Introduction
Gait assessment is an underappreciated clinical skill that yields an enormous amount of diagnostic information before you have even touched the patient. Observing a patient walk from across the room can immediately suggest the system involved — neurological, musculoskeletal, or vascular — and often points to a specific diagnosis. In OSCE stations, gait assessment may appear as part of a neurological examination, musculoskeletal GALS screen, or as a dedicated station.
Performing a Gait Assessment
Ask the patient to walk to the end of the room and back. Observe from the front, side, and behind. Ensure adequate space and confirm the patient is able to mobilise safely.
🧠 Mnemonic
GAIT — Systematic Observation Framework
G — General appearance: symmetry, speed, balance, effort
A — Arms: swing, posture, tremor (reduced in parkinsonism; wide-based in cerebellar disease)
I — Impact and stance: foot clearance, foot strike, stride length, base width
T — Turns: note hesitation, freezing, multiple small steps, loss of balance
What to Observe
For each gait, observe:
- 1Base width: narrow (normal) vs broad (cerebellar, sensory ataxia)
- 2Step length: normal vs short/shuffling (parkinsonism) vs high-stepping (foot drop)
- 3Foot clearance: normal vs scraping
- 4Arm swing: symmetrical vs reduced unilaterally (hemiplegia, parkinsonism) vs absent bilaterally
- 5Trunk: upright vs stooped vs lurching
- 6Turns: smooth vs multiple steps vs freezing
Gait Patterns and Their Causes
| Gait Pattern | Description | Likely Causes |
|---|---|---|
| Antalgic | Short stance phase on painful side; limping | Osteoarthritis, fracture, soft tissue injury |
| Trendelenburg | Pelvis drops on opposite (swing) side; trunk lurches to stance side | Weak hip abductors: hip OA, gluteus medius weakness |
| Parkinsonian | Stooped, shuffling, short steps, reduced arm swing, festination, en bloc turns | Parkinson's disease, drug-induced parkinsonism |
| Cerebellar ataxic | Wide-based, staggering, irregular, veering to ipsilateral side | Cerebellar stroke, MS, alcohol, phenytoin, posterior fossa tumour |
| Sensory ataxic | Wide-based, high-stepping, stamping, worse in dark (Romberg positive) | B12 deficiency, tabes dorsalis, Friedreich's ataxia |
| Foot drop (steppage) | High-stepping to clear foot; foot slaps on ground | Common peroneal nerve palsy, L4/L5 radiculopathy, MS |
| Hemiplegic | Extended leg swings in semicircle (circumduction); arm held flexed | Stroke (contralateral UMN lesion) |
| Scissor | Narrow-based, crossing of legs, stiff, slow | Spastic diplegia, cerebral palsy, bilateral UMN lesion |
| Waddling | Wide-based, bilateral Trendelenburg; swaying side to side | Proximal myopathy, muscular dystrophy, bilateral hip OA |
Gait Patterns In Detail
Antalgic Gait
The patient reduces time spent weight-bearing on the painful limb — the stance phase on the affected side is shortened and the patient swings through quickly, producing an asymmetric, lurching gait.
Parkinsonian Gait
Characterised by:
- Stooped posture with flexion at hips, knees, and trunk
- Shuffling, short steps — feet barely leave the ground
- Reduced or absent arm swing — often asymmetric early in Parkinson's disease
- Festination — progressive acceleration as the patient tries to keep up with their own centre of gravity
- Freezing — sudden inability to initiate movement, especially at doorways or on turning
- En bloc turning — multiple small steps rather than a smooth pivot
⚠️ Red Flag
Drug-induced parkinsonism (e.g. metoclopramide, haloperidol, prochlorperazine) mimics idiopathic Parkinson's disease and is a common, underrecognised cause. Always take a full medication history in a patient with parkinsonian gait.
Cerebellar Ataxic Gait
Wide-based and staggering, with the patient appearing drunk. The gait is irregular in rhythm and direction, and the patient may veer towards the side of the cerebellar lesion. Tandem gait (heel-to-toe walking) is markedly impaired.
Causes: stroke, multiple sclerosis, alcohol excess, phenytoin toxicity, posterior fossa tumour, Friedreich's ataxia, Wilson's disease.
Sensory Ataxic Gait (Posterior Column)
Wide-based with exaggerated stepping — the patient stamps their feet to gain proprioceptive feedback. Romberg's test is positive: the patient can maintain balance with eyes open but sways or falls with eyes closed.
Causes: subacute combined degeneration of the cord (B12 deficiency), tabes dorsalis (neurosyphilis), Friedreich's ataxia.
💎 Clinical Pearl
The key distinguishing test between cerebellar and sensory ataxia is Romberg's test: cerebellar ataxia is Romberg negative (equally unsteady with eyes open and closed); sensory ataxia is Romberg positive (markedly worse with eyes closed). This is a high-yield OSCE point.
Foot Drop (Steppage Gait)
The patient cannot dorsiflex the foot, leading to exaggerated hip and knee flexion to clear the foot during swing phase. The foot then slaps flat against the floor on heel strike.
GALS Screening Examination
The Gait, Arms, Legs, Spine (GALS) screen is a rapid musculoskeletal assessment:
Screening Questions
- 1*"Do you have any pain or stiffness in your muscles, joints, or back?"*
- 2*"Can you dress yourself completely without any difficulty?"*
- 3*"Can you walk up and down stairs without any difficulty?"*
GALS Examination
| Component | Key Tests |
|---|---|
| Gait | Walk to end of room, turn, walk back; observe from all sides |
| Arms | Hands out palms up, turn over; make a fist; squeeze MCP joints; arms above head; behind back |
| Legs | Supine: hip flexion, internal rotation; knee: flex/extend, patello-femoral grind; ankle dorsiflexion; squeeze MTP joints |
| Spine | Lateral cervical flexion; lumbar forward flexion (Schober's test); inspect from behind for scoliosis |
Additional Gait Tests
| Test | Method | Positive Finding | Significance |
|---|---|---|---|
| Romberg's test | Stand feet together, eyes open then closed | Sways/falls with eyes closed | Posterior column/sensory ataxia |
| Tandem gait | Walk heel-to-toe in straight line | Falls off line | Cerebellar disease |
| One-leg stand | Stand on each leg for ≥5 seconds | Pelvis drops on non-standing side | Trendelenburg positive |
| Backwards walk | Walk 5 steps backwards | Inability | Parkinsonism, cerebellar disease |
FAQs
"How do I distinguish between antalgic and Trendelenburg gait in an OSCE?"
Antalgic gait shows a shortened stance phase on the painful limb. Trendelenburg gait shows the pelvis dropping on the swing-side due to contralateral gluteus medius weakness — confirm with the single-leg Trendelenburg test. Both patterns can coexist in hip osteoarthritis.
"What is the most common cause of unilateral foot drop in a medical patient?"
Common peroneal nerve palsy — typically caused by pressure at the fibular head from prolonged leg crossing, tight plaster cast, or prolonged immobility. Check for preserved hip and knee function and a sensory deficit over the dorsum of the foot and lateral lower leg.
"What drugs cause a parkinsonian gait pattern?"
Dopamine antagonists: metoclopramide, prochlorperazine, haloperidol, risperidone, and other antipsychotics. Sodium valproate can also cause a parkinsonian tremor. Drug-induced parkinsonism is fully reversible on stopping the offending agent.
"What is festination?"
Festination is an involuntary acceleration of gait seen in Parkinson's disease. The patient leans progressively further forward and takes progressively shorter, faster steps in an attempt to maintain their centre of gravity above their feet. It frequently ends in a fall if uninterrupted.
"How would you examine gait in an OSCE where the patient cannot walk?"
Acknowledge clearly that the patient is unable to mobilise and state: *"I would assess static balance, bed mobility, and transfer ability instead, and request a formal physiotherapy gait assessment when the patient is able to participate."* You do not lose marks for acknowledging limitations honestly.
Related Posts
- Neurological Examination OSCE — upper and lower motor neurone signs, cerebellar assessment, tone, power, and reflexes
- Hip Examination OSCE — Trendelenburg test, Thomas' test, and range of motion in hip disease
- Knee Examination OSCE — ligament testing, meniscal assessment, and effusion detection