What to check for in a 17-year-old patient with a history of concussion (traumatic brain injury) now presenting with abnormal gait?

Evaluation of Abnormal Gait in a 17-Year-Old Post-Concussion Patient

This patient requires immediate assessment for structural brain injury, vestibular dysfunction, and cervical spine pathology, as gait abnormality is a specific indicator of concussion and may signal incomplete recovery or complications requiring urgent intervention. 1

Immediate Red Flags to Assess

Rule out structural lesions first - any patient with persistent or new neurological deficits after concussion warrants neuroimaging. 1 Specifically evaluate for:

• Prolonged disturbance of conscious state - any alteration in mental status beyond initial injury 1
• Focal neurological deficits - weakness, sensory changes, or cranial nerve abnormalities 1
• Seizure activity - including any convulsive movements since injury 1
• Persistent clinical symptoms - symptoms lasting beyond expected recovery timeline 1
• Signs of increased intracranial pressure - worsening headache, repeated vomiting, increased sleepiness, or abnormal behavior 2

If any of these are present, obtain CT head immediately to evaluate for intracranial hemorrhage (subdural, epidural, intracerebral, or subarachnoid). 1 CT is the test of choice within the first 24-48 hours post-injury for detecting hemorrhage and skull fractures. 1

Comprehensive Physical Examination Components

Balance and Gait Assessment

Perform structured balance testing using validated tools:

• Balance Error Scoring System (BESS) - standardized assessment with documented sensitivity for concussion-related balance deficits 1, 3
• Tandem gait testing - walk heel-to-toe in straight line; abnormality present in approximately 30% of pediatric concussion patients 3
• Romberg test - standing with feet together, eyes closed 3
• Dual-task gait assessment - walking while performing cognitive task to unmask subtle deficits 1

Important caveat: Balance testing should occur more than 15 minutes after cessation of exercise and not on the sideline, as immediate post-exercise testing reduces reliability. 1

Vestibular System Evaluation

Gait abnormality after concussion frequently indicates vestibular dysfunction. 4 Assess:

• Oculomotor function - smooth pursuits, saccades, convergence, and vestibulo-ocular reflex 4
• Dizziness provocation - symptoms with head movements or position changes 4
• Nystagmus - spontaneous or positional 4

Cervical Spine Assessment

Critical and often overlooked: Concussive mechanisms can cause concurrent cervical injury that produces gait abnormality. 4, 5 Examine:

• Cervical range of motion - pain or restriction with movement 4
• Cervical tenderness - palpation of spinous processes and paraspinal muscles 4
• Upper extremity neurological examination - strength, sensation, and reflexes to identify radiculopathy 4

Neurological Examination

Complete assessment including:

• Coordination testing - finger-to-nose, heel-to-shin for cerebellar function 1
• Muscle strength - systematic testing of all major muscle groups 6
• Sensory examination - light touch and proprioception 6
• Deep tendon reflexes - symmetry and pathological reflexes (Babinski) 6
• Gait pattern characterization - identify specific pattern (ataxic, spastic, steppage, waddling) 6

Cognitive and Symptom Assessment

• Standardized Symptom Checklist - Post-Concussion Symptom Scale (PCSS) to quantify symptom burden 1, 3
• Cognitive screening - orientation, memory (immediate and delayed), concentration, and information processing speed 1, 2
• Standardized Assessment of Concussion (SAC) - validated sideline tool with 95% sensitivity for concussion when decreased from baseline 1

Timing Considerations

This presentation is concerning for prolonged or incomplete recovery. 1 The typical concussion recovery timeline is 2-4 weeks in most patients. 4 Gait abnormality persisting beyond the acute period (days to weeks post-injury) suggests:

• Unresolved concussion with ongoing neurometabolic dysfunction 1
• Specific subsystem injury (vestibular, cervical, or visual) requiring targeted rehabilitation 4
• Possible structural complication requiring imaging 1

Immediate Management Steps

1. Remove from all physical activity immediately - no return to play or practice 1
2. Mandate cognitive rest - 2-3 days off school with strict avoidance of strenuous mental activity 2
3. Arrange specialist referral - to TBI specialist or sports medicine physician trained in concussion management, particularly given female gender and persistent symptoms as risk factors for prolonged recovery 2
4. Provide monitoring instructions - clear written guidelines for return to emergency department if deterioration occurs 1, 2

Common Pitfalls to Avoid

• Do not attribute all gait abnormality to concussion alone - concurrent cervical or vestibular injury is common and requires specific treatment 4, 5
• Do not delay neuroimaging if red flags present - structural lesions require urgent identification 1
• Do not use isolated balance testing as sole assessment - combination of PCSS, BESS, tandem gait, and Romberg identifies significantly more patients with deficits than any single test 3
• Do not allow return to activity while symptomatic - "when in doubt, sit them out" 1
• Do not overlook need for academic accommodations - cognitive rest is as important as physical rest 2, 7