Steppage gait results from footdrop caused by weakness or paralysis of the pretibial and peroneal muscles, typically due to lower motor neuron lesions. The foot hangs with toes pointing downward, causing them to scrape the ground during ambulation. Compensatory movements include exaggerated hip and knee flexion to lift the leg, with the foot thrown forward and toes striking the ground first, producing an audible slap. The gait is usually regular in rhythm, with normal upper body posture and arm swing, and can be unilateral or bilateral, permanent or transient depending on the site and severity of neural damage.

Pathophysiology

Steppage gait arises from weakness or paralysis of the pretibial and peroneal muscles, which are responsible for ankle dorsiflexion. Lesions of the lower motor neurons, peripheral nerves (especially the peroneal nerve), or anterior horn cells impair dorsiflexion, causing the foot to hang in plantar flexion. To avoid toe dragging during the swing phase, the patient compensates by increasing hip and knee flexion, resulting in the characteristic high-stepping, slapping gait. Chronic cases may lead to muscle atrophy, contractures, and altered proprioception, which further exacerbate gait abnormalities.

History and Physical Examination

• History: Determine onset and progression of the gait; inquire about family history of similar disorders. Assess for trauma to the buttocks, hips, legs, or knees, and for chronic conditions linked to polyneuropathy (e.g., diabetes mellitus, polyarteritis nodosa, alcoholism). Observe leg crossing when seated, which may indicate peroneal nerve compression.

• Physical Examination: Inspect and palpate calves and feet for muscle atrophy or wasting. Test sensory function along the entire leg using pinprick or vibration testing. Assess strength, deep tendon reflexes (DTRs), and ankle dorsiflexion.

Medical Causes and Distinguishing Features

Special Considerations

• Patients with steppage gait fatigue rapidly due to the extra effort required to lift the foot.

• Increased risk of stubbing toes or falling; monitor activity and encourage rest periods.

• Physical therapy may include gait retraining, and application of in-shoe splints or leg braces to maintain proper foot alignment.

Patient Counseling

• Educate on pacing activities and recognizing exercise limits.

• Train in safe use of splints or braces to prevent falls and maintain mobility.

• Encourage adherence to physical therapy and regular follow-up for neurological assessment.

References

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3. Kwon, Y., & Lee, S. (2015). Management of foot drop in neurological disorders. Journal of Clinical Neurology, 11(4), 299–308.

4. Sheean, G., & McGuire, J. (2009). Spasticity management in neurological disorders. Journal of Neurology, Neurosurgery & Psychiatry, 80(7), 805–812.