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Tremor, numbness in arms, twitching index finger, nerve pain, cramping. Worried about ALS.

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I am 42 years old male, non smoker. I had many health problems in the past 7 years, like severe stomach pain, burning in colon, diahhroea, urinary pain and urgency. All the evaluations revealed nothing and I was given diagnoses of functional dyspepsia, functional bladder problems and IBS. Accordingly to my GP I am hypohondriac as I always assume I have worst possible disease (up to now was cancer).

From middle of september I am having severe (for me at least) neurological problems which are spreading quite rapidly as now it is end of November. I will try to be as brief as I can, but since your answer depends purely on my writing, I can not list everything in 1 sentance, sorry about that.

1. Middle September: I started having night tremor in my hands and arms. Every night in the second part of the night (after like 5 hours sleeping). Till now only nights without tremor were the ones that I slept too little, like <5 hours.
2. At the same time I started getting numbness in my arms and fingers at night. Sometimes left hand, sometimes right hand or arm, sometimes whole arm sometimes only last two fingers (ulnar nerve) and sometimes first three (median nerve). There really isn't any clue where will it happen. Some days I don't have this, I was mostly free for 10 days in October.
3. 2nd october I was awaken by the index finger twitching in my left hand, that didn't stop for whole day. I began googling to search for any remedy and I found out about ALS. I started to get biceps twitch same day for 5 hours. 2 days later fasciculations were everywhere. MOST of the time I just have one single fascs at a time and moments later another one. Like popping here and there. They are in my arms, hands, feet and legs, but also abdomen. They do not happen on my head except eyelid twitch of the right eye, that I have since that day. I can self induce it by closing my eyes tightly and opening them or yawning. Eyelid twitches 5 times every time since that day if I do that. That day my high anxiety started and I started to have fear this has to be ALS, no other possible cause. Let me tell at this point I have 80% of the twitches on the left side of the body and since that day my left cheek feels... strange, I feel it all right, but feels like my skin is too tight.
4. Middle of october I stared to get feet problems. I first thought the happen because I ran to much (17km) instead of my usual 4km, because I was so anxious. First I got way to much twitching in the soles of my foot, mostly at the left foot and not whole foot, but the hallicus brevis muscle, the muscle that goes in the inner arch from toe to heel at the side and under. After twitches pain came, first left leg in the soles near 3rd and 4th finger I felt tingling, pain, numbness) and I thought I had Morton's neuroma. But this pain eventually went away and next days my arches were sore and I was having pain when walking. Since then my right foot is much worse, like the leg would be bigger, all my shoes feel to tight and when I am wearing them my inner arch muscle hurts. Same on the left, but not as much problems in shoes, but much more fasciculation in this leg. So to sum, left leg more fasciculations and right leg more muscle pain. The right foot problem began 7 days after left foot problem.
5. After about 7 days I felt cramping pain in the same feet muscles, first at the right, and now also on the left. In fact left halicus brevis muscle is easier cramped than right one. I don't know if they are hard cramps. But I can self indulge cramp so easily now, just putting my leg away from the knee and bending toes a little down and I can have cramp. At night I have to be carefull how I bend my feet not to have cramps. I am not awaiken by them. They don't seem to be sporadic with no activity, but they seem to be with the movement of the affected muscles and toes.
6. In november I got in the same foot muscle some buzzing sensation on top of the other problems. In left leg same muscle I can feel some nerve pain and buzzing, like if I put battery on my mouth and feel electrical jolts. It has been going on and off for days, sometimes dissapears but comes back.
7. Last 2 weeks I am having trouble with tingling and pricking sensations in my hands and legs during the day also. The hands are not numb, but I feel wierd sensations there. I am also noticing my left leg and arm develop some tremor during the day when I put some preassure on the muscles, but not much. To lean my head on my wrist and my elbow on the desk I get trembling in my left arm. I never felt any muscle weakness, just pain and tremor and other symptoms I mentioned.
8. Last few days I am randomly waken up at night because some single muscle is in a twitch in my arm (between the hand and elbow somewhere). This twitches I get lately are very fast! Feels like tremor but it is from a twitch and different from my early morning tremor where my whole hand/arm is trembling. It is like some machine gun twitch. I strenghten the muscle and it is gone. Next night it come back on some other spot. My hands feel like some wierd sensation is there at night, tonight I felt like some vibrating (inner one), buzzing in my hand and then it went away in the morning.

I went to see the neurologist on October 18th, right before my feet problems started so I told him I didn't have cramps. He made a nevrological examination, inspected me for weakness, reflexes etc. and he told me he doesn't find anything wrong. I didn't have buzzing and pain in my feet then and tingling in my hands.

I am in a total scare that my day tremor in left side where there are more twitches (like one in a minute, but sometimes few hours without and 2 days in Octorer I didn't have more than a few, but since my foot started twitching, they have the most twitches) means I am getting clinically weak. I can still life same amount of weight than before, but is the tremor on activity sign of clinical weakness that accompanies ALS?

I have such anxiety now I can hardly function. I am getting psychological help in a few weeks, but I feel I am dying of ALS that is just progressing, as my symptoms are worse and worse.

I know you can not know if I do have ALS or not, but I am interested to find out, what do you think of my symptoms, where do they point? If I was not so blind minded on ALS, do they point to MS more like it? As I have a history of healt problems that have functional nature rather than phisical, do you think it is even possible all that is happening to me neurologicaly (+ dizzines and nausea I get some days), can this even remotle be possible to be just psychological? My neurolog told me there is not such thing as an early morning tremor for example in medicine. Of course I am more scared of twitching but I do think this symptoms should be looked together. My blood preassure is higher by 20 now since I googled ALS :-( (still healthy 130/85 though).

I know I should make EMG, but there is a waiting line in my country 2 months and I don't know where to do it, in my hands or feet now...

Does ALS represent typically in such a way? I now hve 2 months of twitching, in my foot sometimes I can feel the electric twitch but I can not see it, I am not sure if this ones are sensory or motor even. But most of my twitches are pop in one spot, second later on another type. And sometimes I have minutes or hours free of them. There were a few times I got the hours lasting one like my left biceps, left thigh and the starting index finger twitch in left hand. As I told you they are more on the left, but not exclusevely.

I am so afraid of ALS I don't even want to go to EMG at this point as I am sure in my head I have it. That is why I need to know if there is any other possible diagnoses except ALS according to my history and symptoms that present? I just feel my nervous system is dying off.

Tonight I got calves cramp at night (not a big one, I positioned the leg differently and it didn't develop further), and I don't even have that many fasciculations in my calves (very few). I feel like ALS is progressing up. But where did it start, on my hands or legs... I seem to have all the limbs involved in something with numbness only in my hands at night.

Night does seem to make things worse, as I have tremor in hands, numbness in hands at night and my feet are more sore in the morning! How can this be?

I am sorry for the long post, but it is realy vital that you get as much info as I can give you. I tried magnesium, calcium, B12 supplements, didn't make anything better. I did have 2 good days end of October (pain in feet only and night tremor, almost no fasciculations and no numbness).

I don't even know how twitches in ALS present, are they so popping around or on one place. The one place I really find a lot of popping is left inner arch, but I read this is almost normal place for twitches, so I don't know. I don't think I had them before.

I am in a lot of stress and any answer you can give me would help me. Should I make a spine MRI, CT scan, EMG for ALS or MS? Can this be my stress and anxiety are playing on me? I can hardly believe this, but colon and stomach did play on me, I am not sure if you can have so much nervological symptoms without a serious or deadly disease? I hear about stomach problem with stress but nerve problem and foot muscle nerve/pain/buzzing problem that doesn't go away for 6 weeks...

I am in a lot of stress and september was a very stressfull month for me, but I don't know if it is possible to start trembling every night because of this (I didn't worry this is deadly disease before finger twitch).

We are a small country, there are only 20 ALS cases a year so we don't have many experts for ALS.

Sorry for the long letter

Sincerely yours


PS – One specific question I do have: Is the clinical weakness in ALS like tremor on activity or it is like you can not lift that much any more? I can lift but I have some slight tremor when making force to my left limbs... It is slight, I am not sure if this was there before.
Posted Sun, 6 May 2012 in Brain and Spine
Answered by Dr. Shiva Kumar R 17 hours later

Thanks for posting your query. Your question is a very good one and I will try to provide you with information and recommendations regarding the symptoms you are experiencing.

Regarding the list of symptoms presented to me I personally feel you do not have any symptoms of either ALS (Amyotrophic lateral sclerosis) or MS (Multiple Sclerosis). I think you are suffering from Hypochondriasis which is pretty bad at this point of time. Finding a mental health provider who has experience treating this disorder with talk therapy (psychotherapy) can be helpful. Cognitive behavioral therapy (CBT), a kind of talk therapy, can help you deal with your current.

If you are not treated at this point of time you could land up in complications like invasive testing to look for the cause of symptoms, dependence on pain relievers or sedatives, depression and anxiety or panic disorder and lastly lost time from work due to frequent appointments with health care providers.

Also anxiety in you is the cause of tremors, lack of sleep and twitching in the muscles which are also called as "Benign Fasciculations". I personally feel neither CT (computerized Tomography) or MRI (Magnetic Resonant Imaging) and ENMG (Electroneuromyography) studies are required in you to rule out MS or ALS. You are in a lot of stress now and will benefit from good counseling.

I am sorry you are dealing with this frustrating concern and I hope you can find yourself in better health soon with the help of your psychiatrist and a clinical psychologist.

There is clinical weakness in ALS but ALS by itself, does not cause tremors.

I thank you again for submitting your question. I hope you find my response to be both helpful and adequate. If you have any additional concerns regarding your question I would be happy to address them.


Dr Shiva Kumar R
Above answer was peer-reviewed by
Follow-up: Tremor, numbness in arms, twitching index finger, nerve pain, cramping. Worried about ALS. 2 hours later
Thank you very much for your answer. My doctor said I could have anything and I wanted another opinion. I do have some more concrete questions if I may:

1. I guess with your answer you answered me, that all my problems could indeed be without serious neurological ilness although I am experiencing some very wierd nerve and pain sensations?

2. So ALS weakness is weakness that if I force myself to do something I can not get full strenght in the muscle any more? Simply can't? If I do something and my left arm is trembling but I can still do it, this is tremor on activity, it is not clinical weakness?

3. I have told you about my prior health anxiety problems. If I weren't in anxiety, my symptoms alone could be said to be very inconsistent and scattered over motor, sensory, pain... and this points away from a serious neurological disease, is this assumption correct?

Brief review of my symptoms:

- Twitching all over the body except head (most times single pulse ones, but also machine gun fast ones during night sometimes, in instep on left foot a twitch every minute), twitching is 75% on the left of the body
- Night hands/arms tremor
- Night numbness of hands or arms or fingers in hands/arms or both, not every night
- Wierd feeling in hands at night, like they are stiff (rheumatologist said no rheumatism) with water, half trembling, some twitches, some paresthesia etc.
- Nighmares almost every night for months
- Crampings in inner arch muscle (that goes from big toe to heal) and also some calves cramps (but no twitching there!)
- feet pain ranging from muscle pain in inner arch and pain in the soles of the feet, some nerve pain in the soles of the feet, wierd buzzing in the nerves of the feet, feeling like right leg is too big for the shoe because some wierd pain in the arch etc.
- Day tremor on the left side of the body when I lean on the elbow or do some small muscle force with arm or left leg
- some numb feeling (but not real numbness) in the left cheek sometimes
- some dizzines with nausea not every day
- even if I sleep a lot sometimes I feel exshausted all day

I scare twitching the most, the most bothering is the pain in the feet, it is hard for me to esxcersise and walk, but I do walk normally without limp, but I get pain (muscle and nerve pain for 6 weeks).

no problems with breathing, eating, vision, weakness ...

So according to this, this symptoms are not an immediate sign of a severe neuron dying?

4. Do you think I could have some sort of spine problem and my nerves are trapped? I guess hands tremor and numbness and twitching and feet paresthesia/buzzing/twitching/cramping are uncommon because all 4 limb are affected somehow.

5. I also have 3 finger hand pain for 6 months I didn't tell you about, because this doesn't worry me, it is just a problem to grip things with left hand. Rheumatologist said not rheumatism, neurologist said no carpal tunnel, reason unknown. Is the finger pain I am experiencing and the feet pain as if my muscles are too tight on the feet and the are cramping and irritating nearby nerves (this is how it feels), can this also be because I have mental anxiety problems. Can concrete pain also be from anxiety?

6. Do you have any advice of what can I do to release the feet pain/tingling/twitching? I have tried magnesium, but did me more harm than good (diahhroea), I tried combining calcium + magnesium, I tried B12, nothing helps. Should I visit orthopedic for feet? They can not hurt for 6 weeks with no physical reason, can they? In my mind it was that ALS is killing my hallicus brevis muscle in feet with twitching and then I have cramps and pain because of it and it hurts. But there is inconsistency: my right foot inner arch muscle has more pain than left, but it twitches rarely, my left foot that has the most twitches in my body has less pain, so if twitching would do me pain, it would be vice versa.

7. Could you just briefly tell me what happens to a persons nerves/muscles/tendons during sleep, because how can my feet hurt more in the morning after sleep? If I don't have buzzing in my right leg in the evening I have it in the morning for sure (and twitching in left foot)? Also what happens to person when sleeping that hands go in tremor or in numbness and they don't go at day? I thought when you rest your body is better not worse.

8. You think if I go to therapy as you advised and let the muscles twitch and try to let the fear of ALS/MS go, pain in feet, cramps, tremor could improve by itself?

9. I have more and more symptoms every week. This still doesn't mean I am terminally ill, it can all be psychological fear building up? I never had such fear of cancer as I do for ALS. I am so sorry I found it on the internet in regard to twitching, it is such a desperate and hopeless ilness I can cry just to think of it and all the patients there are.

10. Can the mind itself increase the twitching just because I think it is sign of something terible and listening to myself all the time? Is the mind really so powerfull?

Thank you once again for your time, I know my letters are long and I appreciate the time you took, I am really in a terrible pain/twitch/fear etc... I will start counceling with cognitive therapy next week, but before I can go into that direction I needed to know if all what is happening can possibly be of my anxiety/mind problems without terminal neurological disease. I've had hypohondriasis before but that alone can not spare me that I can not really have ALS/MS, even scared people can get it I guess. But from what I read it would be wierd ALS would present with so many problems on so many limb without noticable weakness (more MS but MS is like a flue compared to ALS where there is no hope).

I will try to believe your reassurance and pursue the other, psychological solution of my problems. Therapeut says it is important I believe that mind can be responsible for all this problems I have. And my doctors just told me, he found nothing but some brisk reflexes that were understandable as my hands were shaking of anxiety). But then again, I didn't have cramps in this feet muscles, I didn't have twitching in the foot every minute, I had less symptoms a month ago. That is why I was trying to find out if all this wierd symptoms point to something sinister.

Thank you very much again! I will report to the site that I really appreciated you took the time to read my posts ;-)


Answered by Dr. Shiva Kumar R 1 hour later

Thanks for writing back.

Regarding the list of symptoms given to me again points out that these do not fit into nerve, muscle or spinal cord problems. There is something called as physiological tremor in every one which is increased by anxiety, intake of caffeine and lack of sleep. I probably feel your tremors are nothing but an exaggerated physiological tremor.

Usually in ALS (Amyotrophic lateral sclerosis) muscle wasting precedes weakness which is not seen in you. Tremors do not occur in ALS. But can occur in people with nerve problem when it is severe, which is also not the case in you.

Pain in your hands and feet is due to increased sensitivity of the pain receptors which is commonly seen in people suffering from anxiety. One can feel painless stimuli as painful. Meditation and exercises can relieve your pain to some extent. Problems in the mind can exaggerate simple problems and make it look more serious like yours.

So to put in a nut shell, you don't have any organic neurological illness and it’s only an exaggeration of the normal physiological process due to sever anxiety and stress. For a while, neglect your symptoms and undergo behavioral therapy along with meditation and you could make the difference to yourself.

I thank you again for submitting your question. I hope you find my response to be both helpful and adequate. If you have any additional concerns regarding your question I would be happy to address them.

Please accept my answer in case you do not have further queries.


Dr Shiva Kumar R
Above answer was peer-reviewed by
Follow-up: Tremor, numbness in arms, twitching index finger, nerve pain, cramping. Worried about ALS. 59 minutes later
I have just 2 more questions:

1. Can the tremor be unilateral, seen more prominent on one side of the body? Night tremor is once in one hand, once in other or both. It is there every night for 2.5 months. So when we sleep, out fears come out as tremor, when we are awake we subside them?

2. The only thing my neurologist found was a suspected muscle atrophy in my left hand. My whole hand is much thinner than my right hand, the tendons in the palm are standing out and my hypothenar eminence is not bulging out like on the right hand, but has a small dent in the middle. He thought this may be from the not using the hand so much as I have pain in 3 fingers as I told you or from ulnar nerve entrapement in elbow since I get numb last 2 fingers at night.

But this wasn't consistent, as some days I get this 2 fingers numb, one day I got middle finger numb and the next week I got fingers in the right hand numb. That is when my fear started to grow, if this is atrophy or not. Doctor was puzzled and didn't think much of it because on clinical examination my hand and fingers were adequately strong. This hand is non dominant and it is weaker since I know about 20%, but I guess that's normal.

So I have suspected wasting but no weakness in hand and my first twitch (that didn't reoccur up to now) was in this hand in index finger twitching and moving all day (twitch was between the thumb and index finger). At that time I wasn't scared of illness but I was under stress that month (september).

Can there be atrophy 2 months before any weakness? Is it possible that my handsa re so different from a long time ago and I didn't notice because I wasn't paying attention to my tendons budling and my muscles smaller? Is that possible to see in normal individum so different muscle size hands (1cm in diameter difference)?

I have some unclear picture from me on the vacation 1.5 years ago vawing with the "atrophied" hand and the tendons were clearly seen simmilar to as they are now, but I am not 100%.

So is it possible hands has so much less muscles and to the doctor it is like borderline atrophy? He couldn't decide if it was atrophy or not and he had no clue from where it was, as the strength was ok, there weren't any twitches in the hand (I dont have a twitch every second everywhere, it pops and goes).

I am submitting picture of both my hands for evaluation. You can clearly see the tendons in the left hand. I noticed this when doctor mentioned this to me. I was sure I would notice it before if this was there, but I may be wrong, I know what self inspection can do to a person.

I have no weakness in this hand, I have pain for 6 months in first 3 fingers and I suspect I've had at least simmilar hand 1.5 years ago on vacation, this is the small picture. Maybe the dents were smaller, I can not know.

Is such hand suspicious of muscle atrophy in your experience? Could have been such from forever? If there is no weakness in the fingers or hand (apart from 20% difference to the right hand), can I let go of the fear my hand is atrophying? I didn't have pain last year, but the tendons were visible to some degree.

This is my last question because this suspected atrophy got the best of me, so I had twitching + atrophy without weakness. Now it is 1.5 months later, "atrophy" seems the same, but I do not know how fast ALS would progress.

Thank you again for your time, I'll make a reccomendation about you. Thanx again.
Answered by Dr. Shiva Kumar R 4 hours later

Thanks for writing back to me again.

Most of the exaggerated physiological tremors are bilateral but exceptions do exist. However it is little odd to get tremors predominantly in the night time. Regarding the muscle atrophy can precede weakness by few months. However ALS does not have sensory symptoms like pain and numbness.

Regarding the picture of the hands provided to me there is prominence of the tendons over the left hand with less muscle mass over the hypothenar eminence. However i do not see appreciable difference over a period of 1.5 years, excluding progressive muscle atrophy. Up to 1.5-2 cms difference is accepted between the dominant and the non-dominant hand.

ALS is rapidly progressive disease a significant weakness and wasting developing in few months. Based on these findings i feel you do not have ALS. I thank you again for submitting your question.

I hope you find my response to be both helpful and adequate. If you have any additional concerns regarding your question I would be happy to address them.

Please accept my answer in case you do not have further queries.


Dr Shiva Kumar R
Above answer was peer-reviewed by
Follow-up: Tremor, numbness in arms, twitching index finger, nerve pain, cramping. Worried about ALS. 25 hours later
Thank you again. As I still have some worries I will ask you some more. This will obviously be the last post, as my 3 questions run out and I really don't want to »bug« you with my symptoms further.


If the still normal diameter around hands can be as much as 1.5-2cm, is it theoretically possible that my left hand was such for a very long time and I just didn't notice it because I didn't have any problems? I start noticing difference after I got first index finger twitch in it and because of pain in the first 3 fingers I am now noticing some days BURNING PAIN in my palm, like the tendons you see are exposed would be burning. Am I right assuming the burning palm pain is again not an ALS/MS sign? I think the burning in palm and the fingers pain and all the other problems are not connected to the »atrophy« as I had similar hand a year and a half ago without any problems. I don't know how I didn't notice it, but I guess human mind can play tricks if one is focused.


Sometimes I really almost don't distinguish tremor and fasciculations as for some night I woke up in the middle of the night and I thought at first I had tremor but it was a single fasciculation in my forearm that was so fast like a »machine gun«. When I strengthen the muscle of the hand, it went away, happened again but then no more. When I have tremor the whole hand pr arm is shaking, if I strengthen it stops but when released it is shaken again even more. But this tremor happens during sleep and in the morning. As my consciosness is more awake it dissapears, if I fall asleep some more it starts again, when I get out of bed it is gone. My psychoterapist said to me this kind of tremor is NOT A MEDICAL symptom of anything, can you agree? You have in your experience not found such tremor in any disease?

The day left side subtle tremor is not a first sign of muscle weakness?


Some stay (like soles of the feet), others move. Today I have a new one (not constant) in my left EYEBROW and in my »atrophied« thenar eminence (subtle one, can not see it). I am more scared because this muscle seems atrophied that I have fasciculation now in it. But all in all, they were first prominent in the big muscles of the arm, then leg, now hand, eyebrow. They move around, they strike me one night in forearm like machine gun and the other time small tiny ones in the thenar eminence. I know the ALS fasciculations follow some pattern. The pattern mine are developing does not seem like ALS type fasciculations even if I get some new ones on new spots, I should for now put worry aside? Should I worry if the fasciculation would go to my tongue? I didn't have one, but then again if I look at my tongue, it is shaking, it is hard to have it in one place (like tremor), so I am not sure if this is twitch or it is just a normal tongue tremor. If I harden the tongue it is solid, nothing moves, if not it is all shaky. I don't know, tremor of twitching? I don't feel any twitching in it (for now).


So you think the best thing to do is to try to live with the pain in this muscles and soles of the feet and all the tingling, morning numbness in heel (new symptom) for now and try to get anxiety in control? Is it not worrying I have feet pain and symptoms for 6 weeks, some days better, some worse, but none good and my right foot seems to big now for any shoe (because of pain, right foot is 1cm less in diameter than left one?) The nerve buzzing in arch is kind of painfull also. Twitching in other foot is just annoying. This does not show any terminal problem even if this symptoms don't improve unless I would get a foot drop or something like this? I have severe cramps in big toe muscle every time I want to bend toe downwards (like going into pants, sleeping extended etc.). My feet muscles are sore and cramping, when I put all fingers up on both feet all the tendons in the sold hurt me very much. 2 fingers feel numb a little. This are not serious symptoms?


So you think this are too much and to fast spreding symptoms for ALS/MS or other disease? They seem to strike me most at the most distant prheripherial nerve endings, like feet and hands. I know ALS doesn't strike without weakness in all 4 limbs at the same time. Could there be any multi limb neuropaty or something like this? My rheumatologist took my blood preassure and after she noticed red lines where the arm stretch was of the machine and she told me I suffer from autonome nerve hyperexchitability. Like overactive nerver system. Does something like this exist? Because I do feel like I was connected to 50V 2 months ago and I shake, tremble, twitch, buzz, have pain... Like I am connected to some electricity. This could be caused by anxiety?

So for goodbye, I listed some new symptoms, fasciculations moving around a little (I had a little finger severe pain like cramping yesterday and then it was gone), all kind of wierd symptoms around and I am getting slowly worse and worse in the body and in my head. I should still try to live without worry even if the symptoms degrade still a little, my feet do not improve another month etc. until I get some serious symptoms like visible atrophy on another part than my left hand and have some clinical weakness? And go for therapy.

Do you see patients with so many muscle/nervous system problems with »just« anxiety?

Thanx again. You are free of me ;-) You were very patient with me, I wish I would have doctor like you here...


Answered by Dr. Shiva Kumar R 11 hours later
Thanks for reverting!
As I already mention ALS does not cause sensory problems. MS can sometimes cause sensory symptoms. A good physical examination by a neurologist can distinguish between tremor and fasciculations causing twitching in the tongue, hands and feet. A neuropathy and can be done in you after consulting your GP. And lastly I do see people with severe anxiety and multiple neurological problems like you in my clinical practice and is not rare.


Dr Shiva Kumar R
Above answer was peer-reviewed by
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