Each gait points to a specific level of the nervous system
Mnemonic
“Romberg separates the two ataxias” and each gait names its lesion:
- Hemiplegic - leg extended, foot circumducted. Unilateral upper motor neurone
- Scissoring - stiff, legs crossing. Bilateral upper motor neurone, cord
- Cerebellar ataxic - broad based, veering towards the lesion. Romberg negative
- Sensory ataxic - broad based, stamping, watches the feet, worse in the dark. Romberg positive
- Parkinsonian - stooped, shuffling, reduced arm swing, festinant
- High stepping - foot drop, common fibular nerve or L5
- Waddling - proximal myopathy, bilateral Trendelenburg
- Apraxic - feet “stuck to the floor”, normal pressure hydrocephalus
Romberg’s test is positive when the patient is steady with eyes open but unsteady on closing them, indicating proprioceptive (dorsal column) loss. Cerebellar ataxia is unsteady with the eyes open, so Romberg is negative; calling that a positive Romberg is the commonest error in the examination.
Always ask for tandem, heel and toe walking, since subtle ataxia and foot drop appear only on these.
Expansion
| Gait | Appearance | Lesion |
|---|---|---|
| Hemiplegic | Leg extended, foot circumducted, arm flexed | Unilateral upper motor neurone |
| Spastic (scissoring) | Stiff, narrow, legs cross | Bilateral upper motor neurone, cord |
| Cerebellar ataxic | Broad based, staggering, veers to the side of the lesion | Cerebellum |
| Sensory ataxic | Broad based, high stepping and stamping, watches feet, worse in the dark | Dorsal columns |
| Parkinsonian | Stooped, shuffling, reduced arm swing, festinant, difficulty turning | Basal ganglia |
| High stepping | Foot drop, slaps the ground | Common peroneal or L5 |
| Waddling | Pelvis drops on the swinging side | Proximal myopathy, bilateral Trendelenburg |
| Antalgic | Short stance phase on the painful side | Pain |
| Apraxic | Feet appear stuck to the floor, magnetic | Frontal, normal pressure hydrocephalus |
Romberg’s test separates the two ataxias. It is positive when the patient is steady with the eyes open but unsteady on closing them, indicating proprioceptive (dorsal column) loss. Cerebellar ataxia is unsteady with the eyes open, so Romberg is negative; calling that a positive Romberg is a common error.
Normal pressure hydrocephalus gives the triad of gait apraxia, urinary incontinence and dementia, and the gait is usually the first and most treatable feature.