Journal of
J Neuro[ (1988) 235:411-414
Complex repetitive discharges in the iliopsoas muscle
B.-U. Meyer l, R. Benecke t, B. Frank 2, and B. Conrad 2
1Neurologische Klinik der Universit~it D0ssetdorf, Moorenstrasse 5, D-4000 DUsseldorf l, Federal Republic of Germany
2Abteilung flit Klinische Neurophysiologie der Universit~t G6ttingen, D-3400 G6ttingen, Federal Republic of Germany
Summary. A prospective electromyographic investigation of
lower limb muscles in patients with different neurogenic disor-
ders showed that complex repetitive discharges (CRD) were
observed predominantly and often only in the iliopsoas mus-
cle. Analysis of the E M G findings in acute and chronic lesions
shows that CRD are a feature of a chronic proximal motor
axon lesion. Furthermore, the frequently focal occurrence of
CRD in the iliopsoas muscle in clinically distal diabetic poly-
ncuropathies suggests that this muscle and its nerves represent
a locus minoris resistentiae.
Key words: Electromyography - Spontaneous activity - Ilio-
psoas muscle - Diabetic polyneuropathies - Radiculopathies
Introduction
In contrast to positive sharp waves and fibrillation potentials,
complex repetitive discharges (also called bizarre high fre-
quency discharges or pseudomyotonic discharge trains) can
occasionally be observed in routine needle electromyography
(EMG). This type of spontaneous activity is usually charac-
terised by polyphasic action potentials repeating with a high
and uniform frequency of 10-150s -I. The discharge trains
generally start and stop abruptly and the shape and the ampli-
tude of the single components remain fairly constant [12].
Single-fibre E M G analyses suggest that the source of these po-
tentials is one pacemaker muscle fibre. Spontaneous impulses
of such a fibre apparently excite adjoining muscle fibres ephapti-
cally [15].
These discharge trains have been observed in different
myopathies and in longstanding lesions of motor axons [3, 5,
11]. It was the aim of the present study to investigate the diag-
nostic significance of complex repetitive discharges (CRD) in
a prospective systematic electromyographic study in patients
with various neurogenic disorders affecting the lower extremi-
ties.
The study demonstrated that in the routine electromyo-
graphic examination of patients with neuropathies CRD pre-
dominantly and often exclusively occurred in the iliopsoas
muscle especially in patients suffering fi'om diabetic poly-
neuropathy. The pathophysiological mechanisms which may
be responsible for this phenomenon will be discussed in the
Offprint requests to: R. Benecke
Neurology
© Springer-Verlag 1988
light of the specific anatomical condition of the iliopsoas mus-
cle.
Patients and methods
Proximal and distal leg muscles were investigated in 162 pa-
tients who were referred for routine electrophysiological ex-
amination of suspected lesions of lumbar nerve roots, lum-
bosacral plexus or peripheral nerves.
The neurophysiological examination included the determi-
nation of the maximal nerve conduction velocity in the
peroneal, tibial and sural nerves and E M G of distal muscles
(extensor digitorum brevis and interossei muscles of the foot,
anterior tibial, extensor hallucis longus and the gastrocnemius
muscle) and of proximal muscles (vastus medialis, rectus
femoris and gluteus medius muscle) and the iliopsoas muscle
(Table 1).
After the clinical and neurophysiological examination the
patients were assigned a diagnosis (see Table 1) without taking
into account the electromyographic findings in the iliopsoas
muscle.
A "control group" (Table 1) was set up to find out whether
CRD occur in neurologically unaffected persons. This group
was divided into two age groups (--< 60 years and > 60 years)
to exclude an age-dependent increase of such findings. Pa-
tients were only assigned to the control group when there
were clearly no clinical or neurophysiological signs of a
peripheral nerve lesion in the lower extremities.
Patients with neurological disorders such as isolated L4
radiculopathies, different types of polyneuropathies, traumat-
ic lesions of the lumbosacral plexus and plexus neuritis were
examined in order to find out whether CRD occur predomin-
antly in certain pathological states (Table 1). Patients with
suspected or manifest myopathies were excluded from this
study.
The electromyographic investigation was performed using
autoclaveable concentric needle electrodes (DISA, Dantec)
with a platinum surface area of 0.07mm z. The optic and
acoustic display of muscle activity was done by means of a
T6nnies D A II electromyograph bandpassing the signals 1-
104 s -1. As the criterion for the occurrence of CRD the above-
mentioned (see Introduction) definition of Simpson [12] was
used. For E M G of the iliopsoas muscle the needle electrode
was inserted 4 cm lateral to the femoral artery and 2 cm distal
412

Table 1. Electromyographic (EMG) findings in muscles of the lower extremity in 162 subjects with different lesions of motor axons. The EMG
findings are summarized for distal muscles (extensor digitorum brevis, first dorsal interosseus, anterior tibial muscle, extensor hallucis longus and
gastrocnemius muscles), for proximal muscles (the vastus medialis, rectus femoris and gluteus medius muscles) and for the iliopsoas muscle

Neurological n Age EMG

disorder (mean, SD) PSW and/or Fi (n) CRD (n)
Dist. Prox. Iliopsoas Dist. Prox. Iliopsoas

None (age ~ 60 yr) 44 48, SD 8 0 0 0 0 0 0

None (age > 60 yr) 17 66, SD 5 0 0 0 0 0 0
Radiculopathy:
L5 and/or SI i8 55, SD 12 12 6(G1) 0 1 1 (GI) 0
L3 and/or L4 19 57, SD 13 7 10 8 0 0 6
Polyneuropathies:
dist. symm. 38 60, SD 13 18 1 2 0 0 8
dist. symm. + prox. i9 73, SD 6 16 13 9 5 3 12
Polyneuroradiculitis 2 (54, 74) 2 2 2 0 0 1
Trauma:
femoral nerve 2 (9, 54) 0 l 2 0 0 1
lumbosacral plexus 3 (69, 59, 21) 2 1 3 0 0 1
PSW - positive sharp waves, Fi - fibrillation potentials, CRD = complex repetitive discharges, Gl = gluteus medius muscle, SD = standard de-
viation

the electromyographic activity was observed. In each patient

different portions of the relaxed iliopsoas muscle were investi-
gated by analysing at least ten different electrode positions.

Results

A total of 162 patients with and without distinct neurological

disorders was investigated. Table 1 summarizes the results of
the E M G and shows the frequency of the different types of
spontaneous activity in various neurological disorders.

Topical distribution of CRD among muscles

Fig. 1. Ventral aspect of the right thigh. For the EMG of the iliopsoas
muscle the needle electrode was inserted 4cm lateral to the femoral
artery and 2 cm distal to the inguinal ligament (0). Muscles: iliacus
(1), psoas major (2), psoas minor (3), sartorius (4), iliopsoas (5),
rectus femoris (6). Bony structures and ligaments: spina iliaca an-
terior superior (7), ligamentum inguinale (8), pecten ossis pubis (9),
tuberculum pubicum (10). Nerves and vessels: femoral nerve (11)
femoral artery and vein (12)
to the inguinal ligament (Fig. 1). To test for a correct elec-
trode position the patients were asked according to Delagi et
al. [2]) to flex the thigh with the knee flexed beyond 90 °, while
of the lower extremity
Figure 2 shows that C R D were observed in the iliopsoas mus-
cle in 83% of the patients (Table 1). C R D in the iliopsoas
muscle were found not only predominantly but often alone (in
71%), i.e. without a concomitant occurrence of C R D in other
muscles of the lower extremity. In 48% of the patients with
C R D in the iliopsoas muscle these discharges were found
bilaterally. When only patients with generalized neuropathies
were considered, 70% of the patients showed C R D in both
iliopsoas muscles.
To answer the question whether C R D occur in parallel
with other well-known types of E M G activity (fibrillation po-
tentials, Fi; positive sharp waves, PSW) the incidence of dif-
ferent types of spontaneous activity in the iliopsoas was com-
pared with that in the rectus femoris muscle, which is also
supplied by the femoral nerve and mostly by the same motor
roots (Fig. 3). First, in general, spontaneous activity was ob-
served with a significantly higher frequency in the iliopsoas
muscle than in the rectus femoris muscle of the same leg, and
secondly the relative and absolute incidence of C R D was
clearly higher in the iliopsoas muscle than in the rectus
femoris muscle.
 413

100- acute chronic

N ~\\\,
~\\\\
s 2 months > 5 months
55555 m

,\\\, \\\N
,\\\\ ,\\'~
.... ~\\\\
\\\\\

\\\\
50. ,\\\,
\\\\~
\\\\\
~-\-\\ .....

,\.\\>

~\\\\ ~\\\\
\\\\\
->.-.- - 2221~
x\\\\ ,'\\\'~
~\\\\ ,\\\\ \\\\\ \\\\\
))))) ~\\\\
?~???
<qqq ,".\\'~
\\\...\
x. .N. .\.' q x" \ '\"\ \
~\\\\ x\\\\
,\\\\~ Ix.?? ~<.~<<
\\\\\
)3))~
x\\\x
~tkmts total isolated ,\\\\
,\\\~
\\\\,
total
\\\\~ 0
patients SA CRD patients SA CRD only
total total CRD

Pig. 4. Incidence of spontaneous activity (SA) including CRD in the

Fig. 2. Distribution of complex repetitive discharges (CRD) in the
iliopsoas muscle and other muscles of the lower extremity in 35 pa-
tients. The figures within the columns indicate the number of patients
with CRD in the specified muscle group. Note that CRD predomin-
antly and often only occurred in the iliopsoas muscle
iliopsoas muscle in acute and chronic states of motor axon lesions
(such as IA radiculopathies, lesions of the femoral nerve and the lum-
bosacral plexus). The states were defined as "acute" when the onset
was 2 months or less and as "chronic" when the onset was 5 months or
longer before recording. Note that CRD were only observed in pa-
tients with chronic motor axon lesions

ili_~soas rectus femoris

1007
[~].
A B C D A B C D
Fig. 3. Incidence of different types of spontaneous activity in the
EMG of the iliopsoas and the rectus femoris muscles. The frequency
of different patterns of spontaneous activity (fibrillation potentials,
Fi; positive sharp waves, PSW; and complex repetitive discharges,
CRD) is shown for the iliopsoas muscle and the corresponding rectus
femoris muscle of the same leg. It can be seen that all types of sponta-
neous activity, but especially CRD, were observed with a significantly
higher frequency in the iliopsoas muscle. A = spontaneous activity; B
= FI and/or PSW; C = FI and/or PSW and CRD; D = only CRD
Occurrence o f CRD in relation to the duration
of the motor axon lesion
The comparison of the E M G findings of the iliopsoas muscles
in patients with acute and chronic axon lesions (Fig. 4) shows
that PSW and Fi were found in nearly all patients of both
groups, while C R D were exclusively observed in chronic
states.
Furthermore, it was found that 50% of the patients with
polyneuropathies and C R D in the iliopsoas muscle (n = 20,
Table 1) were diabetics with a mean duration of their disease
of 11 years (range: 3 - 2 3 years). This is another indication for
the assumption that C R D are a correlate of a chronic process.
CRD in subclinically affected proximal muscles
Table 1 shows that in two groups of subjects (age -< 60 and
> 60 years) without any signs of neurological disorder in the
clinical examination and the electroneurogram, neither C R D
nor other pathological spontaneous E M G activities were ob-
served in the iliopsoas muscle. This was also true in patients
with isolated radiculopathies of the L5 or $1 roots.
In the group of patients with polyneuropathies with a
strictly distal symmetrical distribution, spontaneous E M G ac-
tivity was unexpectedly found in proximal muscles in 24% of
these patients (Table 1). In the iliopsoas muscle spontaneous
E M G activity predominantly occurred as C R D , usually with-
out concomitant PSW and Fi. In theclinically affected distal
muscles examined, only Fi and PSW were observed.
Discussion
The results confirm that complex repetitive discharges C R D
occur with an above-average frequency in the iliopsoas muscle.
The finding that C R D can be observed only in the iliopsoas
muscle (especially in longstanding lesions) and not in other
proximal muscles of patients with polyneuropathies of a
strictly distal symmetrical type (i.e. without any clinical or
electrophysiological indications of a concomitant proximal le-
sion) supports the idea that this type of discharge can be an ex-
pression of a clinically silent irritative process in this muscle
[6].
The question arises as to what are the specific features of
this muscle and its nerve, which induce the frequent occur-
rence of C R D . There are anatomical peculiarities distinguish-
ing the iliopsoas muscle from the other investigated proximal
muscles of the lower extremity. At the site of the recording
distal to the inguinal ligament (compare Fig. 1) the iliopsoas
muscle is the c o m p o u n d of two mainly intrapelvic muscles, the
414
psoas major and the iliacus. Both muscles are supplied by the
lumbar plexus and the femoral nerve and leave the pelvis
through the lacuna musculorum together with the femoral
nerve. The iliopsoas muscle passes anterior to the axis of the
hip joint and is inserted into the trochanter minor of the
femur. The muscle is mainly a strong hip flexor with a high
torque and - depending on the position of the femur - a
rotator and abductor [8].
A m o n g possible anatomical factors leading to impairment
of the neuromuscular integrity in the iliopsoas muscle, the cru-
cial feature seems to be that the muscle uses the os pubis and
the caput femoris as a fulcrum (with the interposed bursae
iliopsoas et iliopectinea), especially in the initial phase of hip
flexion as during walking when the free leg is m o v e d forward.
Simultaneously the itiopsoas muscle is stretched over the os
pubis in the extended hip on the other side. E v e n during re-
laxed standing E M G analyses showed some slight activity in
the iliopsoas muscle [9]. In the muscle/bone contact area the
surface of the os pubis is smooth and excavated slightly be-
tween the eminentia iliopubica and the tuberculum pubicum
in the upright walking hominids as a probable morphological
correlate of the mechanical forces occurring during the
stretching and gliding of the muscle. In contrast, the os pubis
is not smooth in pongids, which are only able to sustain up-
right walking for a short period and with hip and knees flexed
due to an insufficient length and stretchiness of the iliopsoas
and the knee flexors. The iliopsoas muscle was especially in-
volved in a stretching process in the evolution of upright walk-
ing [4, 7].
Since it has been shown that total denervation and block-
ing of neuromuscular transmission by curare during anaes-
thesia did not alter C R D [11, 15], a myogenic origin of this
discharges is possible. O n the other hand, C R D are considered
to be a non-specific finding seen in both neural disorders and
myopathies without any significant differences in their fea-
tures [11, 15]. A l t h o u g h it may be suggested that C R D are of
myogenic origin, neural lesions can be the cause of this type of
spontaneous muscle activity. It may well be that (on the basis
of the specific anatomical topographical situation) a chronic
mechanical irritation of the structures in the lacuna mus-
culorum (i.e. of the iliopsoas muscle and intramuscular nerve
twigs) takes place, which in normal subjects is not accom-
panied by any electromyographically detectable abnormality.
If there is, however, a concomitant neuropathy, a premature
occurrence of neuromuscular abnormality is induced. Beyond
the mechanical compression of nerve twigs there may be dam-
age of the nutrient vessels by stretching while lifting weights,
as has been suggested in some cases of femoral neuropathies
[ 1]. F u r t h e r m o r e , in cases with C R D in the iliopsoas in diabet-
ic polyneuropathies, there may also be microinfarcts in the
nerves due to alterations of the blood-nerve barrier and lumi-
nal encroachment of small arteries and vasa nervorum, which
have been observed in the femoral nerve [13], the obturator
nerve [10] and the proximal sciatic nerve [14].
The results of the present E M G study suggest that C R D in
the iliopsoas muscle are of diagnostic significance and that
they are a correlate of a chronic, often subclinical, proximal
neuromuscular disorder. Their assessment may be helpful for
the decision whether a proximal neurogenic process, espe-
cially in L4 radiculopathies, is acute or longstanding. Further-
more, the observation of C R D in the iliopsoas muscle may be
an indication of subclinical involvement of proximal m o t o r
axons even in mild clinically distal polyneuropathies.
References
1. Calverley JR, Mulder DW (1960) Femoral neuropathy. Neurol-
ogy 10 : 963-967
2. Delagi EF, Perotto A, Jazetti J, Morrison D (1975) Anatomic
guide for the electromyographer. Thomas, Springfield
3. Emeryk B, Hausmanowa-Petrusewicz I, Novak T (1974) Sponta-
neous volleys of bizarre high frequency potentials (b.h.f.p.) in
neuro-muscular diseases. I. Occurrence of spontaneous volleys of
b.h.f.p, in neuro-muscular diseases. Electroencephalogr Clin
Neurophysiol 14:303-312
4. Franzen J (1972) Wie kam cs zum aufrechten Gang des Men-
schen? Natur Museum 102 : 5
5. Hausmanowa-Petrusewicz I, Emeryk B, Wasowicz B, Kopec A
(1967) Electromyography in neuro-muscular diagnosis. Electro-
myography 7 : 203-225
6. Kimura J (1983) Electrodiagnosis in diseases of nerve and muscle:
principles and practice. Davis, Philadelphia, pp 274-277
7. Kummer B (1965) Das mechanische Problem der Aufrichtung auf
die Hinterextremit~iten im Hinblick auf die Evolution der Bipedie
des Menschen. In: Heberer G (ed) Menschliche Abstammungs-
lehre. Fischer, Stuttgart, pp 227-248
8. Lanz TV, Wachsmuth H, Lang J (1972) Praktische Anatomie:
Bein und Statik, 2rid edn, vol I. Springer, Berlin Heidelberg New
York
9. MacConaill MA, Basmajian JV (1977) Muscles and movements -
a basis for human kinesiology. Krieger, Huntington
10. Raft MC, Sangalang V, Asbury AK (1968) lschemic mononeuro-
pathy multiplex associated with diabetes mellitus. Arch Neurol
18 : 487-499
11. Ricker K, Meinck H-M (1972) Discharge pattern and origin of
"pseudomyotonic" (high frequency) discharge trains in denerva-
tion syndromes. EEG-EMG 3 : 170 178
12. Simpson JA (1969) Terminology of electromyography. Electro-
encephalogr Clin Neurophysiol 26:224-226
13. Skanse B, Gydell K (1956) A rare type of femoral-sciatic neuro-
pathy in diabetes mellitus. Acta Med Scand 155 : 463-468
14. Sugimura K, Dyck PF (1982) Multifocal fibre loss in proximal sci-
atic nerve in symmetric distal diabetic neuropathy. J Neurol Sci
53 : 501-509
15. Trontelj J, Stalberg E (1983) Bizarre repetitive discharges re-
corded with single fibre EMG. J Neurol Neurosurg Psychiatry
46 : 310-316
Received February 28, 1988 / Accepted May 20, 1988