WALKING DIFFICULTIES

When a patient complains of difficulty walking, visualize the anatomic components of the leg: skin, muscle, arteries, veins, bones, joints, and peripheral nerves. Going one step further, follow the peripheral artery to its origin (femoral artery, aorta, and so forth) and the peripheral nerve to its origin in the spinal cord, and then follow its secondary connections to the cerebellum and cerebrum. Now it is possible to recall the causes of difficulty walking as the patient is being examined.

1. Skin. Look for calluses, infectious ulcers, and deformities of the feet.
2. Muscle. Check for possible myositis, contusions, and muscular atrophy or dystrophy. The gait of muscular dystrophy is slapping and waddling, and there is a pelvic tilt forward.
3. Arteries. Peripheral arteriosclerosis and Buerger disease will often be detected by palpation of the dorsalis pedis and tibialis pulses. However, do not forget to feel the femoral arteries (to rule out Leriche syndrome) and popliteal arteries. Listening to the heart may determine a cause for a peripheral embolism.
4. Veins. Dilated varicose veins will be obvious, but checking for a positive Homan sign will be necessary to rule out deep vein phlebitis.
5. Bones. Osteomyelitis and sarcomas or metastatic disease of the bone will usually present with significant pain and make the patient extremely reluctant to walk. A mass or deformity in the bone is usually palpable.
6. Joints. Osteoarthritis, gout, and rheumatoid arthritis of the knee are not hard to detect. The gait in diseases in any joint in the leg is a limp. The cause of pain in the other joints may be more difficult to appraise even with an x-ray film. Nevertheless, these and a full joint disease workup will help . An osteoarthritic spur of the heel may be found. Bursitis in numerous areas should be looked for. Congenital lesions such as slipped epiphysis, dislocation of the hip, and aseptic necrosis should be considered in children.
7. Peripheral nerves. A peripheral neuropathy from alcohol or diabetes will cause a steppage gait (due to moderate or severe foot drop), and traumatic or lead neuropathy may cause an overt foot drop. The atrophy of the muscles without fasciculations will help in the diagnosis of these as well as of Dejerine–Sottas hereditary neuropathy and Charcot–Marie–Tooth disease. Sensory changes (glove and stocking anesthesia and analgesia) are also useful.
8. Spinal cord. These diseases present with different types of gaits. There may be a wide-based ataxic gait with a positive Romberg sign in dorsal column and dorsal root involvement, suggesting tabes dorsalis and pernicious anemia. There may be a wide-based reeling ataxia with a negative Romberg sign, suggesting cerebellar disease such as Friedreich ataxia. A spastic gait suggests amyotrophic lateral sclerosis, multiple sclerosis, and diseases with diffuse spinal cord involvement such as anterior spinal artery occlusion. A spastic ataxic gait is typical of multiple sclerosis. Other causes of a spastic gait are compression by tumors, cervical spondylosis, or disks; transverse myelitis; traumatic conditions such as fractures; hematomas; and epidural abscesses. The gait of herniated disks of the lumbosacral spine is usually a list to the left or right or a limp. Loss of the ankle or knee jerk, dermatomal sensory loss, and erector spinae muscle spasm will help in this diagnosis. If there is a cauda equina tumor or poliomyelitis, bladder symptoms are usually present as well. Other conditions of the lumbosacral spine disturb the gait (limp) and include osteoarthritis, rheumatoid spondylitis, spondylolisthesis, metastatic tumors, tuberculosis, and multiple myeloma.
9. Secondary connections to the brain. Involvement of the pyramidal tracts in the brain often produces a hemiplegic gait where the weak or spastic leg is dragged along the floor. The gait of vestibular disease is ataxic and reeling during an attack. Cerebellar disease has already been discussed. Tumors or abscesses here and alcoholic and phenytoin sodium toxicity may cause a cerebellar ataxia. Multiple sclerosis is another condition that may result in this type of a gait. Bilateral cerebral involvement in cerebral arteriosclerosis or presenile and senile dementia produces the short-stepped gait of marche à petit pas. Cerebral palsy may cause a scissor gait. The spastic, shuffling gait of parkinsonism with propulsion and retropulsion is not easily missed.

Approach to the Diagnosis

The clinical picture can help to pinpoint the diagnosis in many cases. If the difficulty develops after walking a block or a certain distance, the patient may have neurogenic or vascular claudication, and spinal stenosis or peripheral arteriosclerosis is suspected. If there is swelling and crepitus of the knee joints, an arthritic condition is likely. Muscular atrophy and fasciculations suggest progressive muscular atrophy, whereas atrophy with sensory changes suggests peripheral neuropathy. A spastic ataxic gait with blurred vision or scotomata suggests multiple sclerosis. The initial workup of a patient with walking difficulties will depend on the clinical picture. If there is possible peripheral vascular disease, Doppler studies and possible femoral angiography or aortography need to be done. If a patient is suspected of having a deep vein thrombosis, he or she should be hospitalized and Doppler studies, impedance plethysmography, or contrast venography will be done. If the patient has clinical radiculopathy, a computed tomography (CT) scan or magnetic resonance imaging (MRI) of the lumbar spine will be done to rule out a herniated disk. If multiple sclerosis is suspected, an MRI of the brain or spinal cord will be done depending on the level of the involvement clinically.

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WEAKNESS AND FATIGUE—GENERALIZED

	V	I	N	D
	Vascular	Inflammatory	Neoplasm	Degenerative
Muscle	Congestive heart failure	Epidemic myalgia		Malnutrition
Myoneural Junction
Peripheral Nerve			Metastatic carcinoma	Pellagra Beriberi
Spinal Cord	Anterior spinal artery occlusion	Poliomyelitis Epidural abscess	Spinal cord tumor	Progressive muscular atrophy
Brain	Carotid or basilar insufficiency or occlusion	Encephalitis Meningitis	Brain tumor (primary and metastatic)	Parkinson disease Amyotrophic lateral sclerosis Senile dementia

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Other Useful Tests

1. Complete blood count (CBC) (pernicious anemia)
2. Drug screen (drug abuse)
3. Sedimentation rate (inflammation)
4. Blood lead level (lead neuropathy)
5. Glucose tolerance test (diabetic neuropathy)
6. Antinuclear antibody (ANA) analysis (collagen disease)
7. Chemistry panel (cirrhosis of the liver, muscle disease)
8. Schilling test (pernicious anemia)
9. Electromyogram (EMG) (muscle dystrophy, peripheral neuropathy)
10. Spinal tap (tumor, multiple sclerosis, neurosyphilis)
11. Urine porphobilinogen (porphyria)
12. X-ray of joints (arthritis)
13. Bone scan (osteomyelitis, neoplasm)
14. Neurology consult
15. Orthopedic consult

Pictures

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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