ANKLE CLONUS
ANKLE CLONUS: Excerpt from Algorithmic Diagnosis of Symptoms and Signs
Ask the following questions:
- What other symptoms and signs are present? Ankle clonus rarely occurs by itself. Usually, there are pathologic reflexes such as a Babinski's sign on the lower extremities. The patient usually also will complain of weakness and may be found to have weakness when the muscles are tested. If the ankle clonus is long-standing, there will be atrophy. There will also frequently be sensory findings, as well as sensory complaints. Finally, with bilateral ankle clonus there will often be hyperactive reflexes throughout the lower extremities and sometimes in the upper extremities.
- Is the ankle clonus unilateral or bilateral? If it is unilateral, then it is a sign of either hemiparesis or monoplegia, and if it is hemiplegia or hemiparesis, one should consider the possibility of a cerebral disorder. If there is headache and papilledema, that disorder is most likely a space-occupying lesion of the brain such as a brain tumor, abscess, or hematoma. If there is hemiparesis and it is acute in onset, there is most likely an occlusion of one of the cerebral arteries, whereas if the hemiparesis is gradual in onset, one should consider multiple sclerosis and, once again, a brain tumor. Ankle clonus associated with monoplegia is more likely related to a spinal cord tumor, but a parasagittal tumor could also be present. Bilateral ankle clonus is more likely due to a disorder of the spinal cord such as a spinal cord tumor, amyotrophic lateral sclerosis, or multiple sclerosis. Syringomyelia and Friedreich's ataxia may also present with bilateral ankle clonus. However, if there are cranial nerve signs, one must consider a brain stem tumor as well as other degenerative diseases of the brain and brain stem.
DIAGNOSTIC WORKUP
Ankle clonus is a significant clinical sign, especially when it is unilateral. Therefore, if a brain disorder is suspected, a CT scan of the brain or MRI of the brain should be done. If a spinal cord lesion is suspected, then a CT scan at the appropriate level of the spinal cord should be done. If there are no findings on the examination to indicate a level, then of course the entire spine would have to be covered. MRI is a more cost-effective method for the cervical and thoracic levels of the cord. The spinal tap with analysis of the fluid for myelin basic protein and gamma globulin levels should be done if multiple sclerosis is suspected. In addition, somatosensory evoked potentials (SSEPs) and visual evoked potentials (VEPs) should also be done if multiple sclerosis is suspected. Finally, the most cost-effective approach to a patient with ankle clonus is to refer the patient to a neurologic specialist.
Book Source Details
- Book Title: Algorithmic Diagnosis of Symptoms and Signs
- Author(s): R. Douglas Collins
- Year of Publication: 2003
- Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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