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Abnormal Gait patterns

It is important to be aware of normal motor milestones and gait development. The normal child begins to walk at between 8 to 14 months of age. Initially, it is normal for the child to walk with a wide based externally rotated gait, taking numerous short steps. The gait then undergoes orderly stages of development. Walking velocity, stride length and the duration of the single-limb stance increase with age. The number of steps taken per minute decreases with age. A mature gait pattern is well established by about 3 years of age, and the gait of a seven-year-old child resembles that of an adult. A normal mature gait cycle consists of the stance phase, during which the foot is in contact with the ground and the swing phase, during which the foot is off the ground. 

Video demonstrations of gait abnormalities suggesting muscle disease.

 Gait pattern

Description

Potential causes

Antalgic 

May present with limp or non-weight bearing due to pain.

A stiff jointed gait may result from arthritis.

Multiple causes and can result from pathology in many different sites (hip or other joints in the lower limb) spine, and extra-articular sites (e.g., hernia, appendix, testes). Consider red flags and pitfalls

Trendelenburg 

Results from hip abductor (gluteal) muscle weakness. While weight-bearing on ipsilateral side, the pelvis drops on the contralateral side (rather than rising as is normal).

With bilateral hip disease - a waddling "rolling sailor" gait can be seen (with hips, knees and feet externally rotated).  

Can also be secondary to painful hip conditions.

Hip joint disease (e.g., Legge-Calve-Perthes, Slipped Capital Femoral Epiphysis, Developmental Dysplasia of Hip, Juvenile Idiopathic Arthritis (JIA).
Muscle disease (Juvenile Dermatomyositis or inherited myopathies such as Duchenne muscular dystrophy). 
Neurologic conditions (e.g., spina bifida, cerebral palsy).

Circumduction

("peg leg")

Due to excessive hip abduction as the leg swings forward creating a semi-circular movement of the leg.

Restricted joint movement (e.g., lack of full knee extension in JIA or post trauma), leg length discrepancy.
Unilateral spasticity (e.g., hemiplegic cerebral palsy).

Waddling

A wide based gait with lumbar lordosis suggests proximal muscle weakness.

Muscular dystrophy, inflammatory myopathies or metabolic muscle disease (e.g., Rickets).

Spastic

Stiff walking and the foot is seen to be inverted and dragged along. Often accompanied by flexion of upper limbs.

Upper motor neuron neurologic disease (e.g., diplegic or quadriplegic cerebral palsy, stroke).

Ataxic

Instability and alternating between a narrow to wide base of gait.

Neurological disease (e.g., ataxic cerebral palsy, cerebellar ataxia and inherited ataxias [e.g., Friedrich's]).

Toe-walking 

Walking on tip toe with lack of heel contact.

Habitual toe walking as a normal variant (associated with normal foot examination, can squat with heels on the floor and normal walking on request).
Persistent toe walking seen with upper motor neuron neurologic disease (e.g.,diplegic cerebral palsy). Also seen in muscular dystrophy (as an adjustment to waddling gait and lumbar lordosis or secondary to tightening Achilles tendon). Also observed in inflammatory joint disease. Consider mucopolysaccharidoses in the context of tip-toe gait, joint contractures and especially if there is carpal tunnel syndrome, hearing problems, recurrent upper airway infections, glue ear and recurrent herniae.

Toe-walking gait can also be seen in children with autism spectrum disorder (ASD).

High Steppage 

Abnormal foot posture with toes pointing down. Foot drop due to loss of dorsiflexion.

Caused by damage to deep peroneal nerve.

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