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Myopathies Clinical Presentation

  • Author: Courtney A Bethel, MD, MPH; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
Updated: Dec 27, 2015


Obtain the family history to determine presence of periodic paralysis or muscular dystrophy. Personal history of autoimmune disease, endocrinopathy, renal insufficiency, and/or alcoholism should be noted.

Discuss any previous episodes of severe weakness, particularly any that occurred after exercise or exposure to cold temperatures, which may indicate one of the periodic paralyses. Some patients with familial hypokalemic periodic paralysis may note that the symptoms occur after eating high-carbohydrate meals.

History of medication use is very important. Steroids, lipid lowering agents, retroviral agents, alcohol, colchicine, pentachlorophenol (PCP), heroin, and a myriad of other medications may cause myopathies. In some cases, the combination of multiple myopathic agents is responsible for the acute deterioration.[4]

Occupational and travel history may lead a physician to consider ingestion of barium chloride or carbonate as a cause for acute hypokalemic paralysis. Note the following:

  • These are absorbable salts (in contrast to nonabsorbable, safe, widely used barium sulfate) that may contaminate table salt or flour. Absorbable salts may be used industrially for glazing pottery.
  • Paralysis results when passive efflux of potassium is blocked at the cell membrane and elevated intracellular potassium decreases the resting membrane potential.

Symptoms noted generally include the following:

  • Symmetric proximal muscle weakness
  • Malaise
  • Fatigue
  • Patient may note dark colored urine and/or fever.
  • No sensory complaints or paresthesias are noted with myopathies.
  • Atrophy and hyporeflexia are very late findings in most patients with myopathy. The early presence of these findings usually implicates neuropathies.

Significant muscle pain and tenderness without weakness should prompt physicians to consider other causes.

Acuity of symptom onset aids in diagnosis, as follows:

  • Weakness progressing over hours suggests a toxic etiology or one of episodic paralyses.
  • Weakness developing over days suggests acute dermatomyositis or rhabdomyolysis.
  • Symptom development over a period of weeks suggests polymyositis, steroid myopathy, or myopathy resulting from endocrine causes (eg, hyperthyroidism, hypothyroidism).

Symptoms of the patient indicate which muscle groups are involved, as follows:

  • Difficulty rising from chairs, getting out of the bathtub, climbing stairs, and/or shaving or combing the hair suggests proximal muscle weakness.
  • Weakness of distal muscles will present with symptoms of weak grasp, handwriting problems, and walking difficulties, (eg, flapping gait).

Physical Examination

Objective weakness, usually in a symmetric distribution of proximal muscle groups is observed. Muscle tenderness is rare; muscle mass should be normal. Atrophy is a very late sign with muscle disorders. Deep tendon reflexes (DTRs) and sensory perception should be normal. DTRs may be diminished or absent in hypokalemic paralysis.

Fever, particularly with pyomyositis or polymyositis may occur. Normal level of consciousness should be preserved.

Skin examination may reveal Gottron papules, which are pink-to-violaceous scaly areas over knuckles, elbows, and knees in dermatomyositis.

Contributor Information and Disclosures

Courtney A Bethel, MD, MPH Clinical Assistant Professor, Department of Emergency Medicine, Mercy Catholic Medical Center, Drexel University School of Medicine

Courtney A Bethel, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, Arizona Medical Association, American College of Osteopathic Emergency Physicians, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

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