Background

Steppage gait, also known as foot drop gait, is a distinct abnormal walking pattern characterized by difficulty in lifting the foot and toes while taking a step. It is named “steppage gait” because affected individuals may have a high stepping gait with exaggerated hip and knee flexion to clear the foot from the ground during the swing phase of walking.

This gait abnormality is typically associated with weakness or paralysis of the muscles responsible for dorsiflexion (lifting the foot upward) and eversion (turning the sole of the foot outward).

Epidemiology

Steppage gait, also known as foot drop, can occur as a symptom of various underlying conditions or injuries, and its epidemiology is closely linked to the prevalence of these causative factors. Here is an overview of the epidemiology of some common conditions associated with steppage gait:

Peripheral Neuropathy: Peripheral neuropathy is a leading cause of foot drop and steppage gait. It has a diverse range of etiologies, including diabetes mellitus, alcoholism, nutritional deficiencies, and autoimmune disorders. The prevalence of peripheral neuropathy varies depending on the underlying cause, but it is estimated that up to 7% of the general population may be affected by peripheral neuropathy to some extent.

Nerve Root Compression: Conditions such as herniated discs and spinal stenosis can lead to nerve root compression and subsequent foot drop. The prevalence of spinal conditions varies across populations, with estimates ranging from 1 to 27% for disc herniation and 4 to 11% for spinal stenosis.

Traumatic Nerve Injury: Trauma or injuries that affect the nerves in the lower leg, such as fractures, dislocations, or direct trauma, can result in foot drop and steppage gait. The incidence of traumatic nerve injuries varies depending on the specific population and the nature of the trauma.

Muscular Dystrophy: Muscular dystrophy is a group of genetic disorders characterized by progressive muscle weakness and degeneration. Duchenne muscular dystrophy, the most common form, predominantly affects males and has an estimated incidence of approximately 1 in 5,000 live male births.

Stroke: Foot drop can occur as a result of damage to the brain or spinal cord caused by a stroke. The incidence and prevalence of stroke vary across populations and increase with age. In high-income countries, the annual incidence of stroke ranges from 100 to 300 cases per 100,000 population.

Anatomy

Pathophysiology

The pathophysiology of steppage gait, also known as foot drop, involves abnormalities in the neuromuscular control and biomechanics of the lower limb. It typically results from weakness or paralysis of the muscles responsible for dorsiflexion (lifting the foot upward) and eversion (turning the sole of the foot outward). The underlying causes of foot drop can vary, and the pathophysiology may differ based on the specific etiology. Here are some common mechanisms involved:

Peripheral Nerve Dysfunction: Peripheral nerve dysfunction is a common cause of foot drop. It can occur due to nerve compression, trauma, or diseases affecting the peripheral nerves. Nerve damage disrupts the normal transmission of signals from the brain and spinal cord to the muscles involved in foot and ankle movement. The nerves most commonly affected include the common peroneal nerve (a branch of the sciatic nerve) and its branches.

Muscle Weakness or Paralysis: Weakness or paralysis of the muscles involved in dorsiflexion and eversion of the foot can lead to foot drop. The primary muscles affected are the tibialis anterior and the extensor muscles of the toes. Muscle weakness or paralysis can result from various conditions, such as muscular dystrophy, motor neuron diseases, stroke, or direct trauma to the muscles.

Disrupted Neural Circuits: The loss of normal neural input and control disrupts the coordinated activity of the lower limb muscles during the gait cycle. Impaired activation of the dorsiflexor muscles leads to difficulty in lifting the foot and clearing it from the ground during the swing phase of walking. The compensatory mechanism of hip and knee flexion during swing phase, characteristic of steppage gait, helps prevent tripping or dragging the foot.

Altered Biomechanics: The absence or weakness of dorsiflexion and eversion movements affects the biomechanics of the foot and ankle. When the foot is not properly lifted during swing phase, it may strike the ground with the toes pointed downward, resulting in an increased risk of stumbling or tripping. To compensate for foot drop, individuals may adopt an exaggerated high stepping gait, with increased hip and knee flexion, to clear the foot during walking.

Sensory Impairments: In some cases, sensory impairments can contribute to the pathophysiology of foot drop. Loss of sensation or abnormal sensation in the foot and lower leg can disrupt the proprioceptive feedback necessary for normal muscle activation and coordination during gait.

Etiology

Steppage gait, also known as foot drop, can have various underlying etiologies. It is important to identify the specific cause of foot drop to guide appropriate treatment and management. Here are some common etiologies of steppage gait:

• Peripheral Nerve Dysfunction: Dysfunction or damage to the peripheral nerves that control the muscles involved in foot and ankle movement is a frequent cause of foot drop. This can occur due to conditions such as:
• Peripheral neuropathy: Conditions like diabetic neuropathy, hereditary neuropathies, autoimmune neuropathies, or nutritional deficiencies can affect the peripheral nerves and lead to foot drop.
• Nerve compression: Compression of the nerves can occur at various sites, such as the lumbosacral plexus, sciatic nerve, or common peroneal nerve, due to conditions like herniated discs, spinal stenosis, or entrapment syndromes (e.g., peroneal nerve entrapment).
• Traumatic nerve injury: Direct trauma, fractures, dislocations, or nerve lacerations can result in nerve damage and subsequent foot drop.
• Muscle Weakness or Paralysis: Weakness or paralysis of the muscles responsible for dorsiflexion and eversion of the foot can lead to foot drop. This can be caused by conditions such as:
• Muscular dystrophy: Inherited muscular dystrophies, such as Duchenne muscular dystrophy, can result in progressive muscle weakness, including weakness in the dorsiflexor muscles.
• Motor neuron diseases: Conditions like amyotrophic lateral sclerosis (ALS) or spinal muscular atrophy (SMA) can lead to muscle weakness and foot drop.
• Stroke: Damage to the brain or spinal cord due to a stroke can affect the motor pathways that control foot and ankle movement, resulting in foot drop.
• Structural Abnormalities: Structural abnormalities in the foot or ankle can contribute to foot drop. These may include:
• Tendon disorders: Conditions like Achilles tendon rupture, posterior tibial tendon dysfunction, or peroneal tendon pathology can disrupt the normal function of the foot and ankle muscles.
• Joint deformities: Arthritis, joint contractures, or congenital abnormalities can affect joint mobility and lead to foot drop.
• Other Causes: Other less common causes of foot drop and steppage gait include:
• Infections: Certain infections, such as Lyme disease, can affect the peripheral nerves and cause foot drop.
• Tumors or masses: Tumors or masses in the lower back, pelvis, or leg can compress or infiltrate the nerves, resulting in foot drop.
• Medications or toxins: Some medications or toxic substances, such as certain chemotherapy drugs or heavy metals, can cause peripheral neuropathy and foot drop.

Genetics

Prognostic Factors

The prognosis of steppage gait, also known as foot drop, depends on several factors, including the underlying cause, the severity of the condition, and the individual’s overall health and response to treatment. In some cases, the prognosis can be favorable with appropriate management, while in other cases, it may be more challenging to achieve significant improvement. Here are some factors that can influence the prognosis of steppage gait:

Underlying Cause: The prognosis is closely tied to the underlying cause of foot drop. If the cause is reversible, such as a nerve compression that can be surgically addressed or a medication-induced neuropathy that can be resolved by changing medications, the prognosis may be favorable. However, if the underlying cause is progressive or irreversible, such as certain neurological disorders or muscular dystrophy, the prognosis may be more guarded.

Timeliness of Intervention: Early recognition and prompt initiation of treatment can improve the prognosis of foot drop. Identifying and addressing the underlying cause as soon as possible can prevent further damage or worsening of symptoms and optimize the chances of recovery.

Treatment Approach: The effectiveness of the chosen treatment approach can impact the prognosis. Treatment modalities such as physical therapy, assistive devices, and surgical interventions can significantly improve gait function and mobility in many cases. Compliance with treatment recommendations and active participation in rehabilitation programs can contribute to better outcomes.

Individual Factors: Individual factors, such as age, overall health, and the presence of other comorbidities, can influence the prognosis. Younger individuals may have a better capacity for recovery and adaptation compared to older individuals. Additionally, comorbid conditions or complications may impact the overall prognosis and functional outcomes.

Rehabilitation and Adherence to Treatment: Active participation in physical therapy and rehabilitation programs is crucial for improving gait function and achieving optimal outcomes. Adherence to treatment recommendations, including exercises, assistive devices, and lifestyle modifications, can significantly influence the prognosis.

Safety Measures: Implementing safety measures and strategies to prevent falls and injuries is important to minimize the risk of complications. Adequate precautions, environmental modifications, and patient education on fall prevention can contribute to a better prognosis.

Psychological and Emotional Support: Addressing the psychological and emotional aspects of living with foot drop is essential. Supportive measures, counseling, and access to appropriate resources can help individuals cope with the challenges associated with the condition and improve their overall well-being.

Clinical History

Clinical history

The clinical history of a patient with steppage gait, also known as foot drop, involves gathering information about the patient’s symptoms, medical history, and any potential underlying causes or contributing factors. Here are some key aspects to consider when taking the clinical history:

• Onset and Duration: Determine when the foot drop symptoms began and whether they have been present continuously or intermittent. Assessing the duration of symptoms can help differentiate acute from chronic causes.
• Symptom Description: Ask the patient to describe their specific symptoms. Typical complaints include difficulty lifting the foot or toes, dragging the foot while walking, tripping or stumbling frequently, and experiencing a sense of weakness or numbness in the affected leg.
• Progression: Inquire about the progression of symptoms over time. Determine if the foot drop has been worsening gradually, stable, or if it has improved. Assessing the rate of progression can help differentiate between progressive conditions and acute injuries.
• Associated Symptoms: Determine if the patient has any additional symptoms or complaints that may be related to the underlying cause of foot drop. These may include sensory changes, muscle weakness or wasting, pain, or other neurological symptoms.
• Medical History: Obtain information about the patient’s medical history, including any pre-existing conditions or previous injuries that may be relevant to the development of foot drop. Pay attention to conditions such as diabetes, peripheral neuropathy, stroke, muscular dystrophy, motor neuron diseases, or spinal cord disorders.
• Trauma: Inquire about any history of trauma or injury to the leg, foot, or lower back. Traumatic nerve injury, fractures, or dislocations can lead to foot drop.
• Medications and Toxins: Ask about the use of any medications that could potentially cause neuropathy or muscle weakness. Inquire about exposure to toxins, heavy metals, or substances that could lead to peripheral nerve damage.
• Functional Impairments: Assess the impact of foot drop on the patient’s daily activities, mobility, and quality of life. Inquire about any compensatory strategies or assistive devices being used to manage the gait abnormality.
• Family History: Determine if there is a family history of neurological or muscular disorders, as certain conditions can have a genetic component.
• Social and Occupational History: Consider the patient’s occupation, hobbies, and lifestyle factors that may contribute to the development of foot drop or impact treatment decisions.

Physical Examination

Physical examination

When performing a physical examination on a patient with steppage gait, also known as foot drop, the goal is to assess the gait pattern, muscle strength, sensory function, and reflexes. Here are key components of the physical examination for steppage gait:

• Observation of Gait: Observe the patient’s gait pattern as they walk. Note any abnormalities such as foot drop, high stepping, or dragging of the foot. Assess if there is increased hip and knee flexion during the swing phase of walking to compensate for foot clearance.
• Muscle Strength Assessment: Evaluate the strength of the muscles involved in foot dorsiflexion and ankle eversion. This includes the tibialis anterior muscle, extensor hallucis longus, and peroneal muscles. Test the patient’s ability to actively dorsiflex and evert the foot against resistance, and compare it to the unaffected side.
• Sensory Examination: Perform a sensory assessment to evaluate for any sensory deficits or abnormalities. Check for loss of light touch, pinprick sensation, and proprioception in the lower extremities, especially the dorsal aspect of the foot and the distal leg. Compare the findings to the unaffected side.
• Reflexes: Assess deep tendon reflexes, particularly the ankle reflex (Achilles reflex). A diminished or absent ankle reflex may be observed in foot drop due to involvement of the associated nerves.
• Coordination and Balance: Evaluate coordination and balance by performing tests such as heel-to-toe walking (tandem gait), hopping on one foot, or performing the Romberg test. Deficits in coordination or balance may suggest additional neurological involvement.
• Muscle Wasting: Examine the lower extremities for any muscle wasting, particularly in the anterior compartment of the lower leg, where the dorsiflexor muscles are located.
• Joint Range of Motion: Assess the range of motion of the foot and ankle joints to identify any limitations or joint contractures that may contribute to foot drop.
• Spinal Examination: Perform a focused examination of the spine, including palpation of the lower back, assessment of spinal mobility, and evaluation of any signs of nerve compression or spinal cord abnormalities.
• Additional Neurological Assessment: Depending on the suspected underlying cause, further neurological assessments may be necessary, such as cranial nerve examination, upper limb motor and sensory examination, or specific reflex testing.
• Special Tests: In some cases, additional tests such as nerve conduction studies, electromyography (EMG), or imaging studies (e.g., MRI) may be required to determine the precise cause and location of nerve dysfunction.

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Differential diagnosis

Steppage gait, also known as foot drop, can be a manifestation of various underlying conditions. When evaluating a patient with steppage gait, it is important to consider a wide range of differential diagnoses. Here are some common conditions that should be considered:

• Peripheral Neuropathy: Peripheral neuropathy, caused by various etiologies such as diabetes, alcoholism, nutritional deficiencies, or autoimmune diseases, can lead to foot drop. Other symptoms such as sensory abnormalities and muscle weakness may also be present.
• Nerve Compression: Conditions that compress the nerves in the lower back or leg can result in foot drop. This includes herniated discs, spinal stenosis, or entrapment syndromes like peroneal nerve entrapment.
• Traumatic Nerve Injury: Direct trauma, fractures, or dislocations affecting the nerves in the lower leg can cause foot drop. History of trauma or injury to the lower limb should be considered.
• Muscular Dystrophy: Certain types of muscular dystrophy, such as Duchenne muscular dystrophy, can cause progressive muscle weakness and foot drop. Symptoms usually manifest in childhood.
• Motor Neuron Diseases: Motor neuron diseases like amyotrophic lateral sclerosis (ALS) or spinal muscular atrophy (SMA) can lead to muscle weakness, including foot drop. Other signs and symptoms of motor neuron dysfunction may be present.
• Stroke or Central Nervous System Lesions: Damage to the brain or spinal cord due to stroke, tumors, or other lesions can affect the motor pathways controlling foot and ankle movement, resulting in foot drop. Associated neurological deficits are often present.
• Tendon Disorders: Pathologies affecting the tendons, such as Achilles tendon rupture or posterior tibial tendon dysfunction, can impair foot and ankle movement and lead to foot drop.
• Joint Pathologies: Arthritis, joint contractures, or congenital abnormalities affecting the foot or ankle joints can result in foot drop.
• Medication or Toxin-induced Neuropathy: Certain medications or toxins, such as certain chemotherapy drugs, lead or heavy metals, can cause peripheral neuropathy and foot drop.
• Infections: Infections like Lyme disease can cause peripheral neuropathy and foot drop. Other signs of infection may also be present.
• Metabolic Disorders: Metabolic disorders like hypothyroidism or vitamin B12 deficiency can result in peripheral neuropathy and foot drop.
• Other Causes: Rare conditions such as hereditary motor and sensory neuropathies, Charcot-Marie-Tooth disease, or neuromuscular junction disorders can also lead to foot drop.

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The treatment of steppage gait, also known as foot drop, aims to address the underlying cause, improve gait function, and enhance the patient’s quality of life. The specific treatment approach depends on the underlying etiology and may involve a combination of conservative measures, assistive devices, physical therapy, and, in some cases, surgical interventions. Here are some common treatment options for steppage gait:

Addressing Underlying Cause: Identifying and treating the underlying cause of foot drop is essential. This may involve managing conditions such as peripheral neuropathy, nerve compression, muscular dystrophy, or stroke through appropriate medical interventions and disease-specific treatments.

Physical Therapy: Physical therapy plays a crucial role in the management of steppage gait. Therapeutic exercises can improve muscle strength, flexibility, and coordination. Specific exercises may target the dorsiflexor muscles, such as ankle dorsiflexion exercises, toe curls, and resisted ankle inversion and eversion exercises.

Assistive Devices: Various assistive devices can aid in improving gait function and mobility for individuals with foot drop. These may include:

Ankle-Foot Orthosis (AFO): AFOs are commonly prescribed to provide stability and support to the foot and ankle. They help maintain proper foot alignment, facilitate dorsiflexion during the swing phase of walking, and prevent foot drop during ambulation.

Functional Electrical Stimulation (FES): FES devices use electrical stimulation to activate the muscles involved in foot dorsiflexion. These devices can assist with lifting the foot during the swing phase of gait.

Orthopedic Interventions: In some cases, surgical interventions may be considered, particularly when there is an anatomical abnormality or structural issue contributing to foot drop. Surgical options may include tendon transfers, lengthening procedures, or decompression surgeries to relieve nerve compression.

Rehabilitation and Gait Training: Rehabilitation programs that focus on gait training, balance exercises, and functional mobility can help individuals with foot drop regain confidence and improve their overall gait pattern. This may involve working with physical therapists or rehabilitation specialists.

Education and Safety Measures: Patient education is crucial to promote self-care and prevent falls or injuries. Educate patients about strategies to maintain safety and minimize the risk of tripping or stumbling, such as being mindful of their surroundings, using appropriate footwear, and modifying the environment to remove hazards.

Supportive Measures: Additional measures, such as pain management, the use of orthopedic footwear, or adaptive equipment, may be recommended to address associated symptoms or functional limitations.

The treatment plan should be individualized based on the specific needs and goals of each patient, considering their underlying condition, functional abilities, and overall health status. A multidisciplinary approach involving healthcare professionals such as neurologists, orthopedic specialists, physical therapists, and occupational therapists is often beneficial to provide comprehensive care and optimize outcomes for individuals with steppage gait.

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References

https://www.ncbi.nlm.nih.gov/books/NBK547672/