	H/o tick bite Hiking trip	Target−like lesions HSM	Clinical diagnosis +Serology	N/A	N/A	N/A
	Influenza	Variable	Proximal and Distal	+	+	−	+	−	−	−	+	Fever Malaise Rhinorrhea Muscle pain worse with movement	Cold weather H/o Ill contacts	Muscle weakness, tenderness, and swelling.	↑↑ Liver enzymes Positive PCR	↑↑	N/A	N/A
	Polio	<5 yrs	Proximal	−	−	−	+	+	+	−	−	Asymmetrical paralysis Muscle atrophy Tremors Skeletal deformities	History of skipped immunization.	Normal Meningeal signs Asymmetrical flaccid paralysis Pharyngeal paralysis	Isolation from pharyngealsecretions, CSF Positive serology	N/A	N/A	Neurological pattern
	Syphilis	Variable	Negative	−	−	−	+	+	−	−	−	Chancre Lymphadenopathy Condylomata lata Neuro syphilis Cardiovascular syphilis	History of risk factors (MSM, unprotected sex, multiple sex partners)	Non−tender chancre in primary syphilis. Followed by rash Generalized lymphadenopathy in secondary syphilis	Darkfield examinations VDRL RPR FTA−ABS	N/A	N/A	N/A
Organ system	Disease	Age of onset	Muscle weakness	Fever	Myalgia	Contractures	Gait abnormality	Neuropathy	Atrophy	Stiffness	Myoglobinuria	Other features	History	Physical Examination	Laboratory Findings	Creatine Kinase	Muscle Biopsy	Electromyogram
Neurologic	Stroke	>65	Proximal & distal	−	−	−	+	+	+	−	−	Dysphagia Unilateral/Bilateral weakness	H/o HTN, dyslipidaemia DM	Weakness of the involved arm	Head CT	Normal	Normal	Neuropathic
	GBS	18 −350	Proximal	−	−	−	+	−	−	+	−	Ascending paralysis	Precedes a gastrointestinal disease	Weakness of lower extremities followed by upper extremities	Cytologic albumin ratio	Normal	Normal	Neuropathic
	Multiple Sclerosis	30's	Proximal & distal	−	−	−	+	+	−	−	−	Ocular findings Urinary incontinence Problems with speech or swallowing	Attacks or exacerbation	Localized weakness Focal sensory disturbances Hyper reactive reflexes Increased tone or stiffness	Head CT ologo−clonal bands	Normal	N/A	Neuropathic
Neuromuscular	Botulinum	Variable	Distal	−	−	−	+	−	−	+	−	Double vision Blurred vision Drooping eyelids Slurred speech Difficulty swallowing	H/O food exposure	Hyporeflexia Decreased strength	+Toxin	Normal	N/A	Myopathic
	Lambert−Eaton syndrome	Variable	Distal	−	−	+	+	−	−	+	−	Weakness of the bulbar muscles Ocular Limb weakness	Weaknessa is often relieved temporarily after exertion or physical exercise.		Antibodies against voltage−gated calcium channels
	Myasthenia gravis	Variable	Proximal	−	−	+	+	−	−	+	−	Ocular Bulbar  Limb weakness Isolated neck, limbs and respiratory weakness	Weakness often worsens with activity		Antibodies that block or destroy nicotinic acetylcholine receptors