Gait, steppage [Equine gait, paretic gait, prancing gait, weak gait]
Steppage gait typically results from footdrop caused by weakness or paralysis of pretibial and peroneal muscles, usually from lower motor neuron lesions. Footdrop causes the foot to hang with the toes pointing down, causing the toes to scrape the ground during ambulation. To compensate, the hip rotates outward and the hip and knee flex in an exaggerated fashion to lift the advancing leg off the ground. The foot is thrown forward and the toes hit the ground first, producing an audible slap. (See Identifying gait abnormalities, pages 286 and 287.) The rhythm of the gait is usually regular, with even steps and normal upper body posture and arm swing. Steppage gait can be unilateral or bilateral and permanent or transient, depending on the site and type of neural damage.
History and physical examination
Begin by asking the patient about the onset of the gait and recent changes in its character. Does a family member have a similar gait? Find out if the patient has had a traumatic injury to the buttocks, hips, legs, or knees. Ask about a history of chronic disorders that may be associated with polyneuropathy, such as diabetes mellitus, polyarteritis nodosa, and alcoholism. While you’re taking the history, observe whether the patient crosses his legs while sitting because this may put pressure on the peroneal nerve.
Inspect and palpate the patient’s calves and feet for muscle atrophy and wasting. Using a pin, test for sensory deficits along the entire length of both legs.
Medical causes
Guillain-Barré syndrome
Typically occurring after recovery from the acute stage of Guillain-Barré syndrome, steppage gait can be mild or severe and unilateral or bilateral; it’s invariably permanent. Muscle weakness usually begins in the legs, extends to the arms and face within 72 hours, and can progress to total motor paralysis and respiratory failure. Other effects include footdrop, transient paresthesia, hypernasality, dysphagia, diaphoresis, tachycardia, orthostatic hypotension, and incontinence.
Herniated lumbar disk
Unilateral steppage gait and footdrop commonly occur with late-stage weakness and atrophy of leg muscles. However, the most pronounced symptom is severe low back pain, which may radiate to the buttocks, legs, and feet, usually unilaterally. Sciatic pain follows, often accompanied by muscle spasms and sensorimotor loss. Paresthesia and fasciculations may occur.
Multiple sclerosis
Steppage gait and footdrop typically fluctuate in severity with multiple sclerosis’characteristic cycle of periodic exacerbation and remission. Muscle weakness, usually affecting the legs, can range from minor fatigability to paraparesis with urinary urgency and constipation. Related findings include facial pain, visual disturbances, paresthesia, incoordination, and sensory loss in the ankle and toes.
Peroneal muscle atrophy
Bilateral steppage gait and footdrop begin insidiously in peroneal muscle atrophy. Foot, peroneal, and ankle dorsiflexor muscles are affected first. Other early signs and symptoms include paresthesia, aching, and cramping in the feet and legs along with coldness, swelling, and cyanosis. As the disorder progresses, all leg muscles become weak and atrophic, with hypoactive or absent deep tendon reflexes (DTRs). Later, atrophy and sensory losses spread to the hands and arms.
Peroneal nerve trauma
Temporary ipsilateral steppage gait occurs suddenly but resolves with the release of peroneal nerve pressure. The gait is associated with footdrop and muscle weakness and sensory loss over the lateral surface of the calf and foot.
Special considerations
The patient with steppage gait may tire rapidly when walking because of the extra effort he must expend to lift his feet off the ground. When he tires, he may stub his toes, causing a fall. To prevent this, help the patient recognize his exercise limits and encourage him to get adequate rest. Refer him to a physical therapist, if appropriate, for gait retraining and possible application of in-shoe splints or leg braces to maintain correct foot alignment.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Walking symptoms
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Gait, waddling (Handbook of Signs & Symptoms (Third Edition))
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