Reemphasizing The Importance Of Watching Your Patients Walk

With a busy schedule and trying to keep up with your record keeping, it sometimes becomes very routine to only examine a patient’s foot in a static position. Unfortunately, it is easy to become narrow minded and solely focus on the foot. In doing so, many of us may even fail to have the patient stand up and bear weight on the foot. Just as important as simple weightbearing is watching your patient walk. 

This past week, I was treating a patient who had an ulcer on the side of his foot and he had a previous transmetatarsal amputation many years ago. The patient was hospitalized recently for a hip fracture and had also developed a decubitus ulceration on his heel of the same foot. After several weeks of wound care, the posterior heel ulceration was improving but the lateral foot ulcer was not.

Long discussions with the patient and his wife demonstrated that they were following all of the proper recommendations to offload the foot when resting and sleeping. The patient noted he was not on his foot that often and when he was, he was wearing his post-op shoe.

During his most recent visit, I had examined the lateral wound and it was very apparent that there was excessive pressure on the wound. He did not think the surgical shoe was too tight and he barely wore it except when walking. He and his wife both noted that he walked flat in the shoe. I had the staff bandage his foot and had the wife apply the surgical shoe for him as she would at home.

I then came back, examined the foot in the shoe and asked him to walk. It became apparent to me what was causing pressure on the wound. He suffered from a mild drop foot and during ambulation, his foot struck the ground first with a slightly inverted forefoot putting pressure on the lateral portion of his foot where the ulcer was located. Even though he wasn't walking much, the first point of contact was the site of this ulcer. The patient and his wife had told me over and over again that he was not putting any “pressure” on the lateral wound as it was on the side of his foot. If I had not taken the time to evaluate him walking, I would have continued to miss this.

I had another similar situation in which a patient came to me for his “bunion.” I examined him and he presented with a very mild bunion deformity that was not painful. Upon further questioning, he said he was having a difficult time walking from the bunion and had heard that fixing it will help him walk better. The patient never mentioned any other neurological or musculoskeletal abnormalities, but just kept insisting that he came to me to have his bunion fixed. His strength did appear to be 5/5 bilaterally.

After watching him walk, he displayed a very subtle steppage type gait on the side of his bunion deformity. He appeared to have a slight drop foot. Further questioning revealed this was a complication that presented after his knee replacement. This was causing him to trip because he was catching his “big toe” at times and he felt this was from his bunion. We constructed a low-profile ankle foot orthotic with a dorsiflexory assist, which resolved his problem.

The point is, we all know how to do a complete exam and we all know how to watch and simply observe someone’s gait. The question is: are we doing it enough? We are all busy but sometimes all it takes is a simple task of having someone stand up and take a few steps. This simple gait assessment can open doors to diagnosing a problem that you may be struggling with treating. Just something to consider.