Changes in Gait (Ambulation, Walking)

January 2024 | Brian Chicoine, MD - Medical Director, Adult Down Syndrome Center

Key Points

A change in gait (walking) is a change seen in many people with Down syndrome.
There are many possible causes for those changes.
Family or other observers can play a critical role in assessing and treating these changes since some people with Down syndrome have difficulty verbally expressing their symptoms.
A thorough evaluation including a history and physical by a health care professional is important to assess and treat the change. Additional studies (labs, x-rays, etc.) and referrals to other health care professionals may be indicated based on the initial evaluation.

What can cause a change in gait?

An adolescent or adult with Down syndrome may begin to walk differently for many reasons. Symptoms may include walking more slowly, walking with a limp, and/or walking more awkwardly or less steadily. Sometimes, they will stop walking altogether. In our experience, the person with Down syndrome often does not complain of the change, but, rather, a family member or other person observes the change. In addition to noting the change in gait, it is important to look for other possible changes or symptoms that may help determine the underlying cause.

Injuries

Acute injuries including fractures, sprains, and strains, particularly of the legs, can alter gait. Injuries in other parts of the body also sometimes result in a gait change. The challenge in understanding the cause in some people with Down syndrome can be that they perceive pain differently or have difficulty expressing pain so the only initial indication of an injury may be the change in walking.

Acute illness

Many acute illnesses can cause a change in gait. These may be symptoms or causes that may not directly affect walking but may reduce the person’s interest or desire to walk. For example, acute abdominal pain may not affect the function of the person’s legs, but walking may increase the pain, so the individual chooses not to walk.

Orthopedic causes

Subluxation of the spine

Subluxation of the spine occurs when the bones in the spine (vertebrae) slip out of position (subluxation). The spinal canal can become narrowed, and the spinal cord can be pinched. The most common joint in the spine in which slippage can occur is the joint between the first and second vertebrae in the neck (cervical spine). This is called atlantoaxial instability (AAI) or atlantoaxial subluxation. Additional symptoms may include urinary and/or stool incontinence (bowel or bladder accidents), weakness of the arms, dropping objects, neck or back pain, or numbness. AAI is more common in people with Down syndrome.

Spinal cord stenosis

Bony changes in the vertebrae due to arthritis may also cause narrowing of the spinal canal causing the spinal cord to get pinched.

Ligamentous laxity

Ligaments are bands of fibrous tissue that connect our bones to each other. In people with Down syndrome, these ligaments tend to be “looser” causing some joint instability (looseness). This is called ligamentous laxity. AAI noted above is an example of ligamentous laxity, but it may also occur in any joint in the body. Where the kneecap (patella) attaches to the thigh bone (femur) is one joint where this is more common in people with Down syndrome. If the kneecap does not stay in normal alignment, it can affect the gait either by causing pain or altering the mechanics of walking.

Bunions

A bunion (also called hallux valgus) is a bony projection or bump that forms at the base of the big toe. Joint laxity contributes to bunions. They can cause gait change due to discomfort or, if the joint is significantly deformed, can alter the mechanics of foot function.

Flat feet and overpronation

Overpronation is a condition in which the foot tends to roll-over too far towards the inside of the foot with walking. It is often associated with flat feet. This can cause a gait change because of pain or by altering the mechanics of walking.

Arthralgia or arthritis

Arthralgia is pain in a joint. Arthritis is a health condition in which there is inflammation in a joint or joints and is usually also associated with joint pain. Osteoarthritis opens in new window (or similarly osteoarthrosis) is a condition that occurs when the protective cartilage the cushions the end of bones is worn down. This is a degenerative condition, the joints develop “wear and tear” over time. Osteoarthritis may be more common in people with Down syndrome because laxity of joints can predispose to osteoarthritis.

Inflammatory arthritis

Inflammatory arthritis is caused by abnormalities that cause inflammation in the joint. It is also more common in people with Down syndrome. Autoimmune conditions (conditions in which one’s own immune system attacks a particular part or parts of the body) are more common in people with Down syndrome. Arthritis due to autoimmune conditions is more common in people with Down syndrome. There are several types of arthritis due to autoimmune, inflammatory conditions that can affect people with Down syndrome. One type is called Down syndrome-associated arthritis opens in new window .

Gout

Gout is another cause of inflammation in joints that can cause a change in gait and is more common in people with Down syndrome.

Skin conditions

Dry skin

Painful, cracked skin on the soles of the feet can cause a gait change. Dry skin is more common in people with DS and the feet are a common area that can become quite dry and cause discomfort.

Skin or nail infections

Skin or nail infections can cause discomfort. Examples are boils on the inner thighs or thickened nails due to fungal infections of the toenails (also called onychomycosis).

Venous disease

Conditions of the veins are referred to as venous disease. Varicose veins and insufficient functioning of the veins in the legs are more common in people with Down syndrome. Discomfort and/or swelling may affect gait.

Changes in the groin area

Infections of the genitals (male or female), changes in the testicles, or hernias can all cause changes in walking. Testicular cancer and hernias are both more common in people with Down syndrome.

Vision changes

There are several eye conditions that are more common in people with Down syndrome and can contribute to a change in walking. Visual acuity impairment (and the need for glasses), cataracts, impaired depth perception, and keratoconus are more common in people with Down syndrome.

Dizziness

A change in walking can be caused by any condition that causes dizziness or vertigo (a sensation of spinning related to inner ear disease or inner ear conditions). There are many conditions that can cause dizziness. Causes include anemia due to celiac disease, medication side effects, dietary changes, heart disease, and many others. Celiac disease is more common in people with Down syndrome.

Vitamins and minerals

Vitamin and mineral deficiencies can contribute to a change in gait. Symptoms of deficiencies in folate, vitamin B12, vitamin E, vitamin D, vitamin C, and copper can include gait changes. Blood tests can be ordered to assess for these deficiencies. Dietary changes and/or supplements can be recommended to address the deficiencies.

Metabolic changes

Many metabolic changes can cause a change in gait. These may include an elevated blood sugar (e.g., secondary to diabetes mellitus), a low blood sugar, an abnormal sodium level, abnormal calcium levels, liver disease, and many others.

Alzheimer's disease

Alzheimer’s disease is more common in people with Down syndrome. It is associated with changes in gait and loss of skills. Since Alzheimer’s disease is more common in people with Down syndrome and it is a common cause for a change in walking in older people with Down syndrome, more information is provided at the end of this article.

Down syndrome regression disorder

Down syndrome regression disorder (DSRD) is a condition in people with Down syndrome, most commonly in their adolescent or early adult years, in which they have significant regression of their skills, sometimes including their walking.

Psychological conditions

Depression, obsessive compulsive disorder, anxiety, and other mental health conditions are sometimes associated with a decline in skills including walking.

Seizures

Some individuals with seizures will be noted to be unsteady or to fall.

Chronic pain

Any chronic painful condition can contribute to a change in walking.

Diagnosis

As noted, some people with Down syndrome are not able to report changes in their symptoms. Therefore, the diagnostic process may have to start with others observing changes in gait and other symptoms. A health care professional should do a thorough history and physical exam that assesses the change in gait and also the broad range of symptoms that may accompany the gait change.

Possible diagnostic tests based on the history and physical exam:

X-rays, computerized tomography (CT) scan, and/or magnetic resonance imaging (MRI) scan of the spine
X-rays of a joint that appears to have significant joint laxity
X-rays to assess for arthritis changes
Blood work (labs) to assess for abnormalities that indicate that it may be inflammatory arthritis and to help diagnose the specific cause
Blood testing to assess for vitamin, mineral, and/or metabolic abnormalities
A joint aspiration in which a needle is inserted into a joint and fluid collected to be analyzed in the lab
An assessment by an ear, nose, and throat doctor (otolaryngologist) to assess the inner ear
Doppler (ultrasound) study of the veins
Vision exam by an ophthalmologist or optometrist

Depending on the findings, further evaluation may be indicated by a surgeon, gynecologist, neurologist, neurosurgeon, orthopedic surgeon, dermatologist, vascular surgeon, podiatrist, urologist, or other specialists to assess and treat for conditions noted above. An assessment by a physical therapist and/or occupational therapist may help clarify the cause.

Treatment

Treatment should be directed based on the findings of the history and physical and additional studies to address the specific cause. A variety of resources are available in our online Resource Library that discuss treatment for specific conditions.

No matter what the cause of the change in gait, treatment by a physical therapist (PT) and/or an occupational therapist (OT) may be helpful to restore, stabilize, and/or optimize the gait. For many people with Down syndrome, even after the underlying cause is treated, they may need support to start walking again and PT and/or OT may be critical in restoring function.

Change in gait in people with Down syndrome and Alzheimer's disease

Many people with Down syndrome who have Alzheimer disease develop gait dysfunction (difficulty walking). Early on, the person may express or display fears of walking before any actual loss of walking skills is noted. Many people seem to have both an impairment in gait and depth perception. Some people first become fearful in situations where there is more of a need to use depth perception. Situations where this may occur include:

Stairs or escalators, especially those that are not enclosed or next to a wall
Changing from one surface to another
Glass elevators
Buildings (often shopping malls) with glass railings overlooking an opening down to the next level

Many people with Down syndrome who don’t have Alzheimer’s disease have mild impairments in walking and depth perception. Worsening of these issues can be a sign that the person is developing Alzheimer’s disease. As difficulties with gait and depth perception worsen, symptoms and signs may include:

Leaning to one side or the other (sometimes even when sitting)
Needing increased assistance to walk
Walking more slowly
Falling
Sitting down when trying to walk longer distances

Evaluation and treatment may include:

Encouraging the person to keep walking to maintain skills as long as possible
Having someone nearby to prevent falls
Assessing the individual for other causes (as discussed above) that the person could have in addition to Alzheimer's disease
Referring the person for a physical and/or occupational therapy assessment for guidance in optimizing walking skills and to evaluate for and train the person in using assistive devices such as a cane or walker. We should note that, in our experience, most people with Down syndrome who are developing Alzheimer's disease struggle to use assistive devices correctly. The device may end up being more harmful than beneficial because it can cause the person to trip and fall.
Using a wheelchair for longer distances

Additional resources are available in the Alzheimer's Disease and Dementia section of our Resource Library.