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 358 and 359.) Steppage gait usually has a regular rhythm, with even steps and normal upper body posture and arm swing. It 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 any recent changes in its character. Does any family member have a similar gait? Find out if the patient has had any 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 this disorder, 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 of a herniated lumbar disk 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 also occur.

Multiple sclerosis (MS)

Like other signs and symptoms of MS, steppage gait and footdrop follow a 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 this disorder. Other early signs and symptoms include paresthesia, aching, cramping, coldness, swelling, and cyanosis in the feet and legs. Foot, peroneal, and ankle dorsiflexor muscles are affected first. 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. Steppage gait is associated with footdrop, muscle weakness, and sensory loss over the lateral surface of the calf and foot.

Poliomyelitis

Steppage gait, usually permanent and unilateral, commonly develops after the acute stage of poliomyelitis. It’s typically preceded by fever, asymmetrical muscle weakness, coarse fasciculations, paresthesia, hypoactive or absent DTRs, and permanent muscle paralysis and atrophy. Dysphagia, urine retention, and respiratory difficulty may also occur.

Polyneuropathy

Diabetic polyneuropathy is a rare cause of bilateral steppage gait, which appears as a late but permanent effect. This sign is preceded by burning pain in the feet and is accompanied by leg weakness, sensory loss, and skin ulcers.

In polyarteritis nodosa with polyneuropathy, unilateral or bilateral steppage gait is a late finding. Related findings include vague leg pain, abdominal pain, hematuria, fever, and increased blood pressure.

In alcoholic polyneuropathy, steppage gait appears 2 to 3 months after the onset of vitamin B deficiency. The gait may be bilateral, and it resolves with treatment of the deficiency. Early findings include paresthesia in the feet, leg muscle weakness and, possibly, sensory ataxia.

Spinal cord trauma

In an ambulatory patient, spinal cord trauma may cause steppage gait. Its other effects vary with the severity of injury and may include unilateral or bilateral footdrop, neck and back pain, and vertebral tenderness and deformity. Paresthesia, sensory loss, asymmetrical or absent DTRs, and muscle weakness or paralysis may occur distal to the injury. The patient may also develop fecal and urinary incontinence.

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.

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Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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