Gait Disorders—Differential Diagnosis

Muscle. Myopathy is proximally predominant in inflammatory myopathies, steroid myopathy, and Duchenne and limb girdle dystrophies. Waddling gait results from dropping of the pelvis. Patients have difficulty ascending stairs, arising from chairs, or arising from a seated position on the floor.

Neuromuscular Junction (NMJ). Of the various NMJ disorders Lambert-Eaton myasthenic syndrome (LEMS) is most likely to present with a gait disorder. Climbing stairs and arising from a chair is impaired. Typically, myasthenia gravis presents with ocular symptoms; gait dysfunction usually does not occur until generalization later in the course. Both NMJ disorders worsen with exertion.

Peripheral Nerve. Peroneal nerve palsy produces foot drop because of tibialis anterior muscle weakness. The leg is lifted high; the foot does not dorsiflex and is slapped down with the ball of the foot hitting the ground first. Femoral neuropathies affect the quadriceps muscles, causing weakness or buckling when navigating stairs, particularly descending as the quadriceps needs to lock to support the after-coming leg.

Generalized peripheral neuropathies are symmetric and length dependent, causing foot slapping because of distal weakness and sensory deafferentation, particularly proprioceptive impairment. The proprioceptive loss contributes to increased difficulties in darkness; the Romberg test is positive. Muscle stretch reflexes are diminished or absent. Lumbosacral polyradiculopathies or plexopathies produce weakness in multiple myotomes, unilaterally or bilaterally, affecting walking.

Spinal Cord. With myelopathies, lower-extremity hypertonicity causes spastic gait, scissoring (legs tending to cross each other), stiff-legged motions, minimal knee flexion, and circumduction. Strength may be preserved. Reflexes are exaggerated with extensor plantar responses, but the jaw jerk is normal.

Cerebellum. Cerebellar gait is wide based, veers from side to side, with a lurching, irregular cadence, and extra steps when turning or making sudden moves. The earliest sign is inability to walk in tandem. Late-stage cerebellar disease destroys truncal stability, making gait impossible without a walker or bilateral support. Unilateral cerebellar lesions produce stumbling and/or ipsilateral falling. Strength is preserved.

Only gold members can continue reading. Log In or Register to continue