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<title>Muscle weakness</title>

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<span id="openzim-page-title" class="mw-page-title-main"><span class="mw-page-title-main">Muscle weakness</span></span>

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</style><div role="note" class="hatnote navigation-not-searchable">"Myasthenia" redirects here. For other uses, see <a href="Myasthenia_(disambiguation)" class="mw-disambig" title="Myasthenia (disambiguation)">Myasthenia (disambiguation)</a>.</div>

<div role="note" class="hatnote navigation-not-searchable">Not to be confused with <a href="Muscle_fatigue" title="Muscle fatigue">muscle fatigue</a>.</div>

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</style><table class="infobox infobox-has-images-with-white-backgrounds"><tbody><tr><th colspan="2" class="infobox-above" style="background:#ccc">Muscle weakness</th></tr><tr><th scope="row" class="infobox-label">Other names</th><td class="infobox-data">Myasthenia</td></tr><tr><th scope="row" class="infobox-label"><a href="Medical_specialty" title="Medical specialty">Specialty</a></th><td class="infobox-data"><a href="Neurology" title="Neurology">Neurology</a></td></tr></tbody></table><style data-mw-deduplicate="TemplateStyles:r1236303919">

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<p><b>Muscle weakness</b> is a lack of <a href="Muscle" title="Muscle">muscle</a> strength. Its causes are many and can be divided into conditions that have either true or perceived muscle weakness. True muscle weakness is a primary symptom of a variety of skeletal muscle diseases, including <a href="Muscular_dystrophy" title="Muscular dystrophy">muscular dystrophy</a> and <a href="Inflammatory_myopathy" title="Inflammatory myopathy">inflammatory myopathy</a>. It occurs in <a href="Neuromuscular_junction" title="Neuromuscular junction">neuromuscular junction</a> disorders, such as <a href="Myasthenia_gravis" title="Myasthenia gravis">myasthenia gravis</a>. Muscle weakness can also be caused by low levels of <a href="Potassium" title="Potassium">potassium</a> and other <a href="Electrolyte" title="Electrolyte">electrolytes</a> within muscle cells. It can be temporary or long-lasting (from seconds or minutes to months or years). The term myasthenia is from my- from Greek μυο meaning "muscle" + -asthenia ἀσθένεια meaning "<a href="Weakness" title="Weakness">weakness</a>".

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<div class="mw-heading mw-heading2"><h2 id="Types">Types</h2></div>

<p>Neuromuscular fatigue can be classified as either "central" or "peripheral" depending on its cause. Central muscle fatigue manifests as an overall sense of energy deprivation, while peripheral muscle fatigue manifests as a local, muscle-specific inability to do work.<sup id="cite_ref-1" class="reference"><a href="#cite_note-1"><span class="cite-bracket">[</span>1<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-2" class="reference"><a href="#cite_note-2"><span class="cite-bracket">[</span>2<span class="cite-bracket">]</span></a></sup>

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<div class="mw-heading mw-heading3"><h3 id="Neuromuscular_fatigue">Neuromuscular fatigue</h3></div>

<p><a href="Nerve" title="Nerve">Nerves</a> control the contraction of muscles by determining the number, sequence, and force of muscular contraction. When a nerve experiences <a href="Synaptic_fatigue" class="mw-redirect" title="Synaptic fatigue">synaptic fatigue</a> it becomes unable to stimulate the muscle that it innervates. Most movements require a force far below what a muscle could potentially generate, and barring <a href="Pathology" title="Pathology">pathology</a>, neuromuscular fatigue is seldom an issue.

</p><p>For extremely powerful contractions that are close to the upper limit of a muscle's ability to generate force, neuromuscular fatigue can become a limiting factor in untrained individuals. In novice <a href="Strength_training" title="Strength training">strength trainers</a>, the muscle's ability to generate force is most strongly limited by nerve's ability to sustain a <a href="Rate_coding" class="mw-redirect" title="Rate coding">high-frequency signal</a>. After an extended period of maximum contraction, the nerve's signal reduces in frequency and the force generated by the contraction diminishes. There is no sensation of pain or discomfort, the muscle appears to simply ‘stop listening’ and gradually cease to move, often <a href="Muscle_contraction#Eccentric_contraction" title="Muscle contraction">lengthening</a>. As there is insufficient stress on the muscles and tendons, there will often be no <a href="Delayed_onset_muscle_soreness" title="Delayed onset muscle soreness">delayed onset muscle soreness</a> following the workout. Part of the process of strength training is increasing the nerve's ability to generate sustained, high frequency signals which allow a muscle to contract with their greatest force. It is this "neural training" that causes several weeks worth of rapid gains in strength, which level off once the nerve is generating maximum contractions and the muscle reaches its physiological limit. Past this point, training effects increase muscular strength through myofibrillar or sarcoplasmic <a href="Muscle_hypertrophy#Strength_training" title="Muscle hypertrophy">hypertrophy</a> and metabolic fatigue becomes the factor limiting contractile force.

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<div class="mw-heading mw-heading3"><h3 id="Central_fatigue">Central fatigue</h3></div>

<p><a href="Central_fatigue" class="mw-redirect" title="Central fatigue">Central fatigue</a> is a reduction in the <a href="Nervous_system" title="Nervous system">neural</a> drive or nerve-based motor command to working muscles that results in a decline in the force output.<sup id="cite_ref-3" class="reference"><a href="#cite_note-3"><span class="cite-bracket">[</span>3<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-4" class="reference"><a href="#cite_note-4"><span class="cite-bracket">[</span>4<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-5" class="reference"><a href="#cite_note-5"><span class="cite-bracket">[</span>5<span class="cite-bracket">]</span></a></sup> It has been suggested that the reduced neural drive during exercise may be a protective mechanism to prevent organ failure if the work was continued at the same intensity.<sup id="cite_ref-6" class="reference"><a href="#cite_note-6"><span class="cite-bracket">[</span>6<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-7" class="reference"><a href="#cite_note-7"><span class="cite-bracket">[</span>7<span class="cite-bracket">]</span></a></sup> There has been a great deal of interest in the role of <a href="Serotonin" title="Serotonin">serotonergic</a> pathways for several years because its concentration in the brain increases with motor activity.<sup id="cite_ref-8" class="reference"><a href="#cite_note-8"><span class="cite-bracket">[</span>8<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-9" class="reference"><a href="#cite_note-9"><span class="cite-bracket">[</span>9<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-10" class="reference"><a href="#cite_note-10"><span class="cite-bracket">[</span>10<span class="cite-bracket">]</span></a></sup> During motor activity, serotonin released in synapses that contact <a href="Motor_neuron" title="Motor neuron">motoneurons</a> promotes muscle contraction.<sup id="cite_ref-11" class="reference"><a href="#cite_note-11"><span class="cite-bracket">[</span>11<span class="cite-bracket">]</span></a></sup> During high level of motor activity, the amount of <a href="Serotonin" title="Serotonin">serotonin</a> released increases and a spillover occurs. Serotonin binds to extrasynaptic receptors located on the <a href="Axon" title="Axon">axon</a> initial segment of <a href="Motor_neuron" title="Motor neuron">motoneurons</a> with the result that nerve impulse initiation and thereby muscle contraction are inhibited.<sup id="cite_ref-12" class="reference"><a href="#cite_note-12"><span class="cite-bracket">[</span>12<span class="cite-bracket">]</span></a></sup>

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<div class="mw-heading mw-heading3"><h3 id="Peripheral_muscle_fatigue">Peripheral muscle fatigue</h3></div>

<p>Peripheral muscle fatigue during physical work is an inability for the body to supply sufficient energy or other metabolites to the contracting muscles to meet the increased energy demand. This is the most common case of physical fatigue—affecting a national average of 72% of adults in the work force in 2002. This causes contractile dysfunction that manifests in the eventual reduction or lack of ability of a single muscle or local group of muscles to do work. The insufficiency of energy, i.e. sub-optimal <a href="Cellular_respiration" title="Cellular respiration">aerobic metabolism</a>, generally results in the accumulation of <a href="Lactic_acid" title="Lactic acid">lactic acid</a> and other <a href="Acid" title="Acid">acidic</a> anaerobic metabolic by-products in the muscle, causing the stereotypical burning sensation of local muscle fatigue, though recent studies have indicated otherwise, actually finding that lactic acid is a source of energy.<sup id="cite_ref-robergs_13-0" class="reference"><a href="#cite_note-robergs-13"><span class="cite-bracket">[</span>13<span class="cite-bracket">]</span></a></sup>

</p><p>The fundamental difference between the peripheral and central theories of muscle fatigue is that the peripheral model of muscle fatigue assumes failure at one or more sites in the chain that initiates muscle contraction. Peripheral regulation therefore depends on the localized metabolic chemical conditions of the local muscle affected, whereas the central model of muscle fatigue is an integrated mechanism that works to preserve the integrity of the system by initiating muscle fatigue through muscle derecruitment, based on collective feedback from the periphery, before cellular or organ failure occurs. Therefore, the feedback that is read by this central regulator could include chemical and mechanical as well as cognitive cues. The significance of each of these factors will depend on the nature of the fatigue-inducing work that is being performed.

</p><p>Though not universally used, "metabolic fatigue" is a common alternative term for peripheral muscle weakness, because of the reduction in contractile force due to the direct or indirect effects of the reduction of substrates or accumulation of metabolites within the <a href="Muscle_fiber" class="mw-redirect" title="Muscle fiber">muscle fiber</a>. This can occur through a simple lack of energy to fuel contraction, or through interference with the ability of Ca<sup>2+</sup> to stimulate <a href="Actin" title="Actin">actin</a> and <a href="Myosin" title="Myosin">myosin</a> to contract.

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<div class="mw-heading mw-heading3"><h3 id="Lactic_acid_hypothesis">Lactic acid hypothesis</h3></div>

<p>It was once believed that <a href="Lactic_acid" title="Lactic acid">lactic acid</a> build-up was the cause of muscle fatigue.<sup id="cite_ref-14" class="reference"><a href="#cite_note-14"><span class="cite-bracket">[</span>14<span class="cite-bracket">]</span></a></sup> The assumption was lactic acid had a "pickling" effect on muscles, inhibiting their ability to contract. The impact of lactic acid on performance is now uncertain, it may assist or hinder muscle fatigue.

</p><p>Produced as a by-product of <a href="Lactic_acid_fermentation" title="Lactic acid fermentation">fermentation</a>, lactic acid can increase intracellular acidity of muscles. This can lower the sensitivity of contractile apparatus to <a href="Calcium" title="Calcium">calcium ions</a> (Ca<sup>2+</sup>) but also has the effect of increasing <a href="Cytoplasm" title="Cytoplasm">cytoplasmic</a> Ca<sup>2+</sup> concentration through an inhibition of the <a href="Sodium-calcium_exchanger" title="Sodium-calcium exchanger">chemical pump</a> that <a href="Active_transport" title="Active transport">actively transports</a> calcium out of the cell. This counters inhibiting effects of <a href="Potassium" title="Potassium">potassium ions</a> (K<sup>+</sup>) on muscular action potentials. Lactic acid also has a negating effect on the chloride ions in the muscles, reducing their inhibition of contraction and leaving K<sup>+</sup> as the only restricting influence on muscle contractions, though the effects of potassium are much less than if there were no lactic acid to remove the chloride ions. Ultimately, it is uncertain whether lactic acid reduces fatigue through increased intracellular calcium or increases fatigue through reduced sensitivity of contractile proteins to Ca<sup>2+</sup>.

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<div class="mw-heading mw-heading2"><h2 id="Pathophysiology">Pathophysiology</h2></div>

<div role="note" class="hatnote navigation-not-searchable">Main article: <a href="Muscle_contraction" title="Muscle contraction">muscle contraction</a></div>

<p>Muscle cells work by detecting a <a href="Action_potential" title="Action potential">flow</a> of electrical impulses from the <a href="Brain" title="Brain">brain</a> which signals them to <a href="Muscle_contraction" title="Muscle contraction">contract</a> through the release of <a href="Calcium" title="Calcium">calcium</a> by the <a href="Sarcoplasmic_reticulum" title="Sarcoplasmic reticulum">sarcoplasmic reticulum</a>. Fatigue (reduced ability to generate force) may occur due to the nerve, or within the muscle cells themselves. New research from scientists at Columbia University suggests that muscle fatigue is caused by calcium leaking out of the muscle cell. This causes there to be less calcium available for the muscle cell. In addition an enzyme is proposed to be activated by this released calcium which eats away at muscle fibers.<sup id="cite_ref-15" class="reference"><a href="#cite_note-15"><span class="cite-bracket">[</span>15<span class="cite-bracket">]</span></a></sup>

</p><p><a href="Substrate_(biochemistry)" class="mw-redirect" title="Substrate (biochemistry)">Substrates</a> within the muscle generally serve to power muscular contractions. They include molecules such as <a href="Adenosine_triphosphate" title="Adenosine triphosphate">adenosine triphosphate</a> (ATP), <a href="Glycogen" title="Glycogen">glycogen</a> and <a href="Phosphocreatine" title="Phosphocreatine">creatine phosphate</a>. ATP binds to the <a href="Myosin" title="Myosin">myosin</a> head and causes the ‘ratchetting’ that results in contraction according to the <a href="Sliding_filament_mechanism" class="mw-redirect" title="Sliding filament mechanism">sliding filament model</a>. Creatine phosphate stores energy so ATP can be rapidly regenerated within the muscle cells from <a href="Adenosine_diphosphate" title="Adenosine diphosphate">adenosine diphosphate</a> (ADP) and inorganic phosphate ions, allowing for sustained powerful contractions that last between 5–7 seconds. Glycogen is the intramuscular storage form of <a href="Glucose" title="Glucose">glucose</a>, used to generate energy quickly once intramuscular creatine stores are exhausted, producing <a href="Lactic_acid" title="Lactic acid">lactic acid</a> as a metabolic byproduct. Contrary to common belief, lactic acid accumulation does not actually cause the burning sensation we feel when we exhaust our oxygen and oxidative metabolism, but in actuality, lactic acid in presence of oxygen recycles to produce pyruvate in the liver which is known as the Cori cycle.

</p><p>Substrates produce metabolic fatigue by being depleted during exercise, resulting in a lack of intracellular energy sources to fuel contractions. In essence, the muscle stops contracting because it lacks the energy to do so.

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<div class="mw-heading mw-heading2"><h2 id="Diagnosis">Diagnosis</h2></div>

<div class="mw-heading mw-heading3"><h3 id="Grading">Grading</h3></div>

<p>The severity of muscle weakness can be classified into different "grades" based on the following criteria:<sup id="cite_ref-Ouellette2008_16-0" class="reference"><a href="#cite_note-Ouellette2008-16"><span class="cite-bracket">[</span>16<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-Rathe2000_17-0" class="reference"><a href="#cite_note-Rathe2000-17"><span class="cite-bracket">[</span>17<span class="cite-bracket">]</span></a></sup>

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<ul><li><b>Grade 0</b>: No contraction or muscle movement.</li>

<li><b>Grade 1</b>: Trace of contraction, but no movement at the joint.</li>

<li><b>Grade 2</b>: Movement at the joint with gravity eliminated.</li>

<li><b>Grade 3</b>: Movement against gravity, but not against added resistance.</li>

<li><b>Grade 4</b>: Movement against external resistance with less strength than usual.</li>

<li><b>Grade 5</b>: Normal strength.</li></ul>

<div class="mw-heading mw-heading3"><h3 id="Classification">Classification</h3></div>

<div class="mw-heading mw-heading4"><h4 id="Proximal_and_distal">Proximal and distal</h4></div>

<p>

Muscle weakness can also be classified as either "<a href="Anatomical_terms_of_location#Proximal_and_distal" title="Anatomical terms of location">proximal</a>" or "<a href="Anatomical_terms_of_location#Proximal_and_distal" title="Anatomical terms of location">distal</a>" based on the location of the muscles that it affects. Proximal muscle weakness affects muscles closest to the body's midline, while distal muscle weakness affects muscles further out on the <a href="Limb_(anatomy)" title="Limb (anatomy)">limbs</a>. Proximal muscle weakness can be seen in <a href="Cushing's_syndrome" title="Cushing's syndrome">Cushing's syndrome</a><sup id="cite_ref-White01_18-0" class="reference"><a href="#cite_note-White01-18"><span class="cite-bracket">[</span>18<span class="cite-bracket">]</span></a></sup> and <a href="Hyperthyroidism" title="Hyperthyroidism">hyperthyroidism</a>.

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<div class="mw-heading mw-heading4"><h4 id="True_and_perceived">True and perceived</h4></div>

<p>Muscle weakness can be classified as either "true" or "perceived" based on its cause.<sup id="cite_ref-Rosen10_19-0" class="reference"><a href="#cite_note-Rosen10-19"><span class="cite-bracket">[</span>19<span class="cite-bracket">]</span></a></sup>

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<ul><li>True muscle weakness (or neuromuscular weakness) describes a condition where the force exerted by the muscles is less than would be expected, for example <a href="Muscular_dystrophy" title="Muscular dystrophy">muscular dystrophy</a>.</li>

<li>Perceived muscle weakness (or non-neuromuscular weakness) describes a condition where a person feels more effort than normal is required to exert a given amount of force but actual muscle strength is normal, for example <a href="Myalgic_encephalomyelitis/chronic_fatigue_syndrome" title="Myalgic encephalomyelitis/chronic fatigue syndrome">myalgic encephalomyelitis/chronic fatigue syndrome</a>.<sup id="cite_ref-20" class="reference"><a href="#cite_note-20"><span class="cite-bracket">[</span>20<span class="cite-bracket">]</span></a></sup></li></ul>

<p>In some conditions, such as <a href="Myasthenia_gravis" title="Myasthenia gravis">myasthenia gravis</a>, muscle strength is normal when resting, but <i>true</i> weakness occurs after the muscle has been subjected to exercise. This is also true for some cases of chronic fatigue syndrome, where objective post-exertion muscle weakness with delayed recovery time has been measured and is a feature of some of the published definitions.<sup id="cite_ref-21" class="reference"><a href="#cite_note-21"><span class="cite-bracket">[</span>21<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-22" class="reference"><a href="#cite_note-22"><span class="cite-bracket">[</span>22<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-23" class="reference"><a href="#cite_note-23"><span class="cite-bracket">[</span>23<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-24" class="reference"><a href="#cite_note-24"><span class="cite-bracket">[</span>24<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-25" class="reference"><a href="#cite_note-25"><span class="cite-bracket">[</span>25<span class="cite-bracket">]</span></a></sup><sup id="cite_ref-26" class="reference"><a href="#cite_note-26"><span class="cite-bracket">[</span>26<span class="cite-bracket">]</span></a></sup>

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<div class="mw-heading mw-heading2"><h2 id="References">References</h2></div>

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</style><cite id="CITEREFBoyasGuével2011" class="citation journal cs1">Boyas, S.; Guével, A. (March 2011). "Neuromuscular fatigue in healthy muscle: Underlying factors and adaptation mechanisms". <i>Annals of Physical and Rehabilitation Medicine</i>. <b>54</b> (2): <span class="nowrap">88–</span>108. <a href="Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a rel="nofollow" class="external text" href="https://doi.org/10.1016%2Fj.rehab.2011.01.001">10.1016/j.rehab.2011.01.001</a>. <a href="PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a rel="nofollow" class="external text" href="https://pubmed.ncbi.nlm.nih.gov/21376692">21376692</a>.</cite></span>

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<li id="cite_note-Ouellette2008-16"><span class="mw-cite-backlink"><b><a href="#cite_ref-Ouellette2008_16-0">^</a></b></span> <span class="reference-text">Page 59 in: <cite id="CITEREFHugue_Ouellette2008" class="citation book cs1">Hugue Ouellette (2008). <i>Orthopedics Made Ridiculously Simple (Medmaster Ridiculously Simple) (Medmaster Ridiculously Simple)</i>. MedMaster Inc. <a href="ISBN_(identifier)" class="mw-redirect" title="ISBN (identifier)">ISBN</a> <bdi>978-0-940780-86-6</bdi>.</cite></span>

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<li id="cite_note-Rathe2000-17"><span class="mw-cite-backlink"><b><a href="#cite_ref-Rathe2000_17-0">^</a></b></span> <span class="reference-text"><a rel="nofollow" class="external text" href="http://medinfo.ufl.edu/year1/bcs/clist/neuro.html#AA21">Neurologic Examination</a> <a rel="nofollow" class="external text" href="https://web.archive.org/web/20090511171055/http://medinfo.ufl.edu/year1/bcs/clist/neuro.html#AA21">Archived</a> 2009-05-11 at the <a href="Wayback_Machine" title="Wayback Machine">Wayback Machine</a> at First Year Medical Curriculum at University of Florida College of Medicine. By Richard Rathe. Created: January 15, 1996. Modified: December 19, 2000</span>

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<li id="cite_note-White01-18"><span class="mw-cite-backlink"><b><a href="#cite_ref-White01_18-0">^</a></b></span> <span class="reference-text"><cite id="CITEREFWhite2019" class="citation book cs1">White, Bruce A (2019). <i>Endocrine and Reproductive Physiology</i> (5th ed.). Mosby/Elsevier. p. 166. <a href="ISBN_(identifier)" class="mw-redirect" title="ISBN (identifier)">ISBN</a> <bdi>978-0-323-59573-5</bdi>.</cite></span>

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<li id="cite_note-Rosen10-19"><span class="mw-cite-backlink"><b><a href="#cite_ref-Rosen10_19-0">^</a></b></span> <span class="reference-text"><cite id="CITEREFMarx2010" class="citation book cs1">Marx, John (2010). <i>Rosen's Emergency Medicine: Concepts and Clinical Practice</i> (7th ed.). Philadelphia, PA: Mosby/Elsevier. p. Chapter 11. <a href="ISBN_(identifier)" class="mw-redirect" title="ISBN (identifier)">ISBN</a> <bdi>978-0-323-05472-0</bdi>.</cite></span>

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<li id="cite_note-20"><span class="mw-cite-backlink"><b><a href="#cite_ref-20">^</a></b></span> <span class="reference-text"><cite id="CITEREFEnokaStuart1992" class="citation journal cs1">Enoka RM, Stuart DG (1992). "Neurobiology of muscle fatigue". <i>J. Appl. Physiol</i>. <b>72</b> (5): <span class="nowrap">1631–</span>48. <a href="Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a rel="nofollow" class="external text" href="https://doi.org/10.1152%2Fjappl.1992.72.5.1631">10.1152/jappl.1992.72.5.1631</a>. <a href="PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a rel="nofollow" class="external text" href="https://pubmed.ncbi.nlm.nih.gov/1601767">1601767</a>. <a href="S2CID_(identifier)" class="mw-redirect" title="S2CID (identifier)">S2CID</a> <a rel="nofollow" class="external text" href="https://api.semanticscholar.org/CorpusID:1572573">1572573</a>.</cite></span>

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<li id="cite_note-21"><span class="mw-cite-backlink"><b><a href="#cite_ref-21">^</a></b></span> <span class="reference-text"><cite id="CITEREFPaulWoodBehanMaclaren1999" class="citation journal cs1">Paul L, Wood L, Behan WM, Maclaren WM (January 1999). "Demonstration of delayed recovery from fatiguing exercise in chronic fatigue syndrome". <i>Eur. J. Neurol</i>. <b>6</b> (1): <span class="nowrap">63–</span>9. <a href="Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a rel="nofollow" class="external text" href="https://doi.org/10.1046%2Fj.1468-1331.1999.610063.x">10.1046/j.1468-1331.1999.610063.x</a>. <a href="PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a rel="nofollow" class="external text" href="https://pubmed.ncbi.nlm.nih.gov/10209352">10209352</a>. <a href="S2CID_(identifier)" class="mw-redirect" title="S2CID (identifier)">S2CID</a> <a rel="nofollow" class="external text" href="https://api.semanticscholar.org/CorpusID:33480143">33480143</a>.</cite></span>

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<li id="cite_note-22"><span class="mw-cite-backlink"><b><a href="#cite_ref-22">^</a></b></span> <span class="reference-text"><cite id="CITEREFMcCullyNatelson1999" class="citation journal cs1">McCully KK, Natelson BH (November 1999). "Impaired oxygen delivery to muscle in chronic fatigue syndrome". <i>Clin. Sci</i>. <b>97</b> (5): <span class="nowrap">603–</span>8, discussion 611–3. <a href="CiteSeerX_(identifier)" class="mw-redirect" title="CiteSeerX (identifier)">CiteSeerX</a> <span class="id-lock-free" title="Freely accessible"><a rel="nofollow" class="external text" href="https://citeseerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.585.905">10.1.1.585.905</a></span>. <a href="Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a rel="nofollow" class="external text" href="https://doi.org/10.1042%2FCS19980372">10.1042/CS19980372</a>. <a href="PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a rel="nofollow" class="external text" href="https://pubmed.ncbi.nlm.nih.gov/10545311">10545311</a>.</cite></span>

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<li id="cite_note-23"><span class="mw-cite-backlink"><b><a href="#cite_ref-23">^</a></b></span> <span class="reference-text"><cite id="CITEREFDe_BeckerRoeykensReyndersMcGregor2000" class="citation journal cs1">De Becker P, Roeykens J, Reynders M, McGregor N, De Meirleir K (November 2000). <span class="id-lock-subscription" title="Paid subscription required"><a rel="nofollow" class="external text" href="http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=11088089">"Exercise capacity in chronic fatigue syndrome"</a></span>. <i>Arch. Intern. Med</i>. <b>160</b> (21): <span class="nowrap">3270–</span>7. <a href="Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a rel="nofollow" class="external text" href="https://doi.org/10.1001%2Farchinte.160.21.3270">10.1001/archinte.160.21.3270</a>. <a href="PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a rel="nofollow" class="external text" href="https://pubmed.ncbi.nlm.nih.gov/11088089">11088089</a>.</cite></span>

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<li id="cite_note-24"><span class="mw-cite-backlink"><b><a href="#cite_ref-24">^</a></b></span> <span class="reference-text"><cite id="CITEREFDe_BeckerMcGregorDe_Meirleir2001" class="citation journal cs1">De Becker P, McGregor N, De Meirleir K (September 2001). <a rel="nofollow" class="external text" href="https://doi.org/10.1046%2Fj.1365-2796.2001.00890.x">"A definition-based analysis of symptoms in a large cohort of patients with chronic fatigue syndrome"</a>. <i>J. Intern. Med</i>. <b>250</b> (3): <span class="nowrap">234–</span>40. <a href="Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<span class="id-lock-free" title="Freely accessible"><a rel="nofollow" class="external text" href="https://doi.org/10.1046%2Fj.1365-2796.2001.00890.x">10.1046/j.1365-2796.2001.00890.x</a></span>. <a href="PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a rel="nofollow" class="external text" href="https://pubmed.ncbi.nlm.nih.gov/11555128">11555128</a>.</cite></span>

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<li id="cite_note-25"><span class="mw-cite-backlink"><b><a href="#cite_ref-25">^</a></b></span> <span class="reference-text"><cite id="CITEREFCarruthersJainDe_MeirleirPeterson2003" class="citation book cs1">Carruthers, Bruce M.; Jain, Anil Kumar; De Meirleir, Kenny L.; Peterson, Daniel L.; Klimas, Nancy G.; et al. (2003). <i>Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols</i>. Vol. 11. pp. <span class="nowrap">7–</span>115. <a href="Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<a rel="nofollow" class="external text" href="https://doi.org/10.1300%2FJ092v11n01_02">10.1300/J092v11n01_02</a>. <a href="ISBN_(identifier)" class="mw-redirect" title="ISBN (identifier)">ISBN</a> <bdi>978-0-7890-2207-3</bdi>. <a href="ISSN_(identifier)" class="mw-redirect" title="ISSN (identifier)">ISSN</a> <a rel="nofollow" class="external text" href="https://search.worldcat.org/issn/1057-3321">1057-3321</a>.</cite> <span class="cs1-visible-error citation-comment"><code class="cs1-code">{{cite book}}</code>: </span><span class="cs1-visible-error citation-comment"><code class="cs1-code">|journal=</code> ignored (help)</span></span>

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<li id="cite_note-26"><span class="mw-cite-backlink"><b><a href="#cite_ref-26">^</a></b></span> <span class="reference-text"><cite id="CITEREFJammesSteinbergMambriniBrégeon2005" class="citation journal cs1">Jammes Y, Steinberg JG, Mambrini O, Brégeon F, Delliaux S (March 2005). <a rel="nofollow" class="external text" href="https://doi.org/10.1111%2Fj.1365-2796.2005.01452.x">"Chronic fatigue syndrome: assessment of increased oxidative stress and altered muscle excitability in response to incremental exercise"</a>. <i>J. Intern. Med</i>. <b>257</b> (3): <span class="nowrap">299–</span>310. <a href="Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<span class="id-lock-free" title="Freely accessible"><a rel="nofollow" class="external text" href="https://doi.org/10.1111%2Fj.1365-2796.2005.01452.x">10.1111/j.1365-2796.2005.01452.x</a></span>. <a href="PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a rel="nofollow" class="external text" href="https://pubmed.ncbi.nlm.nih.gov/15715687">15715687</a>.</cite></span>

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</ol></div></div>

<div class="mw-heading mw-heading2"><h2 id="Further_reading">Further reading</h2></div>

<ul><li><cite id="CITEREFSaguil_A2005" class="citation journal cs1">Saguil A (April 2005). <a rel="nofollow" class="external text" href="http://www.aafp.org/afp/2005/0401/p1327.html">"Evaluation of the patient with muscle weakness"</a>. <i>Am Fam Physician</i>. <b>71</b> (7): <span class="nowrap">1327–</span>36. <a href="PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a> <a rel="nofollow" class="external text" href="https://pubmed.ncbi.nlm.nih.gov/15832536">15832536</a>.</cite></li></ul>

<div class="mw-heading mw-heading2"><h2 id="External_links">External links</h2></div>

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<div class="side-box-text plainlist">Look up <i><b><a href="https://en.wiktionary.org/wiki/Special:Search/muscle_weakness" class="extiw external" title="wiktionary:Special:Search/muscle weakness">muscle weakness</a></b></i> in Wiktionary, the free dictionary.</div></div>

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</style><div id="Symptoms_and_conditions_relating_to_muscle133" style="font-size:114%;margin:0 4em">Symptoms and <a href="Myopathy" title="Myopathy">conditions</a> relating to <a href="Muscle" title="Muscle">muscle</a></div></th></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="Pain" title="Pain">Pain</a></th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em">

<ul><li><a href="Myalgia" title="Myalgia">Myalgia</a>

<ul><li><a href="Fibromyalgia" title="Fibromyalgia">Fibromyalgia</a></li>

<li><a href="Acute_muscle_soreness" title="Acute muscle soreness">Acute</a></li>

<li><a href="Delayed_onset_muscle_soreness" title="Delayed onset muscle soreness">Delayed onset</a></li></ul></li></ul>

</div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%"><a href="Inflammation" title="Inflammation">Inflammation</a></th><td class="navbox-list-with-group navbox-list navbox-even hlist" style="width:100%;padding:0"><div style="padding:0 0.25em">

<ul><li><a href="Myositis" title="Myositis">Myositis</a>

<ul><li><a href="Pyomyositis" title="Pyomyositis">Pyomyositis</a></li></ul></li>

<li><a href="Edema" title="Edema">Myoedema</a> (<a href="Hypothyroidism" title="Hypothyroidism">Hypothyroid myopathy</a>)</li></ul>

</div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Destruction</th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em">

<ul>

<li><a href="Rhabdomyolysis" title="Rhabdomyolysis">Rhabdomyolysis</a></li>

<li><a href="Muscle_atrophy" title="Muscle atrophy">Muscle atrophy</a>/<a href="Amyotrophy" title="Amyotrophy">Amyotrophy</a></li></ul>

</div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Low ATP reservoir</th><td class="navbox-list-with-group navbox-list navbox-even hlist" style="width:100%;padding:0"><div style="padding:0 0.25em">

<ul><li><a href="Muscle_fatigue" title="Muscle fatigue">Muscle fatigue</a></li>

<li><a href="Exercise_intolerance" title="Exercise intolerance">Exercise intolerance</a></li>

<li>Myogenic hyperuricemia</li>

<li><a href="Symptoms" class="mw-redirect" title="Symptoms">Dynamic symptoms (exercise-induced)</a></li>

<li><a href="Sinus_tachycardia#Metabolic_myopathy" title="Sinus tachycardia"> Inappropriate rapid heart rate response to exercise (tachycardia)</a></li>

<li><a href="Cardiovascular_fitness" title="Cardiovascular fitness">Exaggerated cardiorespiratory response to exercise (tachycardia with tachypnea and/or hyperpnea (exercise hyperventilation))</a></li>

<li><a href="Hitting_the_wall" title="Hitting the wall">Hitting the wall</a></li>

<li><a href="Second_wind" title="Second wind">Second wind</a></li>

<li>(<a href="Metabolic_myopathy" title="Metabolic myopathy">Metabolic myopathies</a></li>

<li><a href="Diabetes" title="Diabetes">Diabetes</a></li>

<li><a href="Hypothyroidism" title="Hypothyroidism">Hypothyroid myopathy</a></li>

<li><a href="Hyperthyroidism" title="Hyperthyroidism">Hyperthyroid myopathy</a></li>

<li><a href="Hypoparathyroidism" title="Hypoparathyroidism">Hypoparathyroidism</a></li>

<li><a href="Hypokalemia" title="Hypokalemia">Hypokalemia</a></li>

<li><a href="Hypoxia_(medical)" class="mw-redirect" title="Hypoxia (medical)">Hypoxic muscle</a></li>

<li><a href="Pseudohypoxia" title="Pseudohypoxia">Pseudohypoxia</a></li>

<li><a href="Intermittent_claudication" title="Intermittent claudication">Intermittent claudication</a></li>

<li><a href="Scurvy" title="Scurvy">Scurvy</a></li>

<li><a href="Fasting" title="Fasting">Fasting</a> / <a href="Starvation" title="Starvation">Starvation</a></li>

<li><a href="Alcoholism" title="Alcoholism">Alcoholism</a>)</li></ul>

</div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Abnormal movement</th><td class="navbox-list-with-group navbox-list navbox-odd hlist" style="width:100%;padding:0"><div style="padding:0 0.25em">

<ul><li><a href="Cramp" title="Cramp">Muscle cramp</a></li>

<li><a href="Myokymia" title="Myokymia">Myokymia</a></li>

<li><a href="Spasm" title="Spasm">Muscle spasm</a></li>

<li><a href="Fasciculations" class="mw-redirect" title="Fasciculations">Fasciculations</a></li>

<li><a href="Muscle_contracture" title="Muscle contracture">Muscle contracture</a>

<ul><li><a href="Fibrosis" title="Fibrosis">Fibrosis</a></li>

<li><a href="Adhesion_(medicine)" title="Adhesion (medicine)">Adhesion</a></li></ul></li>

<li><a href="Myotonia" title="Myotonia">Myotonia</a>

<ul><li><a href="Channelopathy" title="Channelopathy">Muscle channelopathies</a></li></ul></li>

<li><a href="Myotonia" title="Myotonia">Pseudo-myotonia</a> (<a href="Brody_myopathy" title="Brody myopathy">Brody myopathy</a>)</li>

<li><a href="Spasticity" title="Spasticity">Spasticity</a></li>

<li>Rippling muscle disease</li>

<li><a href="Periodic_paralysis" title="Periodic paralysis">Periodic paralysis</a></li>

<li><a href="Hypotonia" title="Hypotonia">Hypotonia</a> / <a href="Hypertonia" title="Hypertonia">Hypertonia</a></li></ul>

</div></td></tr><tr><th scope="row" class="navbox-group" style="width:1%">Other</th><td class="navbox-list-with-group navbox-list navbox-even hlist" style="width:100%;padding:0"><div style="padding:0 0.25em">

<ul><li><a href="Myositis_ossificans" title="Myositis ossificans">Myositis ossificans</a>

<ul><li><a href="Fibrodysplasia_ossificans_progressiva" title="Fibrodysplasia ossificans progressiva">Fibrodysplasia ossificans progressiva</a></li></ul></li>

<li><a href="Compartment_syndrome" title="Compartment syndrome">Compartment syndrome</a>

<ul><li><a href="Anterior_compartment_syndrome_of_the_lower_leg" class="mw-redirect" title="Anterior compartment syndrome of the lower leg">Anterior</a></li></ul></li>

<li><a href="Diastasis_(pathology)" title="Diastasis (pathology)">Diastasis of muscle</a>

<ul><li><a href="Diastasis_recti" title="Diastasis recti">Diastasis recti</a></li></ul></li>

<li><a href="Pseudoathletic_appearance" title="Pseudoathletic appearance">Pseudoathletic appearance</a> (<a href="Hyperplasia" title="Hyperplasia">Muscle hyperplasia</a> / <a href="Muscle_hypertrophy" title="Muscle hypertrophy">Muscle hypertrophy</a> / <a href="Pseudohypertrophy" title="Pseudohypertrophy">Pseudohypertrophy</a>)</li></ul>

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