STEPPAGE GAIT

QUESTIONS AND ANSWERS

Causes of Steppage Gait

The causes of steppage gait in children point to various factors, including nerve damage or weakness in the muscles that lift the foot. Common causes include conditions such as peripheral neuropathy, muscular dystrophy, or other neurological disorders. It’s important to consult with a healthcare professional, such as a pediatrician or a neurologist, to determine the underlying cause.

For more specific conditions that can cause unilateral foot drop and steppage gait, peroneal nerve palsy and L5 radiculopathy are often identified. These conditions involve nerve issues that can result in the inability to lift the foot, leading to the characteristic high-stepping walk. The severity of the underlying condition will determine its classification—serious concern or not. Early diagnosis and intervention can often lead to better outcomes, so doctors urge parents to seek medical advice promptly.

Understanding these causes and their implications is crucial for developing an effective treatment plan and improving mobility and quality of life. The muscles responsible for elevating the front of the foot are weak or paralyzed, which leads to foot drop. Foot drop may result from several factors, such as:

Nerve Injury

The nerve in your child’s leg that handles the muscles involved in elevating the foot is most frequently the cause of foot drop (peroneal nerve). Injuries to this nerve can also occur during knee or hip replacement surgery, which can result in foot drop. Foot drop can also result from a spinal “pinched nerve” or damage to a nerve root. Diabetes makes people more prone to nerve conditions that are linked to foot drop.

Who is at risk for peroneal nerve injury?

Peroneal neuropathy, the nerve problem most often responsible for foot drop, tends to occur more frequently in males than females, with a ratio of about 2.8 to 1. In most cases—nearly 90%—it affects only one side of the body, and neither side is especially more likely to be affected.

Surgical risk factors

Certain types of knee surgeries, such as total knee replacement (also called total knee arthroplasty), can carry a risk of developing peroneal nerve injury. Statistics show that after this procedure, there is about a 0.3% to 4% chance of foot drop developing. Another operation, proximal tibial osteotomy, may cause foot drop in 3% to 13% of cases.

Understanding these risks can help you and your child’s care team make informed choices if surgery is being considered, and helps explain why nerve injuries are a leading cause of steppage gait in children.

Muscle or Nerve Disorders

Foot drop is a condition that actually gets worse through several types of muscular dystrophy, a genetic condition that causes gradual muscle weakening. Likewise, conditions like polio and Charcot-Marie-Tooth disease are also possible.

Brain and Spinal Cord Disorders

“Foot drop” can also occur as a result of conditions that damage the spinal cord or brain, including ALS, MS, and stroke.

Upper vs. Lower Motor Neuron Causes of Foot Drop

Not all foot drop is created equal—understanding whether the cause involves the upper or lower motor neurons is important for both diagnosis and treatment.

Upper Motor Neuron (UMN) Causes:
When foot drop originates from an upper motor neuron issue—such as after a stroke or with conditions like ALS or multiple sclerosis—the problem begins in the brain or spinal cord. Children (and adults) with UMN-related foot drop might exhibit other symptoms, including muscle stiffness (spasticity), increased reflexes, and sometimes a distinct style of walking called “cock-walk gait.” Weakness is often paired with changes in reflexes, like an upward-moving big toe when the sole of the foot is stroked (the Babinski sign), and sometimes other neurological changes, such as difficulty with speech or one-sided body weakness.

Lower Motor Neuron (LMN) Causes:
On the other hand, lower motor neuron causes are rooted at the level of the spinal cord, nerve roots, peripheral nerves, or muscles themselves. This group includes nerve injuries (like the peroneal nerve), certain types of muscular dystrophy, Charcot-Marie-Tooth disease, and polio. Foot drop from LMN issues is typically accompanied by muscle weakness or atrophy, reduced or absent reflexes, and sometimes sensory loss on the top of the foot or shin.

Key Differences at a Glance:

UMN causes:

• Brain/spinal cord origin (e.g., stroke, ALS, MS)
• Increased reflexes, spasticity
• “Cock-walk” gait may be present
• Possible speech and language difficulties

LMN causes:

• Peripheral nerve, root, or muscle involvement (e.g., peroneal nerve injury, muscular dystrophy)
• Weakness and muscle wasting
• Diminished or absent reflexes
• Possible sensory changes in the lower leg or foot

Recognizing these patterns during examination helps guide further evaluation and treatment for your child.

Additional Causes of Bilateral Foot Drop and Steppage Gait

In addition to the above causes, bilateral foot drop and steppage gait are specifically associated with certain medical conditions. Amyotrophic Lateral Sclerosis (ALS) and Charcot-Marie-Tooth (CMT) disease are prominent culprits. Severe peripheral neuropathies and certain forms of muscular dystrophy also play significant roles.

Understanding the underlying causes of bilateral foot drop and steppage gait is crucial for effective diagnosis and management. Each condition presents unique challenges and requires a tailored approach for treatment and rehabilitation.

Severe polyneuropathies can also lead to a steppage gait that includes elements of both sensory ataxia and foot drop. Typically, a steppage gait arises when an individual experiences foot drop, which occurs frequently. However, when polyneuropathies become severe, they can affect both the sensory and motor components of walking. This combination can result in a gait pattern that reflects not only the challenges of lifting the foot (due to motor deficits) but also balance issues related to sensory ataxia. This dual impact on mobility underscores the complex nature of severe nerve disorders.

Symptoms of Steppage Gait

A foot drop might make it difficult to walk. Your child can’t lift the front of their foot, so to prevent dragging his or her toes or tripping, your child lifts their leg higher than usual. Therefore, when the foot strikes the ground, it generates a slapping sound. This is called a steppage gait.
In more detail, this type of high-stepping gait occurs because the foot cannot dorsiflex, meaning the toes can’t naturally lift. To compensate, there’s exaggerated flexion of the hip and knee, lifting the foot high enough so the toes clear the ground during each step. Unlike normal walking, where the heel strikes the ground first, with foot drop, the toes hit the floor first, creating a distinct ‘double tap’ as the heel follows.

This altered walking pattern is essential to prevent tripping and maintain balance.  This highlights the significant adjustments needed for those with this condition.

Other Distinct Gait Abnormalities May Also Be Present, Depending On the Underlying Neurological condition:

• Circumduction gait: Most often seen after a stroke, this pattern is due to upper motor neuron involvement, causing the affected leg to be stiff and swing outward in a semicircular motion. Alongside the altered gait, additional signs such as speech difficulties, swallowing challenges, and upper limb weakness are commonly observed.
• Cerebellar gait: Damage to the cerebellum, the part of the brain responsible for balance and coordination, can make tandem walking (walking heel-to-toe) particularly difficult and cause a wide-based, unsteady walk.
• Ataxic gait: When both sides of the body are affected by impaired proprioception—often resulting from spinal cord lesions or severe alcohol misuse—the gait becomes high-stepping and unsteady, with noticeable swaying from side to side.
• Parkinsonian gait: In Parkinson’s disease, changes in the substantia nigra disrupt the normal rhythm of walking. This often leads to a shuffling gait, difficulty initiating movement, and a tendency for the steps to become progressively shorter, increasing the risk of falls.

Recognizing these specific gait patterns is essential for pinpointing the underlying neurological disorder, as each type points to different regions of the nervous system and guides further diagnosis and management.

Treatment for a Steppage Gait

Physical therapists treat steppage gait by targeting and strengthening the anterior tibialis muscle through specific exercises. Your child can strengthen this muscle by doing ankle workouts that improve foot control and support proper walking mechanics. Calf stretches maintain ankle flexibility and help preserve the joint’s full range of motion. Physical therapists may also recommend gait training and walking drills to improve how your child moves.

To boost body awareness and coordination, therapists include balance exercises that enhance proprioception during therapy sessions. In some cases, they use neuromuscular electrical stimulation to activate and support the anterior tibialis muscle. This electrical stimulation creates artificial muscle contractions that help the muscle work more effectively over time. Therapists might also prescribe back exercises that relieve pressure on the sciatic nerve when it causes tibialis weakness.

These stretches and movements support proper nerve signal transmission in the lower back and legs. Treatments for foot drop depend entirely on its underlying cause. Sometimes, resolving the main issue will also resolve the foot drop. However, if the cause is long-term or chronic, foot drop may not fully go away. In many cases, physical and occupational therapy can still help improve function and manage symptoms. The long-term outlook for steppage gait depends on what causes it in the first place.

If nerve testing shows no active motor units and severe damage, recovery may remain uncertain. However, if tests show delayed nerve signals but no permanent damage, doctors may diagnose neurapraxia. Neurapraxia often responds well to treatment and gives your child a better chance of regaining normal movement.

Coordinated Care and Specialist Support

Treatment for steppage gait often involves a team of specialists working together. A doctor specializing in physical medicine and rehabilitation (called a physiatrist) might evaluate your child’s muscle strength and nerve function, sometimes using tests that measure electrical activity in the nerves and muscles. The physiatrist may coordinate care by referring your child to a physical therapist for movement and strength training, as well as to an orthotist—a professional who designs and fits braces or support devices for children with weakened muscles due to injury or nerve conditions. This collaborative approach ensures your child’s treatment plan is comprehensive and tailored to their unique needs.

Possible Treatments for a Steppage Gait:

1. In order to support the foot and keep it in a more natural posture, use braces, splints, or shoe inserts.
2. Physical therapy can improve your child’s walking by stretching and strengthening your child’s muscles.
3. By using nerve stimulation, the nerves and muscles of the foot can be retrained with the use of nerve stimulation.
4. To try to heal the nerve or release the strain on it, surgery may be required. Your doctor could advise fusing the ankle or foot bones to treat long-term foot drop. Your child could also have tendon surgery. This involves moving a functioning tendon and its accompanying muscle to a different area of the foot.

In some cases, a test called an electromyogram (EMG) may check the activity in your child’s muscles and nerves. If the EMG shows a full loss of nerve connection, your child may need to use an ankle-foot orthosis (AFO).  This is a special brace that supports the foot in a neutral position, especially during the push-off phase of walking. If your child needs a brace, be sure to regularly check the area where the brace touches the skin.  Because of the decreased sensation from nerve damage, unnoticed pressure sores may occur. Also, make sure your child’s shoes are roomy enough to fit the brace comfortably.

Sometimes, surgery could involve moving a tendon from the back of the calf to another part of the foot. This will help restore function and improve walking. These options will depend on the underlying cause and severity of your child’s steppage gait.

Conclusion

The Medical City Children’s Orthopedics and Spine Specialists doctors only treat children.

Our doctors at Medical City Children’s Orthopedics and Spine Specialists are located in five convenient locations: Dallas, Arlington, Flower Mound, Frisco, and McKinney, TX, for families in the Dallas and Fort Worth area. Selecting a pediatric orthopedic doctor for your child is a crucial decision that requires careful consideration. Doctors Shyam Kishan, Richard Hostin, and Kathryn Wiesman have spent years studying children’s health and have devoted their lives to treating them.The Pediatric Orthopedic Doctors at Medical City Children’s Orthopedics and Spine Specialists, treat kids with steppage gait by diagnosing the cause and treating the child to a speedy recovery.

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Footnote:

National Library of Medicine: Steppage Gait