Abnormal gait

Published on 02/04/2015 by admin

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Last modified 22/04/2025

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61 Abnormal gait

Instruction

Look at this patient walking.

Test this patient’s gait.

Salient features

Examination

There are several types of abnormal gait. Keep in mind the phases and pathogenesis of gait (Fig. 61.1):

1 Heel strike: the lateral calcaneus makes contact with the ground and the muscles, tendons and ligaments relax, providing for optimal energy absorption.

2 Midstance: the foot is flat and is able to adapt to uneven terrain, maintain equilibrium and absorb the shock of touchdown; the calcaneus is just below the ankle, keeping the front and back of the foot aligned for optimal weight bearing.

3 Heel rise: the calcaneus lifts off the ground, the foot pronates, the muscles, tendons and ligaments tighten, and the foot regains its arch.

4 Toe push-off: the foot leaves the surface.

Fig. 61.1 The phases of the normal gait cycle.

Cerebellar gait

The patient has a broad-based gait, reeling and lurching to one side:

• Proceed by telling the examiner that you would like to examine the patient for other cerebellar signs (p. 201).

Parkinsonian gait

Steps are small and shuffling, and the patient walks in a haste (festinates). The entire body stoops forwards, knees bent, head hunched forward and the feet must hurry to keep up with it as if trying to catch up with the centre of gravity. There is associated loss of arm swing and mask-like facies:

• Proceed by telling the examiner that you would like to look for other signs of Parkinson’s disease (p. 191).

Hemiplegic gait

Gait is slow, spastic and shuffling. With each step the pelvis is tilted upward on the involved side to aid in lifting the foot off the ground, and the entire affected limb is circumducted, rotated in a semicircle at the pelvis. The upper limb is flexed, adducted and does not swing, and the lower limb is extended.

Sensory ataxia

The feet stamp, the movement of the legs bearing no relation to the position of the legs in space since proprioception is impaired or absent. The patient has to look down at the ground to compensate for the loss of proprioception. The patient walks on a wide base; the feet are lifted too high off the ground and are brought down too vigorously.

Proceed as follows:

• Check for Romberg’s sign vibration and position sense

• Sensory ataxic gait may be caused by tabes dorsalis, subacute combined degeneration of the cord

• Tell the examiner that you would like to look for Argyll Robertson pupils and anaemia.

High steppage gait

Usually unilateral and results from foot drop. The patient has to lift the foot high in order to avoid dragging the forefoot. It is seen in:

• Lateral popliteal nerve palsy

• Poliomyelitis

• Charcot–Marie–Tooth disease

• Lead or arsenic poisoning.

Scissor gait

Seen in spastic paraplegia. The adductor spasm may be so severe as to lead to the legs crossing in front of one another. Short steps with the front of the feet clinging to the ground result in a wearing out of the toes of shoes:

• Proceed to tell the examiner that the underlying aetiology would probably be cord compression, multiple sclerosis or cerebral palsy.

Waddling gait

The legs are held wide apart and the patient shifts weight from one side to the other when walking:

• Comment on the lumbar lordosis

• Waddling gait is seen in advanced pregnancy and proximal weakness (Cushing syndrome, osteomalacia, thyrotoxicosis, polymyositis, diabetes, hereditary muscular dystrophies).

Advanced-level questions

What do you understand by the term astasia abasia?

This is seen in psychogenic disturbances in which the patient is unable to walk or cannot stand. The patient falls far to the side on walking but usually regains balance before hitting the ground. The legs may be thrown out wildly or the patient may kneel with each step.

What do you understand by the term marche à petits pas?

This is to describe a gait in which the movement is slow and the patient walks with very short, shuffling and irregular steps with loss of associated movements. It is seen in normal-pressure hydrocephalus. This gait bears some resemblance to that seen in Parkinson’s disease.

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