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Difficult case
35 y/o F with severe ankle sprain sent for EDX 4 mos after injury. Strength in ADF 4-/5, APF 3/5, in particular she is unable to plantar flex 2-5th toes, strength in FDL 1-/5, FHL 3-/5, EHL 4/5, foot inversion 5-/5, eversion 2/5, she has tingling in planter foot and some dorsal foot. No proximal weakness. MRI ankle nc with complete ATFL tear, tarsal tunnel wnl.
NCS- Tibial CMAP wnl, Fibular CMAP from EDB was low 3.5 mv( opposite 8mv) , Fibular from TA intact bilateral. Sural, Sup fibular, Saphaneous wnl. Lateral and medial plantar mixed nerves were intact (but opposite side was not done ) needle emg intact in Tib ant, Med gastroc, EHL, vastus med, biceps short head, but she could not activate any MUPs in FDL and Peron longus. she couldnt tolerate EDB, tried Abd Hallucis but she couldn't activate any units. All her weakness in foot started after this ankle injury. Lumbar spine MRI unremarkable. I am puzzled with multiple nerves affected after ankle injury, distal Tibial, superficial and deep fibular? any thoughts on localization? what is also baffling no MUP duration/amp changes, no denervation in any of the muscles. She says she has gained ADF strength, it was about 2/5 early on, but no improvement in toe plantaflexion.
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