Patient with abnormal gait? How to treat: Dr Amdekar
M3 India Newsdesk Jan 24, 2022
With the power of observation, doctors can identify the prevalence of gait with the help of clues from a patient's position while sitting, standing or going up and down. In this article, Dr YK Amdekar discusses cases that can help in localising the probable site and cause of the disease causing problems in gait.
Gait is rhythmical, alternating movements of the trunk and limbs that result in the forward progression of the centre of gravity, and hence the forward movement of the body. As the patient walks into a doctor's office, one can observe the gait - the way he/she walks. It often offers a clue to a probable diagnosis. Even in normal people, gait can be a measure of general physical fitness and level of confidence.
Gait cycle
Stance is the phase when the foot is on the ground. It accounts for 60% of one cycle. Swing is the phase when the foot is off the ground to begin forward movement and it accounts for the remaining 40% of the cycle. Normally the heel of the foot touches the ground first and then the toes.
The length of the step in an adult is about 30 inches (two and a half feet) but that depends on height and age (child will have proportionate short step length) as well as physical fitness. There exists reciprocal swing of arms while walking, the left arm comes forward along with the right foot.
Observe the gait
It is useful to observe the child while standing, walking and climbing up and down, as well as while turning around. Observing the child when getting up from sitting to standing position may also bring to notice abnormality if any.
As described above, observe the following:
- The stance like the distance between two feet, erect position, and stability
- The part touching the ground first - heal or toes
- The length of each step (small or large)
- The reciprocal swing of arms (position and stretch of the arms, ease of movements)
- Turning around (well balanced, smooth and the ease of turning)
Such observations are very useful in the diagnosis of neurological and musculoskeletal disorders and also define the probable sites of pain in painful conditions.
Types of abnormal gait
- Antalgic gait or limping gait is a result of a painful condition in which an individual takes a short step with minimal weight-bearing on the affected side. In such a situation, the pain may arise from bones, joints or muscles of the affected limb but also may arise from nerve roots supplying the limb.
- Hemiplegic gait is a result of spastic hemiparesis resulting from brain stroke. The patient stands on toes (plantarflexion and inversion) and maintains the same in the swing phase. In order to keep the foot in plantar flexion, the hip and knee must be flexed but it is not possible due to spasticity of muscles and hence it results in circumduction - moving the affected side in half a circle. It leads to a long step length on the affected side and a short step length on the other side. Reciprocal swing of the upper limb is absent on the affected side.
- Shuffling gait is because of rigidity. The patient stoops forward and that displaces the centre of gravity and hence takes short steps in order to avoid falling and walks fast. It is typically seen in parkinsonism.
- Stamping gait is a result of weakness of dorsiflexors of the foot leading to foot-drop. In order to clear the foot off the ground, the patient lifts the affected leg higher to avoid dragging the foot and then stamps the foot on the ground touching the toes first - high stamping gait. It is seen typically in peripheral neuropathy or cauda equina syndrome.
- Ataxic gait is an unstable gait with a wide base - feet wide apart from each other and the patient is unable to walk in a straight line (drunken gait), often stumbles and falls. It is seen in cerebellar disorders as well as incoordination caused by sensory loss or involuntary movements.
- Waddling gait (like a duck) presents with a wide base with the body moving from side to side with each movement of the limbs, lurching on both sides with excessive shoulder swings. It is seen in muscle hypotonia as in muscular dystrophy, spinal muscular atrophy and congenital dislocation of the hip.
- Short-limb gait results from a discrepancy between the length of two lower limbs. If the shortening is mild (less than 1.5 cm), compensation is done by tilting the pelvis on the affected side and if shortening is moderate (more than 1.5 cm up to 5 cm), toe walking results (toe walking may be normal in children below 2 years of age).
- Trendelenburg gait is due to one-side weakness of the gluteus medius muscle. During the stance phase, the trunk is shifted to the affected side and the pelvis is dropped at the beginning of the swing. It is seen in congenital dislocation of the hip.
Importance of general observation
The following examples will help understand the importance of observing a patient’s gait.
Case 1
A person presented with difficulty in walking. Observation of his gait revealed an obvious limp, step length was small with minimal weight bearing on one side and that clearly showed painful lesion resulting in antalgic gait on that side.
Diagnosis: The painful lesion is rarely neurological and hence it must be either traumatic or inflammatory disease affecting one leg. Thus, one can further focus on local swelling if any that would reveal the exact site of affection.
Case 2
A patient presented with difficulty in walking. Observation of his gait revealed a larger length of the step on one side with circumduction, toe walking without the swing of the upper limb on the affected side.
Diagnosis: This is typical of hemiplegia. One can further observe evidence of cranial nerve palsy if any, that would detect the probable site of the lesion. Same sided facial palsy as hemiplegia suggests middle cerebral artery block, squint with contralateral hemiplegia suggests midbrain lesion, affection of 6th and 7th cranial nerve (eye deviated to lateral side with facial weakness) denotes pontine lesion and involvement of lower cranial nerves (pooling of saliva in mouth, nasal twang to voice, deviation of uvula and tongue) indicates medullary lesion.
Case 3
A patient presented with difficulty in walking. Observation of his gait revealed rigid stance, a short length of steps - shuffling gait with forward bending, without movement of upper limbs and difficulty in initiating turning. Tremors in small hand muscles were observed.
Diagnosis: This is typically due to Parkinson's disease.
Case 4
A patient presented with difficulty in sitting, standing and walking and frequent falls. Observation revealed instability - swaying while sitting and standing, walking with a wide base gait but not in a straight line (as in a drunken state). One can also observe intentional tremors (tremors seen during an action) and also nystagmus.
Diagnosis: This indicates a cerebellar disease.
Case 5
A child presented with difficulty in walking and frequent falls. Observation revealed toe walking (denotes weakness of dorsiflexors of the foot).
Diagnosis: It may be due to hemiplegia or peripheral neuromuscular disorders such as muscular dystrophy (evident by hypertrophy of calf muscles and lordosis) or peripheral neuritis.
Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.
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