Gait Abnormalities

I'm now going to demonstrate a couple of gaits. It would be a great shame for a patient to come to us with an abnormal gait and for us to send the patient for testing or consultation when the diagnosis might be fairly evident in the gait. The most common gauge you will see is the hemiplegic gait and this is one that you see in hemiplegia where the arm is typically in this posture and the leg on the affected side is typically somewhat stiff.

They will then have a gait that looks something like this and the characteristic of the gait is the circumduction of the foot. The fact that the foot is making a circle like that is what makes this gait so characteristic. If the condition is mild the hand may not be flexed up like that and the only manifestation might just be a little circumduction and the hand may not be swinging normally the way the other hand swing. That is called the hemiplegic gait. It's important to understand why they do what they do when you cut the pyramidal tract. On the left side you have abnormalities of tone that manifests on the right side. So you develop flexion hypertonia in the upper limb and extensor hypertonia in the lower limb and that accounts for the leg being like that and the hand being like this. In addition, they develop much more distal weakness than proximity weakness. Their shoulder is strong and the fingers are very weak.

The tie is strong but the foot is weak and so they have foot drop and so the circumduction comes about because a) they have extensor hypertonia. The length of the leg is stiff. Otherwise. they could just step like this you know they could go like this.  And b) because they have foot drop because their weakness distally. They can't lift up the leg and step like that so they wind up circumducting so this is the most common gait we will see around here probably.  It's called the hemiplegic gait.

Another case that we would commonly identify is the gait of Parkinson’s disease. It's a posture that's characterized by universal flexion. Every joint is flexed and the patient typically will take very small steps. This is called a festination gait. The French call it the marche. A petit power walk of little steps and there might also be an associated tremor with the gait. The patient may have a myriad other abnormalities related to the Parkinson's that we are not going to cover in this session.

Another gait that's very helpful to recognize and it may be one that you're all familiar with from watching police videos and hopefully not from personal experience is the cerebellar gait. The cerebellar gait is characterized by a broad stand and by a wide staggering quality to it. People will tend to fall towards the side of their illness so if the illness is in the cerebellar hemisphere on the left they might fall in that direction. When asked to stand still, their trunk may sway like this and that is called titubation and obviously they would have problems with all the other cerebellar tests.

One caveat: many people think of the Romberg test as being a test of cerebellar disease. Now the Romberg test has nothing to do with the cerebellum. The cerebellum patient is already swinging and it gets a lot worse when you have them proprioception. When you and I are standing like this with our eyes open we are getting signals from our joints to tell us where we are in space. If however you have a problem with proprioception because of your peripheral nerves or posterior columns, then you're relying on your eyes to tell you where you are in space. Therefore, the moment you ask the patient to stand still and close their eyes the patient begins to sway and that is a positive Romberg test it has very little to do with the cerebellum.

Talking about proprioception leads me to the other gait related to proprioception. Once again if you have trouble with your proprioception and cannot feel when your foot has arrived on the floor you are relying on a lot of visual cues and especially in the dark. You might develop what's called a stomping or stamping gait where you tend to walk like this needing to slam your foot down to get the vibration in your trunk to let you know that your foot has landed. So this gait may be much more prominent in the dark and not as evident in the daytime because they can see where they're going.

I get that we should mention in the context of the hemiplegic gait. This is the gait that is commonly seen in cerebral palsy. It's a diplegia gait, if you will, with hemiplegia on both sides. It’s a gait that I'm sure you’ve seen often in children and in adults affected by this from childhood. Typically the patients have extensor spasm and almost seem to be walking on tiptoe and although they have some circumduction they have a lot of adductor spasm that keeps their feet close together so they tend to be walking on tiptoe the arm is flexed like this. The adduction is a prominent feature in fact in some parts of the world where children do not get adductor releases you might actually see a scissors gait where the leg swings all the way over to the other side and again. That is another manifestation of the diplegia gait.

I want to talk about a gait that happens in people with myopathy and this is a gait where the patient develops a waddle. In order to understand this gait you have to do a couple of things with me. If you don't mind put your hands on your hip and appreciate that when you take a step to step forward the hip on the side where you are stepping forward that hip actually moves up. It moves up and it's a function of having very strong pelvic girdle muscles that allow you to do that if you have a myopathy when you lift your leg up to take a step because you can't hold your pelvis up and stabilize it. There's a tendency for the hip to fall on that side and for you to fall over and to compensate for that you lean your trunk this way.

So you develop a waddling kind of gait compensating for the fact that your pelvis and your pelvic muscles aren’t strong. You're getting a waddling kind of gait leaning away from the side where you have the weakness. You know in a sense it's a manifestation also of the Trendelenburg sign. The Trendelenburg sign says that when you lift the hip on the affected side the pelvis sags down and it's a suggestion that you have weakness in the pelvic stabilizing muscles.

Another gait that I will discuss is the neuropathic gait. If you have a peripheral neuropathy and you have foot drop, then typically you have to have a high step in gait. Otherwise you will trip on your foot and fall forward. So patients in neuropathy especially if it's bilateral will have a gait like this which is nicely also called the equine gait or the stepping or step edge gait. The reason they do this is they can't step forward without tripping on their foot because they can't really dorsiflex their foot because of weakness. The foot is weak and so to overcome that weakness they have to lift it up like so.

The choreiform gait does not in my mind strictly constitute a gait. These patients are already exhibiting driving movements and voluntary movements when seated and when they walk they can have the most bizarre sorts of gaits. I don't think it's fair to call it a gait because really the involuntary movement is manifest and pretty much everything they do.

I would offer as a caveat that all our hospitals have long corridors, great opportunities to watch patients walking towards you and away from you and I encourage you to make a habit of studying gaits as people come and go and realize what a miracle it is for people to have a normal gait and how easily it is rendered abnormal by disease.