Chapter 69

### Introduction

Would ye not think his cunning to be great that could restore this cripple to his legs again?

William Shakespeare (1564–1616), King Henry VI, Part II, Act 2, Scene 1

The clinical evaluation of the patient presenting with difficulty walking can be very complex, especially for abnormal gaits caused by neurological conditions. Not all gaits fall into a single category; gait disturbances may be multifactorial, especially in the elderly.

Non-neurological conditions are the most common cause of walking difficulties. They include various arthritic conditions of the lower limbs, usually presenting as a limp, other mechanical factors, such as swelling of the legs, disorders of circulation such as intermittent claudication, and general debility (e.g. malignancy, anaemia and endocrine disorders such as hyperparathyroidism).

It is important for the general practitioner not to overlook hypokalaemia and drugs or the myopathies as a cause of walking difficulty. The drugs that require special consideration include alcohol, corticosteroids, chloroquine, colchicine, clofibrate, bretylium, HMG-CoA reductase inhibitors (the statins), gemfibrozil, penicillamine, diuretics, beta blockers and general anaesthetic agents.

### Abnormal gaits

It is convenient to classify abnormal gaits as painless or painful (antalgic). With antalgic gaits the rhythm is disturbed; with painless abnormal gaits the contour is affected. One type of skeletal mechanical abnormality is described as arthrogenic (due particularly to hip disorders) and a second type as osteogenic (due to a shortened limb).

Neurogenic gaits and myogenic gaits are considered together below, under the heading ‘Neurological disorders of gait’.

Psychogenic or ‘hysterical’ gait may have to be considered if the gait is bizarre or seems greatly exaggerated. On the other hand, loss of confidence, especially in the elderly, is an important cause of gait disturbance. However, many abnormal gaits that are caused by neurological disease may also appear bizarre, and caution is advised. Doubtful cases should be referred for an expert opinion.

### Examination of gait and posture1

Disorders of gait and posture go hand in hand because of a common physiological process.

The source of the abnormality is indicated.

1. Ask the patient to stand.

Note any difficulty in reaching a standing position. Difficulty = proximal muscle weakness.

2. Ask the patient to stand with eyes closed (Romberg test).

If positive (sways or falls) = loss of proprioception (e.g. peripheral neuropathy).

3. Ask the patient to walk (ensure sufficient testing length).

 Gait initiation: hesitancy = basal ganglia or frontal cortex Stride length: very short = basal ganglia or frontal cortex irregular = cerebellar Narrow or broad base: narrow = UMN, muscle weakness, basal ganglia broad = cerebellum, proprioception, vestibular Stiff or ‘sloppy’: stiff = UMN, basal ganglia sloppy = LMN, muscle weakness Heel strike: loss of normal ...

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