Abnormal Gait in Adults
Very few patients present with abnormal gait. It is more often noticed by the GP, while the patient’s complaint is usually a manifestation of the gait (e.g. unsteadiness in Parkinson’s disease) or of its cause (e.g. pain in arthritis). Congenital causes are not considered here as patients are most unlikely to present such problems to the GP.
Differential diagnosis
Common Diagnoses
- Trauma (Back and Leg)
- Osteoarthritis (OA) or Other Painful Joint Problem
- Vestibular Ataxia (Vestibular Neuritis, Ménière’s Disease, CVA)
- Parkinson’s Disease
- Intermittent Claudication (IC)
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.