Evaluation of the Elderly Patient With an Abnormal Gait Moe R. Lim, MD Abstract Russel C. Huang, MD Distinguishing between the normal gait of the elderly and Anita Wu, MD pathologic gaits is often difficult. Pathologic gaits with neurologic Federico P. Girardi, MD causes include frontal gait, spastic hemiparetic gait, parkinsonian Frank P. Cammisa, Jr, MD gait, cerebellar ataxic gait, and sensory ataxic gait. Pathologic gaits with combined neurologic and musculoskeletal causes include myelopathic gait, stooped gait of lumbar spinal stenosis, and steppage gait. Pathologic gaits with musculoskeletal causes include Dr. Lim is Assistant Professor of Orthopaedic Surgery, Department of antalgic gait, coxalgic gait, Trendelenburg gait, knee Orthopaedics, University of North hyperextension gait, and other gaits caused by inadequate joint Carolina–Chapel Hill, Chapel Hill, NC. mobility. A working knowledge of the characteristics of these gaits Dr. Huang is Assistant Professor of Orthopaedic Surgery, Weill Medical and a systematic approach to observational gait examination can College of Cornell University, New York, help identify the causes of abnormal gait. Patients with abnormal NY, and Assistant Attending gait can benefit from the treatment of the primary cause of the Orthopaedic Surgeon, Hospital for Special Surgery, New York. Dr. Wu is disorder as well as by general fall-prevention interventions. Assistant Professor of Neurology, Weill Treatable causes of gait disturbance are found in a substantial Medical College of Cornell University. proportion of patients and include normal-pressure hydrocephalus, Dr. Girardi is Assistant Attending vitamin B deficiency, Parkinson’s disease, alcoholism, medication Orthopaedic Surgeon, Hospital for 12 Special Surgery. Dr. Cammisa is toxicity, cervical spondylotic myelopathy, lumbar spinal stenosis, Associate Attending Orthopaedic joint contractures, and painful disorders of the lower extremity. Surgeon, Hospital for Special Surgery. None of the following authors or the departments with which they are ait abnormalities exist in ap- The mere fear of falling contrib- affiliated has received anything of value Gproximately 15% of people old- utes to the loss of functional inde- from or owns stock in a commercial er than age 64 years. By age 85, the pendence in many elderly individu- company or institution related directly or prevalence increases to 40%.1 In the als.4 In one study, nearly 20% of the indirectly to the subject of this article: elderly, gait disorders contribute to elderly acknowledged limiting their Dr. Lim, Dr. Huang, Dr. Wu, Dr. Girardi, the risk of falls and subsequent inju- activities because of the fear of fall- and Dr. Cammisa. ry. In a study of 1,103 community- ing.5 Falls also contribute to perma- Reprint requests: Dr. Lim, Department living persons older than age 72 nent institutionalization of elderly of Orthopaedics, University of North years, nearly 50% of the partici- individuals, with concomitant de- Carolina–Chapel Hill, 3152 pants experienced at least one fall cline in functional status and social/ Bioinformatics Bldg, CB #7055, during a 2.5-year period.2 Approxi- physical activities.6,7 Chapel Hill, NC 27599-7055. mately 25% of the elderly who fall Although patients rarely present experience a serious injury, and ap- to the orthopaedic surgeon with gait J Am Acad Orthop Surg 2007;15:107- proximately 5% have a fracture. Bal- abnormality as a chief complaint, 117 ance and gait impairment nearly difficulty walking is a very common Copyright 2007 by the American double the risk of falling and the risk secondary symptom. The primary Academy of Orthopaedic Surgeons. of experiencing a subsequent serious clinical focus of orthopaedic sur- injury.3 geons has been on the injuries conse- Volume 15, Number 2, February 2007 107 Evaluation of the Elderly Patient With an Abnormal Gait Table 1 Classification of Gait Disorders Neurologic Combined Neurologic/Musculoskeletal Musculoskeletal Frontal gait Myelopathic gait Antalgic gait Dementias (Alzheimer’s disease) Cervical spondylotic myelopathy Knee osteoarthritis Normal-pressure hydrocephalus Vitamin B12 deficiency Other painful disorders of the lower Binswanger’s disease (subcortical Multiple sclerosis extremity dementia) Thoracic disk herniation Coxalgic gait Spastic hemiparetic gait Stooped gait of lumbar spinal Hip osteoarthritis Cerebrovascular accident stenosis Other painful hip disorders Parkinsonian gait Steppage gait (foot drop) Mild hip abductor insufficiency Parkinson’s disease Acquired or hereditary peripheral Trendelenburg gait Drug-induced parkinsonism neuropathy Severe hip abductor insufficiency Progressive supranuclear palsy Sciatic/peroneal neuropathy Knee hyperextension gait Cerebellar ataxic gait Lumbar radiculopathy Ankle equinus contracture Alcoholism Quadriceps deficiency Phenytoin toxicity Inadequate knee extension gait Paraneoplastic syndromes Knee flexion contracture Hereditary ataxias Inadequate knee flexion gait Sensory ataxic gait Knee extension contracture or Tabes dorsalis (syphilis) fusion Vitamin B12 deficiency Inadequate hip extension gait Polyneuropathy (diabetes, HIV, Hip flexion contracture neurotoxic medications) HIV = human immunodeficiency virus quent to falling. However, by identi- Parkinson’s disease, and cerebellar must coordinate the maintenance of fying causes of gait disorders, or- degeneration9,10 (Table 1). balance. Once motor activity is thopaedic surgeons can play an im- generated, feedback and modulation portant role in a multidisciplinary Normal Gait are relayed through the cerebellum. effort to prevent falls and improve As the support shifts from one leg the quality of life in the elderly. Normal gait is an unconsciously co- to the other in a dynamic equilib- The identification of the cause of ordinated activity resulting from rium, reflexive adjustments of the a gait abnormality can be challeng- the interaction between the muscu- legs and trunk must occur. These re- ing because many abnormal gaits in loskeletal and nervous systems. In flexive adjustments are based on sen- the elderly look similar. Common animals, the center of walking coor- sory information from the visual, compensatory patterns of gait often dination lies in the pattern genera- vestibular, and proprioceptive sys- mask the helpful characteristic fea- tor of the spine. Lower order animals tems.11,12 tures. For example, the cautious gait have the capacity for stepping when of the elderly, with short wide steps this spinal pattern generator is stim- Gait Cycle and increased time in double-limb ulated. In contrast, walking in support, is entirely nonspecific.8 Fol- higher order primates depends on To begin walking, one foot is raised lowing an exhaustive diagnostic supraspinal activity. Locomotion and accelerated forward. The hip and workup, many gait disturbances are centers have been identified in the knee flex and the ankle dorsiflexes found to be nonspecific and multi- brainstem. Spontaneous walking re- as the foot clears the ground. Muscle factorial. However, potentially treat- quires the basal ganglia and thala- action on the supporting contralater- able causes of gait impairment can mus, as well, but not the cerebral al leg accelerates the body’s center of be found in nearly one third of pa- cortex. Clearly, however, the higher gravity forward. The moving foot is tients. The most common causes of centers in the cerebral cortex are im- then placed on the ground, and gait disorder in the elderly are portant in initiating and directing weight is subsequently transferred cerebral infarcts, painful arthritic ambulation.11,12 to that leg. The heel strikes the disorders of the lower extremities, In addition to generating motor ac- ground first, followed by gradual cervical spondylotic myelopathy, tivity, the central nervous system also transfer of weight to the sole and 108 Journal of the American Academy of Orthopaedic Surgeons MoeR.Lim,MD,etal Figure 1 Phases Stance Swing Initial Second Single-limb Initial Mid- Terminal Periods Double-limb Double-limb Stance Swing Swing Swing Support Support Foot Strike Opposite (Reversal of Opposite Toe-Off Foot Tibia Foot Strike Toe-Off Fore-Aft Foot Clearance Vertical Shear) Strike % of Cycle 0% 62% 100% The normal gait cycle. (Adapted with permission from Sutherland DH, Kaufman KR, Moitoza JR: Kinematics of normal human walking, in Rose J, Gamble JG [eds]: Human Walking, ed 2. Baltimore, MD: Williams and Wilkins, 1994, pp 23-44.) then to the toes. The other foot is vice versa. Stance takes up about distance between the two feet), and then raised and accelerated forward. 60% of the time of the gait cycle and stride length (longitudinal distance The body is held erect, with the head the swing phase, about 40%. Both covered during a complete gait cycle, facing forward and the arms swing- feet are on the ground for two peri- representing the sum of the left and ing equally, smoothly, and loosely. ods during each cycle. Each of these right step lengths).12 The pelvis and shoulders remain rel- double-support periods lasts for atively level. As the body passes over about 10% of the cycle. Normal Gait of Elderly the weight-bearing leg, it displaces The gait cycle can be further char- the center of gravity toward the acterized by subdividing each of the The globally degenerative changes of weight-bearing side, causing a slight phases. The stance phase is subdi- aging have deleterious effects on side-to-side movement with each vided into initial double-limb sup- gait. Therefore, it may