What is Steppage Gait?
Steppage gait is a walking issue caused by an inability to lift the foot due to weak foot muscles, often leading to a condition known as ‘foot drop’. Foot drop isn’t very common. Typically, a person with foot drop might suddenly find it hard to lift their foot while walking. This could be as a result of unusual physical activity, undergoing surgery, staying in bed for a very extended period of time, breaking a bone in an accident, or wearing a cast that’s too tight on the lower part of their body.
Another possible cause is something called ‘collagen vascular diseases’ which can affect blood flow to the nerves. Peripheral neuropathies, nerve conditions often caused by diabetes, can also cause foot drop, affecting one or both feet. Some form of nerve damage can also cause foot drop. However, this situation often comes with additional issues like weakened movement on one side of the body (hemiplegia) and difficulty with speaking or understanding speech (aphasia).
What Causes Steppage Gait?
Foot drop and steppage gait, which is a specific kind of limp, can be caused by any damage or pressing on the nerves running from our brain to our legs. Potential causes to this could be from injuries such as broken bones in the pelvis or leg, a tight cast, or being in a certain position for too long during surgery. Foot drop could also be caused by something taking up space and pressing on the nerves along this path. Certain illnesses such as lupus or Waldenstrom macroglobulinemia, which can cause vasculitis (the inflammation of blood vessels), hindering blood flow to the nerves, are also potential causes.
Peripheral neuropathies are conditions affecting the nerves in the outer parts of the body, and they may damage the protective covering of nerves (demyelinating) or the nerves themselves (axonal), or both. You could be born with these conditions, or acquire them later due to inflammation. The inflammation could be short-term or long-term, as seen with conditions like the Acquired Inflammatory Demyelinating Polyneuropathy (AIDP) and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP). Inherited conditions like Charcot-Marie Tooth (CMT) and Hereditary Preponderance to Pressure Palsies (HNPP) also exist. Rare instances include conditions like Nonaka Myopathy, Glycyl-tRNA Synthetase 1-associated axonal neuropathy, and alkaptonuria.
There are other potential causes for damage to nerves, such as exposure to toxins, viral or bacterial infections, and even certain chemotherapy drugs. Conditions like diabetes, alcohol intoxication, and kidney disease can cause mixed damage to the protective nerve covering and the nerve itself.
The most common causes of foot drop include strokes (also known as a Cerebral Vascular Accident), and a condition called Amyotrophic Lateral Sclerosis (ALS). Strokes can cause one-sided body weakness or paralysis and difficulties with swallowing, speech, or language abilities.
An upper motor neuron type of foot drop can be recognized by a specific type of limping, often referred to as “cock-walk gait”.
Risk Factors and Frequency for Steppage Gait
Peroneal neuropathy is a condition that happens more often in males than females, with the ratio being approximately 2.8 to 1. About 90% of the time, this condition affects just one side of the body, with no specific side being more prone. Certain procedures may increase the risk of peroneal neuropathy:
- After a total knee replacement surgery, also known as total knee arthroplasty (TKA), there’s a 0.3 to 4% chance of occurrence.
- Between 3 and 13% of patients may end up with a condition called foot drop after a surgery called proximal tibial osteotomy.
Signs and Symptoms of Steppage Gait
If a person is struggling with walking like before due to muscle weakness that helps lift the front of the foot, it could be a sign of a specific health issue. This can also lead to falls. This usually occurs in individuals who have had a stroke, autoimmune diseases, undergone surgery, broken their shin or calf bone, or have been bedridden for a prolonged period like in an Intensive Care Unit.
In a physical examination, doctors will notice weakness in the muscles at the front of the leg. There might also be a loss of sensation in the front of the foot. Reflexes could be unusually strong, with an upward-pointing foot reflex in stroke patients, or missing in cases of disorders that affect the lower motor neurons – these are the nerve cells that control muscles.
Testing for Steppage Gait
If you’ve experienced a trauma and there’s a possibility that you might have fractures or dislocations in your pelvis or the bone between your knee and ankle (tibia or fibula), your doctor may order X-rays to check for these issues. If there’s a suspicion that you may have problems with your nerves (plexopathies), an MRI (magnetic resonance imaging) scan might be recommended. This is a type of imaging test that uses strong magnets and radio waves to create detailed images of the inside of your body.
If there’s a possibility that you have an autoimmune disease, which is a condition where your immune system attacks your own body thinking it’s foreign, your doctor may order tests to check for certain markers in your blood. These markers include rheumatoid factor and antinuclear antibody (ANA), which are often present in people with autoimmune diseases. Your doctor may also recommend a complete blood count, which evaluates the cells in your blood, as well as other tests to make sure you don’t have an infection in your blood (sepsis).
Your doctor may also use tests called electromyography (EMG) and nerve conduction velocity (NCV) to learn more about how your nerves and muscles are functioning. These tests can show if there’s any damage to the nerves or muscles that might be causing your symptoms. If the EMG shows a complete loss of nerve function along with signs that a nerve was injured, you may be fitted with a brace for your ankle and foot (ankle-foot orthosis) to keep your foot positioned properly during walking.
This brace can help enhance your mobility, but it’s important to regularly check your skin for any pressure sores, as you may not feel any discomfort due to the nerve damage. You’ll also need to ensure that you wear shoes that can accommodate the size of the brace.
In mild cases, attending physical therapy sessions can be beneficial. Here, you can learn exercises that can help alleviate your pain, strengthen your weak muscles, and maintain your ankle’s range of motion to prevent stiffening of joints (contractures).
Treatment Options for Steppage Gait
If you’ve got a mild case of this condition, your doctor may recommend you to see a physical therapist. The physical therapist will show you special exercises to reduce pain and strengthen your muscles. They’ll also show you movements to keep your ankle flexible, preventing any stiffness that might occur if you’re not moving it much due to pain.
If an electromyogram (EMG, a test that detects activity in muscles and nerves) shows full loss of connection along your nerves, you may need to use a brace on your ankle and foot, also known as an ankle-foot orthosis (AFO). The brace supports your foot in a neutral position during the part of walking where you push off with your toes. If you’re going to be wearing a brace, make sure to regularly check your skin where the brace touches it. This is because feet that can’t feel anything due to nerve damage might get pressure sores from the brace. Also, ensure your shoe is large enough to fit the brace comfortably.
In some cases, you might require surgery, like transferring a tendon (the tissue that connects a muscle to a bone) from the back of your calf to help treat a condition called foot drop, which can cause you to walk with a heightened stepping gait.
Finally, the therapist may give you exercises to perform at home. Incorporating a home exercise program into your daily routine could be key to your therapy.
What else can Steppage Gait be?
The diagnosis for this specific medical condition can be challenging because it involves a broad spectrum of neuromuscular disorders that can stem from different areas of the body – from the brain to the peripheral nerves.
Here are several possible causes:
- Central triggers like strokes or multiple sclerosis which affect the brain or spinal cord. People with these conditions also exhibit symptoms like exaggerated reflexes, increased muscle tension, and issues with bladder and bowel control.
- Lumbar radiculopathy due to disc displacement or spinal stenosis in the lower back.
- Problems with the lumbar plexus – a network of nerves in the lower back.
- Damage to the sciatic nerve which runs from the lower back to the back of each leg.
Foot weakness may also reflect particular conditions affecting the way a person walks. These include:
- Circumduction gait: This type of walking pattern is caused by upper motor neuron involvement in stroke and leads to weakness in the entire extremity. People walk with a circumduction gait where the limb is artificially long due to paralysis. Other stroke signs such as swallowing difficulties, speech problems and upper limb weakness are also present.
- Cerebellar gait: When the cerebellum, which controls balance, is impacted, it could result in difficulties in tandem walking.
- Ataxic gait: The inability to walk normally is evident when both sides are affected. Lack of proprioception (body awareness) and position sense due to spinal cord involvement leads to a distinct high-stepping and sway from side to side. This condition is common with alcohol misuse.
- Parkinsonian gait: Seen in Parkinson’s disease, this ambulating pattern is due to changes in the substantia nigra (a brain region). It manifests with difficulties initiating movement, leading to a ‘shuffling’ gait. Additionally, these changes disturb the smooth transition of the gait cycle phases and potentially cause falls. Braces, if ill-fitted, could potentially cause skin abrasions due to friction on insensitive skin. They may also become loose over time due to wear and tear.
What to expect with Steppage Gait
The tests known as EMG (Electromyography) and NCV (Nerve Conduction Velocity) are useful tools for diagnosing the type and location of nerve compression, as well as predicting the outcome. If these tests reveal a delay in signal transmission and slow speed, coupled with blockage of conduction at the affected segment with no evidence of nerve damage (denervation potentials), and plenty of motor units (which are necessary for muscle function) observed during the needle EMG test, it suggests a condition called neurapraxia. Neurapraxia generally has a good outcome.
On the other hand, if the tests show signs of nerve damage (denervation potentials) along with no functioning motor units, the prognosis or outcome tends to be more uncertain.
Possible Complications When Diagnosed with Steppage Gait
The issues often come from not being able to lift the foot properly while walking, which can lead to falls. A brace that doesn’t fit correctly may rub against the skin that has reduced sensation, possibly leading to skin scrapes. Over time, brace components might wear out and become loose.
Common Problems:
- Difficulty in walking leading to falls
- Skin abrasions from ill-fitting brace
- Loose brace components due to wear and tear
Recovery from Steppage Gait
Meeting with a specialist in physical medicine and rehabilitation, often called a physiatrist, is an important step. They will conduct a careful evaluation, perform tests using electricity to study the nerves and muscles, and manage any required support devices like braces.
Usually, it’s the physiatrist who arranges for a patient to see a physiotherapist, a professional who helps people regain movement and physical ability after an injury or illness.
Additionally, a physiatrist can refer the patient to an orthotist, a healthcare professional who designs and fits braces and other devices to support people’s bodies when they have weakened or damaged areas due to conditions or injuries.
Preventing Steppage Gait
The patient plays a crucial role in their treatment journey. They should be involved in all major decisions, such as identifying their medical condition and picking from different treatment options. Learning about things like exercise routines, at-home workout programs, skin care tips, and how to take care of a medical brace can really help to improve the results of treatment.
