Gait abnormalities or unsteadiness are a common presenting complaint, especially in older patients. It may be a trivial complaint with no underlying pathology or herald a more serious illness. The concept of 'off legs' usually refers to elderly patients, who were previously mobile and active, with a sudden deterioration. The cause of 'off legs' is usually an acute illness - eg, chest infection, urinary tract infection.
Those who lose independent mobility are less likely to remain in the community, have higher rates of disease, have a poorer quality of life and a greater likelihood of social isolation.
This article is primarily focused on walking difficulties in adults.
- The most common risk factors for mobility impairment are older age, low physical activity, obesity, strength or balance impairment, and chronic diseases such as diabetes or arthritis.
- One third of patients over the age of 65 years will report difficulties with walking.
- Patients may complain directly of problems with walking or simply of unsteadiness.
- It is important to clarify exactly what the patient feels - eg, which aspect of walking is difficult.
- Ask about falls - establish when the last fall occurred, how frequent falls are and whether there are any syncope or presyncope symptoms.See the separate article Prevention of Falls in the Elderly for full details (including management).
- Also, determine duration of problems.
- A full review of systems is required, especially looking for cardiac or neurological disease.
- Ask specifically for features suggestive of cord compression - eg, urinary retention, sensory and/or motor loss.
- Take a full drug history, especially as the aetiology may relate to polypharmacy or drug side-effects.
- Pulse rate, rhythm, volume and presence or absence of carotid bruits.
- Blood pressure including postural hypotension.
- Cardiovascular examination looking particularly for murmurs - eg, aortic stenosis.
- Full neurological examination looking for pyramidal, extrapyramidal and cerebellar dysfunction, and testing sensation for signs of peripheral neuropathy. See also the separate article on Neurological Examination of the Lower Limbs.
- Do not forget the possibility of fractures and injuries - look for leg asymmetry and test the spine and lower limbs for tenderness.
- Examine the gait - asymmetrical or symmetrical problems, presence of waddling gait, broad-based gait, scissoring gait (bilateral leg spasticity), or ataxia.
Causes and differential diagnosis
Causes of difficulty in walking
Causes of difficulty in walking can be broad and the following table lists some of these:
|Causes of walking abnormalities|
|Causes||Examples of diseases|
|Balance and co-ordination|
Causes of 'off legs'
As mentioned above, 'off legs' usually present in elderly patients and can be interpreted in various ways. This ranges from unsteadiness and difficulty with walking to dizziness or lethargy. The exact meaning should be sought during the assessment of the patient.
The causes of 'off legs' are usually acute and some causes include:
- Urine or chest infections.
- Neurological causes - eg, head injury, cord compression/cauda equina syndrome.
- Orthopaedic causes - eg, fractures (consider especially in elderly patients with osteoporosis who can fracture their neck of femur without major trauma).
- Metabolic abnormalities - eg, hyponatraemia, hypercalcaemia, hypoglycaemia or hyperglycaemia.
- Alcohol, drug or medications, especially as there are risks of polypharmacy in elderly patients.
These should be guided by the history and examination and may include cerebral imaging (eg, CT or MRI scanning) and blood tests (eg, TFTs, syphilis serology, etc).
This is directed towards the underlying cause. If the cause is multifactorial then a multidisciplinary approach may be appropriate - eg, physiotherapist, occupational therapists and allied healthcare professionals.
See also the separate article on Prevention of Falls in the Elderly.
Further reading and references
Manini TM; Mobility decline in old age: a time to intervene. Exerc Sport Sci Rev. 2013 Jan41(1):2. doi: 10.1097/JES.0b013e318279fdc5.
Brown CJ, Flood KL; Mobility limitation in the older patient: a clinical review. JAMA. 2013 Sep 18310(11):1168-77. doi: 10.1001/jama.2013.276566.
Gillespie L; Preventing falls in elderly people. BMJ. 2004 Mar 20328(7441):653-4.
Ganz DA, Bao Y, Shekelle PG, et al; Will my patient fall? JAMA. 2007 Jan 3297(1):77-86.