IMPORTANCE Gait impairments are common in patients with chronic supratentorial upper motor neuron lesions and are a source of disability. Clinical management aimed at improving the gait pattern in these patients is generally perceived as a challenging task because many possible abnormalitiesmay interact. Moreover, a multitude of treatment options exist, ranging from assistive devices and muscle stretching to pharmacologic and surgical interventions, but evidence is inconclusive for most approaches and clear treatment guidelines are lacking. OBSERVATIONS Gait deviations in adults with a chronic supratentorial upper motor neuron lesion can approximately be reduced to the following 3 groups of primary deficits: (1) imbalance of muscle strength, length, and activity around the ankle and tarsal joints leading to pes equinovarus or pes equinus; (2) calf muscle weakness; and (3) overactivity of proximal leg muscles. CONCLUSIONS AND RELEVANCE A stepwise treatment algorithm emphasizes medical-Technical interventions, which are based on evidence when available and otherwise reflect practice-based experience.