CASE REPORT A 28yearold male patient presented with progressive weakness of both forearms and hands along with clawing of hands for past eight years. Right side was affected more than the left. There was no history of similar illness in the family. There was no past history of any prolonged illness in childhood. There was no history of sensory, pyramidal or bladder dysfunction. There was evidence of atrophy of muscles of both forearms and hands. Muscle power was normal in both upper limbs. Nerve conduction studies showed reduced amplitude in bilateral median and ulnar nerves. Tendon reflexes were normal. Magnetic resonance imaging (MRI) examination was performed in nonflexion and flexed position. Subsequently, diffusion tensor imaging (DTI) was performed in nonflexion, which very clearly showed the cord atrophy at C7 – T1 level (Figure 1). This cord atrophy was not appreciated on routine flexion and nonflexion studies. The diagnosis of Hirayama Disease (HD) was thus established on DTI. CLINICAL IMAGES OPEN ACCESS