WALKING DIFFICULTIES

WALKING DIFFICULTIES

1. Skin. Look for calluses, infectious ulcers, and deformities of the feet.
2. Muscle. Check for possible myositis, contusions, and muscular atrophy or
dystrophy. The gait of muscular dystrophy is slapping and waddling and there is a
pelvic tilt forward.
3. Arteries. Peripheral arteriosclerosis and Buerger disease will often be detected by
palpation of the dorsalis pedis and tibialis pulses. However, do not forget to feel
the femorals (to rule out Leriche syndrome) and popliteals. Listening to the heart
may determine a cause for a peripheral embolism.
4. Veins. Dilated varicose veins will be obvious, but checking for a positive Homans
sign will be necessary to rule out deep vein phlebitis.
 5. Bones. Osteomyelitis and sarcomas or metastatic disease of the bone will usually
present with significant pain and make the patient extremely reluctant to walk. A
mass or deformity in the bone is usually palpable.
6. Joints. Osteoarthritis, gout, and rheumatoid arthritis of the knee are not hard to
detect. The gait in diseases in any joint in the leg is a limp. The cause of pain in
the other joints may be more difficult to appraise even with an x-ray film.
Nevertheless, these and a full joint disease workup will help (see page 347). An
osteoarthritic spur of the heel may be found. Bursitis in numerous areas should be
looked for. Congenital lesions such as slipped epiphysis, dislocation of the hip,
and aseptic necrosis should be considered in children.
7. Peripheral nerves. A peripheral neuropathy from alcohol or diabetes will cause a
steppage gait (due to moderate or severe foot drop) and traumatic or lead
neuropathy may cause an overt foot drop. The atrophy of the muscles without
fasciculations will help in the diagnosis of these as well as in Dejerine–Sottas
hereditary neuropathy and Charcot–Marie–Tooth disease. Sensory changes (glove
and stocking anesthesia and analgesia) are also useful.
8. Spinal cord. These diseases present with different types of gaits. There may be a
wide-based ataxic gait with a positive Romberg sign in dorsal column and dorsal
root involvement, suggesting tabes dorsalis and pernicious anemia. There may be
a wide-based reeling ataxia with a negative Romberg sign, suggesting cerebellar
disease such as Friedreich ataxia. A spastic gait suggests amyotrophic lateral
sclerosis, multiple sclerosis, and diseases with diffuse spinal cord involvement
such as anterior spinal artery occlusion. A spastic ataxic gait is typical of multiple
sclerosis. Other causes of a spastic gait are compression by tumors, cervical
spondylosis, or disks and transverse myelitis, traumatic conditions like fractures,
and hematomas and epidural abscesses. The gait of herniated disks of the
lumbosacral spine is usually a list to the left or right or a limp. Loss of the ankle
or knee jerk, dermatomal sensory loss, and erector spinae muscle spasm will help
in this diagnosis. If there is a cauda equina tumor or poliomyelitis, bladder
symptoms are usually present as well. Other conditions of the lumbosacral spine
disturb the gait (limp) and include osteoarthritis, rheumatoid spondylitis,
spondylolisthesis, metastatic tumors, tuberculosis, and multiple myeloma.
9. Secondary connections to the brain. Involvement of the pyramidal tracts in the
brain often produce a hemiplegic gait where the weak or spastic leg is dragged
along the floor. The gait of vestibular disease is ataxic and reeling during an
attack. Cerebellar disease has already been discussed. Tumors or abscesses here
and alcoholic and phenytoin sodium toxicity may cause a cerebellar ataxia.
Multiple sclerosis is another condition that may result in this type of a gait.
Bilateral cerebral involvement in cerebral arteriosclerosis or presenile and senile
dementia produces the short-stepped gait of marche à petits pas. Cerebral palsy
may cause a scissor gait. The spastic, shuffling gait of parkinsonism with
propulsion and retropulsion is not easily missed.

Approach to the Diagnosis

The clinical picture can help pinpoint the diagnosis in many cases. If the difficulty
develops after walking a block or a certain distance, the patient may have neurogenic or
vascular claudication, and spinal stenosis or peripheral arteriosclerosis is suspected. If
there is swelling and crepitus of the knee joints, an arthritic condition is likely.
Muscular atrophy and fasciculations suggest progressive muscular atrophy, whereas
atrophy with sensory changes suggests peripheral neuropathy. A spastic ataxic gait
with blurred vision or scotomata suggests multiple sclerosis.

The initial workup of a patient with walking difficulties will depend on the clinical
picture. If there is possible peripheral vascular disease, Doppler studies and possible
femoral angiography or aortography need to be done. If a patient is suspected of having
a deep vein thrombosis, he or she should be hospitalized and Doppler studies,
impedance plethysmography, or contrast venography will be done. If the patient has
clinical radiculopathy, a CT scan or MRI of the lumbar spine will be done to rule out a
herniated disk. If multiple sclerosis is suspected, an MRI of the brain or spinal cord will
be done depending on the level of the involvement clinically.

Other Useful Tests

1. CBC (pernicious anemia)

2. Drug screen (drug abuse)
3. Sedimentation rate (inflammation)
4. Blood lead level (lead neuropathy)
5. Glucose tolerance test (diabetic neuropathy)
6. ANA analysis (collagen disease)
7. Chemistry panel (cirrhosis of the liver, muscle disease)
8. Schilling test (pernicious anemia)
9. EMG (muscle dystrophy, peripheral neuropathy)
10. Spinal tap (tumor, multiple sclerosis, neurosyphilis)
11. Urine porphobilinogen (porphyria)
12. X-ray of joints (arthritis)
13. Bone scan (osteomyelitis, neoplasm)
14. Neurology consult
15. Orthopedic consult