Musculoskeletal & Integumentary · Topic 7 of 11

Gait Disturbances

Neuro & musculoskeletal · gait assessment

Gait Disturbances

Watch the patient walk: the pattern localizes the lesion — cerebellum, proprioception, basal ganglia, upper motor neuron, peripheral nerve or muscle.

Key numbers

Timed Up and Go ≥ 12 sTUG ≥ 12 s

01 · Look forWide-based, lurching gait: cerebellar

Cerebellar ataxia gives a wide-based, unsteady gait with irregular, unpredictable trunk sway and variable step length and width; finger-to-nose and heel-to-shin testing are abnormal.

02 · Look forShuffling with festination: parkinsonism

Parkinsonian gait: trouble starting, turning and stopping; short shuffling steps with flexed posture and little arm swing; festination (steps quicken and shorten) that can lead to freezing, propulsion or retropulsion.

03 · Look forPositive Romberg: lost position sense

Inability to stand with feet together and eyes closed (Romberg) means impaired lower-extremity position sense — sensory ataxia from dorsal column disease (eg, B12 deficiency) or neuropathy; patients watch their feet to avoid falling.

Causes & risk factors

Why it happens

Antipsychotics can cause parkinsonian gaitDopamine-blocking drugs (typical and atypical antipsychotics) can reduce arm swing and, rarely, cause festination; multiple psychoactive drugs make cadence and stride highly variable.

Presentation

What you'll see

Spastic leg circumducts: upper motor neuron lesion must knowA spastic leg that cannot flex at the knee swings outward in an arc (circumduction) with the trunk leaning to the strong side — the hemiparetic gait of an upper motor neuron lesion such as stroke.

High-stepping gait: foot drop must knowA steppage gait (lifting the leg high to clear the toe) means foot drop from tibialis anterior weakness, eg, a peroneal neuropathy at the lateral knee from trauma, compression or diabetes.

Waddling gait: proximal pelvic muscle weaknessWeakness of the pelvic girdle muscles causes a waddling gait; weakness of the stance-side gluteus medius lets the pelvis drop toward the swinging leg.

Scissoring: spastic legs cross the midlineIn scissoring, spastic legs cross an imaginary central line with each step, like a runway walk; it reflects lower-limb spasticity from upper motor neuron disease.

Magnetic gait, incontinence, dementia: NPHNormal pressure hydrocephalus causes a magnetic gait (feet seem stuck to the floor) with urinary incontinence and dementia; improvement after removing 30–50 mL CSF by lumbar puncture predicts response to a ventriculoperitoneal shunt.

Antalgic gait: short stance on painful sideAn antalgic (painful) gait shortens stance time on the painful leg and leans the trunk over the stance leg to unload an arthritic hip or knee; arthritis is the most common cause of gait disorders in older adults.

Feet stuck at start: frontal gait disorderGait initiation failure (feet seem stuck), freezing, variable step width and path deviation suggest a frontal or subcortical gait disorder (eg, NPH) or a cautious gait from fear of falling.

Diagnosis & monitoring

Work-up

Timed Up and Go ≥ 12 sIn the Timed Up and Go, the patient rises from a chair, walks 3 m (10 ft), turns, returns and sits; an older adult taking ≥ 12 seconds is at risk for falling.

Slow gait speed predicts disability and deathGait speed, chair-rise time and tandem stance independently predict loss of instrumental ADLs, nursing home admission and death; gait speed predicts mortality as strongly as the number of chronic conditions.

Cerebellar or sensory ataxia?

Commonly confused

Lesion	Cerebellum
Eyes open	Already unsteady, wide-based
Romberg	Unsteady even with eyes open — test with feet as close as tolerated
Other findings	Abnormal finger-to-nose and heel-to-shin

More detail

Reference

Show 6 reference facts

The short step belongs to the healthy leg: a weak or painful leg shortens its own stance phase, so the opposite (normal) leg takes the shorter step.

With normal aging gait speed is stable until about 70, then slows through shorter steps at an unchanged cadence; double-stance time increases and the legs rotate outward about 5°.

Postural instability early in parkinsonism suggests a diagnosis other than Parkinson disease; retropulsion occurs with frontal gait disorders, parkinsonism, CNS syphilis and progressive supranuclear palsy.

The Tinetti performance-oriented mobility gait score is out of 12; a score < 10 usually means limited mobility-related function.

Patients with cerebellar disease are unsteady with eyes open, so for the Romberg they first stand with feet as close as they can manage and then close their eyes; rarely, severe bilateral vestibular loss causes a positive test.

Treatment targets each contributing cause, plus strength and balance training and a properly fitted assistive device.

Pearl

Wide and lurching with eyes open is cerebellar; steady until the eyes close is proprioceptive — that is the Romberg.

Sources · Merck Manual Professional — Gait Disorders in Older Adults (reviewed Aug 2025) · Merck Manual Professional — How To Assess Gait, Stance, and Coordination · Merck Manual Professional — How To Assess Sensation (Romberg test) · Merck Manual Professional — Normal Pressure Hydrocephalus · Merck Manual Professional — Parkinson Disease · CDC STEADI — Assessment: Timed Up & Go (TUG) · Merck Manual Professional — Vitamin B12 Deficiency (loss of position and vibratory sense, ataxia) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).