How can I differentiate between neurological and musculoskeletal causes of gait abnormalities in my patients?

To differentiate between neurological and musculoskeletal causes of gait abnormalities in patients, consider the following clinical features and assessment steps:

• Neurological causes often present with unsteady gait that may be sudden-onset, rapidly progressive, or gradually progressive, and can be associated with other neurological signs such as limb weakness, coordination difficulties, or sensory changes. Sudden or rapidly progressive unsteady gait requires urgent neurological referral and assessment, including consideration of stroke, transient ischaemic attack, or other central nervous system pathology NICE NG127.
• Difficulty initiating and coordinating walking (gait apraxia) suggests a neurological cause and warrants referral to neurology or elderly care clinics to exclude conditions like normal pressure hydrocephalus NICE NG127.
• Neurological gait abnormalities may be accompanied by other signs such as handwriting difficulties without musculoskeletal cause, dystonia, or posture distortion, which also indicate neurological assessment NICE NG127.
• Musculoskeletal causes typically involve mechanical pain, joint stiffness, or deformity and are less likely to present with rapidly progressive or sudden-onset gait disturbance without other neurological signs. Musculoskeletal gait abnormalities usually improve with rest and are related to physical joint or muscle problems rather than coordination or sensory deficits NICE NG127.
• In patients with unsteadiness at risk of falling, multifactorial falls risk assessment and referral to falls prevention teams are appropriate, which may include musculoskeletal evaluation NICE NG127.

Summary: Focus on the onset and progression of gait abnormality, presence of neurological signs (weakness, coordination, sensory changes), and associated symptoms (handwriting difficulty, posture distortion) to differentiate neurological from musculoskeletal causes. Urgent referral is indicated for sudden or rapidly progressive neurological signs, while musculoskeletal causes are generally more chronic and mechanical in nature NICE NG127.