Creator: Dr. Gursimran
Published: 2020-10-29T06:30:02-04:00

Patient's Query

Hi doctor,

I have cramps in my calf and thigh for about three months and now twitching in the leg. I am anxious about ALS. Is the twitching in ALS constant, or does it disappear when moving? I am currently taking Levothyroxine.

Answered by Dr. Gursimran

Hi,

Welcome to icliniq.com.

Sorry to hear regarding the problem that you are facing. Please clarify your age. Does the cramps in the thigh and calf is one-sided or on both sides? Twitching in ALS (Amyotrophic lateral sclerosis) starts inconstantly and typically appears when we try to tap the muscle. There are many more symptoms, and the frequency of cramps increases, and twitching also happens in the shoulder region. There is a lot we should discuss about ALS. There are entity names benign fasciculations which happens to everyone. We need to talk more. So either you book a phone consult, or we continue discussing it by this means.

Patient's Query

Hello doctor,

Thank you for your reply.

You are the first person who has responded in detail; I appreciate it. I am 53 years old. The cramp started three months back. I would get one in my calf while sitting and watching the TV. And sometimes, when sitting with my leg up or exercising, I will get it in my thigh. The twitching began about five weeks ago. I went to the GP a couple of weeks ago, and he looked at my leg and tested the strength. There is no weakness. I have another appointment tomorrow as it is causing a lot of anxiety. I have been exhausted after reading on the internet that these can be an initial symptom of ALS. I also read that the twitching can be constant and does not disappear when you move a muscle. Mine disappears when I walk. The GP did flick my calf, but I did not know why he did that until you mentioned it. My cramps have not increased in frequency, but then the thigh cramps up if I lift my leg out to the back.

Answered by Dr. Gursimran

Hi,

Welcome back to icliniq.com.

Thanks for appreciating. I completely understand the worry and anxiety around these symptoms. Two months is a relatively short period. Please answer these few questions.

Do the cramp and twitching happens on both legs and thighs?
Did the twitching also occur in the shoulder region?
Do you have any problem with swallowing liquids?

On examination in ALS, the legs, thighs, and arms tend to thin out in muscle bulk in due time, let us say around one year or so, but the power remains near normal even till the end.

Vitamin D deficiency is a prevalent cause of twitching and cramps, so please take OTC (over the counter) vitamin D.

If you have to be 100 percent sure, then you need to get an EMG (electromyography) NCV (nerve conduction velocity) done.

The history you have given does not fall for ALS because firstly, ALS is slow to progress; twitching comes and goes in various parts of the body, such as calves, back of the shoulder, tongue (when the tongue is inside the mouth and not protruding out).

Patient's Query

Hi doctor,

Thank you for your reply.

The cramp came first spontaneously in the right calf, and then thigh only during exercise. The twitching came later, mostly in the calf, then in the thigh a little but only at rest, not when I am moving around, and no twitching in the shoulder. There is no problem with swallowing and no twitching in the tongue. My muscles seem to be fine, but it is as though I am waiting for the weakness to come. If it is due to vitamin D deficiency, could it just be in one leg? Would the muscle bulk usually show before the cramp and twitching starts? I have an underactive thyroid, which is why I went to the GP initially. After the cramping, I thought it might be my thyroid, but the GP said it would not be only in one leg.

Answered by Dr. Gursimran

Hello,

Welcome back to icliniq.com.

I read your reply. Everything seems to be fine. Vitamin D deficiency or benign fasciculations or twitching usually happens in one place. It subsides for one to two months because of our intervention, like giving vitamin D supplements or decreasing anxiety, or decreasing caffeine. Then these benign twitchings will happen at some other area but with a gap of a few months. Muscle bulk reduces relatively early; for example, there a muscle called first dorsal interossei (FDI) that atrophies (check on the internet where is FDI and then close). Thyroid problems will give generalized twitchings. That does not seem to be the cause. So right now, the best way is to wait for two weeks and take vitamin D supplements, reduce the caffeine intake (you can take decaf beverages), and get into some yoga program to reduce the anxiety level. Then after two weeks, we can decide from there. Does it sound fine for you?

Patient's Query

Thank you, doctor, for your reply.

Do benign fasciculations cause localized muscle cramps and twitching? I am seeing my GP today for my anxiety caused by this. Is there anything I should ask?

Answered by Dr. Gursimran

Hello,

Welcome back to icliniq.com

Twitching is another name for fasciculations. Cramps are not a part of benign fasciculation syndrome; it can again be a sign of vitamin D deficiency. Please ask your GP to reassess you for tap-induced fasciculations around the shoulder region and the other calf. Another thing to stay ahead of this is checking your plantar response and tone of legs (this is a part of general neurological examinations); tone tends to increase, and plantar response will be extensor if there is a problem. Lastly, she or he can check for tongue fasciculations.

Patient's Query

I went to the GP yesterday and was there for some time. she gave me a full check over. looked at my body both sides. test muscle strength from top to bottom including face. She tested all my reflexes that were normal and I think she did the babimski test on the soles of my feet , she ran a blunt instrument over them with some pressure. she asked about swallowing and speech . all normal too. since cramps a twitching started months ago would we be seeing something else by now?

Answered by Dr. Gursimran

# Hello Allison ! By the meaning of your message , I think your Neuro exam went fine and that’s a good news . Yes definitely , new symptoms and new places of cramps and fasciculations do get involved in patients with ALS. and there are no induced twitchings also . So it seems all good . Otherwise GP would have referred you to a Neurologist . So kindly take vitamin D supplements and please let me know in future , how things turn up . Regards .

Patient's Query

Thank you, I will use this last question up if that is ok just to clarify a few things in my head and put this whole thing to bed. Would the reflexes be abnormal? would the weakness be apparent after 3 months from onset of cramp? would the plantar response and tone of leg be abnormal at this point? I am still running every day and doing other physcial exercise and yoga, would I have noticed something? could the twitching be anxiety related but still only be in the one leg and lastly could an electrolyte imbalance only appear symptons in one leg? The GP looked at the muscle in my hand , the one you mentioned and was not concerned I think she was more worried about my health anxiety and has put in place an appointment to see someone about it? so in conclusion as a qualified Neurologist you would say from all the above that there would be further issues and that I should stop worrying? thank u for your help

Answered by Dr. Gursimran

# Hi again ! 1) As far as ALS is concerned The reflexes ( at least one of them will be abnormal even at this stage ) . Weakness doesn’t come in 3 months and actually comes very late . Yes the plantar reflexes and tone does have changes but also depends on patient to patient . 2) if by gods grace u r still running and doing workout , then ALS is already ruled out . Electrolyte imbalance and anxiety related can have twitchings just at one place . 3) yes if there are anxiety issues , they need to be sorted out systematically .4) we usually suggest Deep breathing exercises ( actually I suggest deep breathing to everyone) 5) yes I would be confident enough by having these above conversations that there is nothing to worry . 6) we will not get ahead of time and I will be glad if you follow it up with me after a month . 7) please take vitamin D supplements or natural sunlight .

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