Abnormal Gait in Adults
Differential Diagnosis
Common Diagnoses
- Trauma (Back and Leg)
- Osteoarthritis (OA) or Other Painful Joint Problem
- Parkinson’s Disease
- Intermittent Claudication (IC)
- Vestibular Ataxia secondary to CVA
- Vestibular Ataxia secondary to Ménière’s Disease
- Vestibular Ataxia secondary to Vestibular Neuritis
Occasional Diagnoses
- Foot Drop (Peroneal Nerve Atrophy)
- Multiple Sclerosis
- Spinal Nerve Root Pain (Especially L5 and S1)
- Cauda Equina Lesions
- Myasthenia Gravis
Rare Diagnoses
- Tabes Dorsalis (Syphilis)
- Dystrophia Myotonica
- Motor Neurone Disease
- Cerebellar Ataxia
- Functional Neurological Disorder
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Trauma | OA/Other | Vestibular | Parkinson’s | IC | |
|---|---|---|---|---|---|
| Sudden Onset | Yes | Possible | Yes | No | Possible |
| Painful Unilateral Limp | Yes | Yes | No | No | Yes |
| Worse with Exercise | Yes | Yes | No | No | Yes |
| Shuffling Gait | No | Possible | No | Yes | No |
| Staggering Gait | No | No | Yes | No | No |
Possible Investigations
Likely:None.
Possible:X-ray, FBC, ESR/CRP, RA factor/anti-CCP, uric acid.
Small Print:Syphilis serology, scans, lumbar puncture, angiography.
- FBC, ESR/CRP, RA factor/anti-CCP, uric acid: Some forms of arthritis will result in an anaemia of chronic disorder. ESR/CRP may also be raised. Depending on the pattern of joint pain, RA factor/anti-CCP and uric acid may provide useful information in the diagnosis of rheumatoid arthritis and gout.
- X-rays useful in bony trauma. Limited value in OA except to exclude other bony pathology.
- Syphilis serology: If tabes dorsalis suspected.
- If neurological signs of incoordination, consider CT/MRI scan and lumbar puncture – usually arranged by the specialist.
- Angiography: Arranged by the vascular surgeon if surgery contemplated in claudication.
Top Tips
- Look up from the notes or computer as the patient walks in – otherwise you may miss a useful clue in the patient’s gait.
- If the patient actually complains of problems walking, take your time in assessing the symptom – in particular, give the patient the opportunity to demonstrate the problem by walking him or her up and down the corridor.
- If the cause is not immediately apparent from the history, perform a careful neurological examination – this is a situation where there may be hard signs which contribute significantly to diagnosis.
Red Flags
- Vestibular neuritis usually settles within a few days. If patient remains ataxic, especially with persistent nystagmus, consider a central lesion and refer urgently.
- Numbness in both legs (saddle pattern) with back pain and incontinence suggests a cauda equina lesion. Admit urgently.
- If the patient is ataxic and has a past history of neurological symptoms, such as paraesthesia or optic neuritis, consider multiple sclerosis.
- Beware of labelling the patient as hysterical – apparently bizarre gaits may signify obscure but significant neurological pathology.