Gait Disorders and Their Approach
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Direct answer
Gait disorders are abnormalities of walking that localise to the motor, sensory, cerebellar, vestibular or extrapyramidal systems, and pattern recognition is the core skill. Each pattern points to a lesion site: hemiparetic and spastic gait to upper motor neurons, ataxic gait to cerebellar or sensory loss, parkinsonian gait to the basal ganglia, and steppage gait to foot drop from a lower motor neuron lesion.
What you must remember
- Hemiparetic gait: circumduction of the affected leg with the arm held flexed and adducted, the classic picture of a contralateral hemiparesis after stroke.
- Spastic gait: stiff legs with adducted, crossing thighs, often called scissoring, from bilateral upper motor neuron lesions such as cervical myelopathy.
- Ataxic gait: wide-based and staggering; midline cerebellar disease causes truncal instability, while sensory ataxia worsens in the dark.
- Parkinsonian gait: short shuffling steps, reduced arm swing, festination and en bloc turning, with start hesitation.
- Steppage gait: high stepping to clear a dropped foot, typical of peroneal nerve palsy, L5 radiculopathy or Charcot-Marie-Tooth disease.
- Waddling gait: side-to-side trunk lurch from weak hip abductors, the signature of proximal myopathy such as Duchenne dystrophy.
- Apraxic gait: the feet seem stuck to the floor, with short steps and difficulty initiating walking, seen in normal pressure hydrocephalus and frontal disease.
- Romberg test: positive in sensory ataxia from dorsal column disease, but not in cerebellar ataxia, where sway occurs even with eyes open.
Pattern recognition at the bedside
Gait is best classified by observing the walk, the posture and the turns, and then linking each finding to a localisation. The table summarises the seven patterns.
| Gait | Key feature | Typical cause | Bedside clue |
|---|---|---|---|
| Hemiparetic | Circumduction, arm flexed | Stroke, internal capsule | Unilateral weakness and spasticity |
| Spastic | Scissoring, toe-walking | Cervical myelopathy, paraparesis | Brisk reflexes, Hoffmann sign |
| Ataxic | Wide base, staggering | Cerebellum, dorsal columns | Romberg test and finger-nose test |
| Parkinsonian | Shuffling, festination | Basal ganglia disease | Rigidity, bradykinesia, rest tremor |
| Steppage | High stepping, foot drop | Peroneal palsy, CMT | Weak ankle dorsiflexion, distal wasting |
| Waddling | Side-to-side trunk lurch | Proximal myopathy | Gowers sign, calf pseudohypertrophy |
| Apraxic | Feet stuck, short steps | Normal pressure hydrocephalus | Difficulty starting, urinary urgency |
Most stems can be solved by identifying whether weakness, tone, coordination or initiation is the dominant problem. Reflexes and the Romberg test then separate upper motor neuron, cerebellar and sensory causes.
Localisation rests on the combination of findings rather than a single sign: a hemiparetic gait with an extensor plantar response points to the corticospinal tract, whereas a steppage gait with absent ankle reflexes points to the peripheral nerve or root.
Where the exam tries to catch you
Gait questions reward the candidate who links the pattern to the lesion rather than to age or fatigue.
- Trap: calling every wide-based gait cerebellar Correct: a positive Romberg test with proprioceptive loss points to sensory ataxia, as in B12 deficiency or tabes dorsalis.
- Trap: attributing a shuffling gait to ageing alone Correct: short steps with rigidity and bradykinesia signal parkinsonism, which needs evaluation.
- Trap: reading a foot drop as a central lesion Correct: a steppage gait with distal weakness is lower motor neuron, from peroneal nerve or L5 root compression.
- Trap: labelling a stiff, scissoring gait as myopathy Correct: spasticity with brisk reflexes and extensor plantar responses indicates an upper motor neuron lesion.
Frequently asked questions
What gait is seen in cervical myelopathy?
Cervical myelopathy typically produces a spastic, sometimes broad-based gait with stiff legs and an unsteady walk. Hyperreflexia, Hoffmann sign and clonus support the diagnosis, and clumsy hands often accompany the gait change.
How does the Romberg test help localise an ataxic gait?
The Romberg test checks balance with eyes closed, and it is positive in sensory ataxia from dorsal column disease. Cerebellar ataxia is not a Romberg-positive state, because patients sway even with eyes open.
What is the gait of normal pressure hydrocephalus?
Normal pressure hydrocephalus classically causes a magnetic, apraxic gait with short steps, a broad base and difficulty initiating walking. It forms part of the triad with urinary urgency and dementia, and a response to shunting is the key clue.
Why does steppage gait occur in Charcot-Marie-Tooth disease?
Steppage gait in Charcot-Marie-Tooth disease results from distal weakness and wasting of the anterior compartment muscles, which causes foot drop and high stepping. It is a lower motor neuron pattern, often accompanied by pes cavus and distal sensory loss.
Which gait is typical of Duchenne muscular dystrophy?
Duchenne muscular dystrophy produces a waddling gait from proximal hip girdle weakness. Children rise from the floor with Gowers sign, and calf pseudohypertrophy is another classic feature of the disease.