What type of neurological gaits are associated with peripheral neuropathy?

Neurological Gaits Associated with Peripheral Neuropathy

Peripheral neuropathy most commonly presents with a steppage gait characterized by high foot lifting and slapping due to distal weakness and sensory loss in a stocking-and-glove distribution. 1

Common Gait Patterns in Peripheral Neuropathy

Steppage Gait (Most Common)

• Characterized by high lifting of the foot to avoid dragging toes
• Foot slap during heel strike due to weakness of ankle dorsiflexors
• Exaggerated hip and knee flexion to compensate for foot drop
• More pronounced in the feet than hands due to length-dependent nature of most neuropathies 2

Sensory Ataxic Gait

• Wide-based, unsteady gait with irregular stepping
• Worsens with eyes closed (positive Romberg sign)
• Results from loss of proprioception and vibratory sensitivity
• Patient may look down at feet while walking to compensate for sensory loss 1
• Often associated with changes in proprioception and vibratory sensitivity 2

Mixed Patterns

• Combination of steppage and ataxic features
• Particularly common in diabetic polyneuropathy
• May include elements of:
  • Foot drop (motor component)
  • Sensory ataxia (sensory component)
  • Painful stepping (neuropathic pain component) 1

Underlying Pathophysiology

The gait abnormalities in peripheral neuropathy result from:

1. Motor Deficits:

   • Distal weakness affecting ankle dorsiflexors (foot drop)
   • Occurs in approximately 10% of peripheral neuropathy cases 2
   • Results in characteristic high-stepping to avoid toe dragging

2. Sensory Deficits:

   • Loss of proprioception and vibratory sense
   • Reduced touch detection threshold
   • Impaired sharpness detection
   • Elevated thresholds for temperature sensation 2
   • Results in unsteady, ataxic components of gait

3. Pain and Paresthesia:

   • Stinging sensations or numbness in distal extremities
   • Pain that typically does not subside between episodes
   • Can cause antalgic components to gait 2

Clinical Assessment of Neuropathic Gait

When evaluating gait in suspected peripheral neuropathy:

• Observe for high-stepping pattern and foot slap
• Test for reduced deep tendon reflexes proportional to sensory loss
• Evaluate proprioception and vibratory sensitivity
• Assess for stocking-and-glove distribution of sensory symptoms
• Look for greater involvement of feet compared to hands (length-dependent pattern) 2, 1

Special Considerations

Autonomic Involvement

• Orthostatic hypotension occurs in about 10-12% of peripheral neuropathy cases
• Can contribute to gait instability and fall risk 2

Small vs. Large Fiber Involvement

• Large fiber neuropathy: More pronounced proprioceptive deficits and sensory ataxia
• Small fiber neuropathy: More pain and temperature sensation abnormalities with less effect on gait 1

Parkinson's Disease with Peripheral Neuropathy

• Peripheral neuropathy affects 40.4% of Parkinson's patients
• When present with Parkinson's, results in:
  • Shorter stride length
  • Slower gait speed
  • Smaller toe-off angles
  • Greater balance impairment, especially with eyes closed 3

Diagnostic Approach

Proper diagnosis of neuropathic gait requires:

• Nerve conduction studies and electromyography to identify mononeuropathies vs. polyneuropathy
• Differentiation between axonal and demyelinating patterns
• Skin biopsy for small fiber neuropathy if electrodiagnostic studies are normal 2, 1

Recognizing the characteristic gait patterns associated with peripheral neuropathy is essential for proper diagnosis and management, as these gait abnormalities significantly impact mobility, fall risk, and quality of life.