Gait

Aka: Gait, Abnormal Gait, Gait Abnormality, Antalgic Gait, Cautious Gait, Cerebellar Gait, Choreic Gait, Dystonic Gait, Frontal Gait, Gait Apraxia, Hemiparetic Gait, Paraparetic Gait, Parkinsonian Gait, Psychogenic Gait, Sensory Ataxia Gait, Vestibular Ataxia Gait, Waddling Gait, Pelvic Rotational Wink, Gait and Stance Exam, Walking Exam, Tandem Walk, Tandem Gait, Toe Walk, Heel Walk

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II. Physiology

  1. Gait has 2 phases (walk cycle)
    1. Stance Phase (foot in contact with ground)
      1. Sub-phase 1: Initial double-limb support (20%)
      2. Sub-phase 2: Subsequent single-limb stance (60%)
      3. Sub-phase 3: Return to double-limb support (20%)
    2. Swing Phase (foot in air)
      1. Each foot is in the air 40% of the time of the walk cycle
  2. Age-related changes
    1. Mature gait is established by age 3 years, and is adult-like by age 7 years
    2. With age comes increased walk velocity, step length and duration of single-limb stance

III. Exam: Joint Specific Exams

  1. See Low Back Exam
  2. See Hip Exam
  3. See Knee Exam
  4. See Ankle Exam

IV. Exam: Leg Neurologic Exam

  1. Strength
    1. Hip Extension (L5 and S1)
    2. Hip flexors (L2-3, Iliopsoas Muscle, femoral nerve)
    3. Knee Extension (L3-4, Quadriceps Muscle)
    4. Knee Flexion (S1, Sciatic nerve)
    5. Ankle dorsiflexion (L4, tibialis anterior Muscle, deep peroneal nerve)
    6. Great toe extension and foot dorsiflexion (L5)
    7. Ankle plantar flexion (S1, Gastrocnemius and Soleus Muscles, tibial nerve)
  2. Deep Tendon Reflexes
    1. Patellar Reflex (L2-4, Knee Jerk)
    2. Medial Hamstring Reflex (L5)
    3. Achilles Reflex (S1, Ankle Jerk)
  3. Standing and Walking
    1. Patient stands unassisted
    2. Romberg Test
    3. Walk Cycle
      1. Observe patient walking across a room or down a hall and back
      2. Observe balance
      3. Observe swinging of the arms
      4. Observe movement of the legs
      5. Observe turning (typically smooth)
    4. Heel Walking (L4 and L5, ankle dorsiflexion)
      1. Weak dorsiflexion may suggest Upper Motor Neuron Deficit
      2. Also consider distal Muscle Weakness
    5. Toe Walking (L5 and S1, ankle plantar flexion)
      1. Consider distal Muscle Weakness
    6. Tandem Walking (heel-to-Toe Walk)
      1. Patient walks heal to toe in as straight line
      2. Observe for Ataxia (may otherwise be subtle)
  4. Other Testing
    1. Get Up and Go Test
      1. See Gait and Balance Evaluation in the Elderly
      2. Patient gets up from chair unassisted and walks
      3. Observe for ability to rise from chair without upper body force from arm rest
    2. Hip Abduction while standing
      1. May perform if patient able to balance on one leg (L5 and gluteus medius)
    3. Hop in place on one foot at a time
      1. Consider in able patient to test for Muscle Weakness and position sense
      2. May be abnormal in motor weakness, loss of proprioception or cerebellar disorders
    4. Shallow knee bend with one leg at a time
      1. Patient may need light support of elbow
      2. Consider weak hip extensors or knee extensors

V. Types: Abnormal

  1. See Nonantalgic Gait in Children
  2. Antalgic Gait
    1. Limited joint range of motion with an inability to bear full weight on affected extremity
    2. Stance phase duration shortens to compensate pain in the affected leg
    3. Results in limp with slow and short steps
    4. Causes: Joint Pain due to Degenerative Joint Disease or injury, Stress Fractures, Septic Arthritis
  3. Cautious Gait
    1. Careful gait, slow and wide based with abducted arms, similar to that of walking on ice
    2. Causes: Prior falls, deconditioning, sensory deficit (e.g. low sight)
  4. Cerebellar Gait
    1. Staggering, wide-based gait
    2. Associated cerebellar signs (Dysarthria, dysmetria, Intention Tremor, Nystagmus, Positive Romberg test)
    3. Causes: Vitamin B12 Deficiency, Multiple Sclerosis, Cerebellar CVA, Thiamine deficiency
  5. Choreic Gait
    1. Wide-based gait, with slow leg raising and simultaneous knee flexion
    2. Associated with similar Choreoathetosis involving upper extremities
    3. Causes: Huntington's Chorea, Levodopa-induced Dyskinesia
  6. Dystonic Gait
    1. Hyperflexed hips with dragging of foot, exacerbated by walking
  7. Frontal Gait (Gait Apraxia)
    1. Hesitation on starting to walk and on turning
    2. Causes: Dementia, Frontal Lobe degeneration, Normal Pressure Hydrocephalus
  8. Hemiparetic Gait
    1. Weak and spastic limb extended and circumducted
    2. Associated with Hemiparesis, hyperreflexia
    3. Causes: CVA with Hemiparesis
  9. Paraparetic Gait
    1. Stiff, scissor-like walk with leg adduction and extension
    2. Associated with bilateral leg weakness, hyper-reflexia, spasticity
    3. Causes: Spinal cord lesion, bilateral Cerebral Hemisphere abnormalities
  10. Parkinsonian Gait
    1. Shuffling gait with short steps
    2. Causes: Parkinsonism
  11. Pelvic Rotational Wink
    1. Pelvis rotates >40 degrees in axial plane towards the affected hip
    2. Maladaptive gait allows for terminal hip extension on walking
    3. Causes: Intraarticular hip disorder, hip flexure contracture
  12. Psychogenic Gait
    1. Bizarre, non-physiologic, lurching gait
    2. Associated with normal Neurologic Exam (especially with distraction)
    3. Causes: Somatoform Disorder, Malingering
  13. Sensory Ataxia Gait
    1. Unstead gait, worse with impaired Vision or at night
    2. Associated with decreased distal Sensation, Positive Romberg test
    3. Causes: Dorsal column dysfunction, Vitamin B12 Deficiency, Diabetic Neuropathy
  14. Steppage Gait
    1. Hyper-flexed hips and knees on ambulation compensating for foot-drop
    2. Associated with distal leg atrophy and loss of Achilles Reflex
    3. Causes: Distal motor Neuropathy
  15. Trendelenburg Gait
    1. See Trendelenburg Gait
    2. Causes: Abductor weakness (esp. Gluteus Medius) or Intrinsic Hip Pathoplogy
  16. Vestibular Ataxia Gait
    1. Unsteady gait with a falling to one side
    2. Causes: See Vertigo, Ataxia
  17. Waddling Gait
    1. Swaying, symmetric, wide-based gait with Toe Walking
    2. Associated with proximal Muscle Weakness in lower extremities
    3. Causes: Muscular Dystrophy, Pregnancy, Athletes, Osteitis Pubis

VI. References

  1. Zawora in Arenson (2009) Reichel's Care of the Elderly, 6th ed, Cambridge University Presss, p. 143

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