Gait and Motor Milestones
Normal gait and musculoskeletal development.
Further details about Gross Motor Milestones and when to be concerned is available.
A triage guide is available and includes when to be concerned about delayed walking.
Gross Motor Milestones:
- 6-8 months: Sits with support. Concern if not sitting independently by 9 months.
- 9 months: Stands while holding on to objects.
- 10 months: Pulls to standing.
- 12 months: Walks with assistance, along furniture; often able to take one or two unsupported steps. Concern if not walking by 18 months.
- 15 months: Walks well, unaided; gait is wide-based.
- 18 months: Runs well, unaided; gait is wide-based.
- 2 years: Goes up and down stairs, with two feet per step, without assistance.
- 2.5 years: Jumps on both feet; may walk on tip toes. Concern if cannot jump by school age.
- 3 years: Stands on one foot (few seconds). Goes up stairs 1 foot per step, comes down 2 feet per step.
- 4 years: Hops on one or both feet. Goes up and down stairs like an adult (1 foot per step). Heel and tiptoe walk.
- 5 years: Skips.
- 7 years: Balance on one foot for 20 seconds. Should be coordinated.
- Gross motor development beyond age 5-7 years is primarily related to tasks of coordination, and are most manifest when the child is engaging in play or sports with other children. Concern if the parent or supervisor feels the child is markedly less coordinated in activity than peers.
- The normal child begins to walk at 12 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 or step length and the duration of the single-limb stance increase with age and the number of steps taken per minute decreases.
- 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.
- The normal adult gait cycle involves heel strike, stance and then toe-off. The stance phase is the foot in contact with the ground and the swing phase is the foot off the ground.
- There is considerable variation in the way normal gait patterns develop - such variation may be familial (e.g., ‘bottom-shufflers’ often walk later) and subject to racial variation (e.g., African black children tend to walk sooner and Asian children later than average). However, regardless of family history or race, a child who is unable to walk well, independently, by 18 months should be urgently referred to a physician with expertise in developmental paediatrics.
- And the feet may be in-toed. The normal toddler has a broad-based gait for support, and appears to be high-stepped and flat footed with arms outstretched for balance. The legs are externally rotated with a degree of bowing. Heel strike develops 15–18 months with reciprocal arm swing.
- Running and change of direction occur after the age of 2 years, although this is often accompanied by frequent falls until the child acquires balance and coordination. In the school-age child, the step length increases and step frequency slows.
- Waddling gait is the typical gait of a 2 year old who is learning to walk. The feet are broad based in order to maintain balance, and the child falls frequently. A waddling gait is abnormal in a child over the age of 3 years and if observed, it is important to look for other abnormal signs such as tip toe walking or protruding belly (due to lumbar lordosis) in an attempt to maintain balance. These observations suggest proximal muscle weakness.
A delay in reaching motor milestones has many potential causes, such as:
- Neuromuscular problems - e.g., Hypotonia, Cerebral Palsy, Muscular Dystrophy.
- Metabolic problems - e.g., Rickets, Mucopolysaccharidoses.
Referral to a paediatrician or sub-specialist in muscle disease is recommended if muscle disease is suspected, based on any of the following are present;
- Delay in walking (beyond 18 months of age) or a persistent waddling gait (beyond 3 years of age) - consider muscular dystrophies.
- Delay in other milestones (i.e., speech, communication, feeding)
- Clumsiness or prone to falling.
- Family history of delayed walking or muscle disease.
- Muscles appear 'bulky' (calf pseudohypertrophy).
- Difficulty getting up from the floor (Gower's sign).
Regression of achieved motor milestones is consistent with inflammatory joint or muscle disease but can be due to other causes. Regression is a major red flag throughout paediatrics, and regression in any domain of development (motor, cognitive, social, or language) typifies pathology. If regression of motor milestones occurs in the context of other developmental delay (cognitive, social, language), a more global cause must be considered. Essentially, Regression is described as:
- The child can no longer do activities that they had previously been able to perform.
- Regression may be subtle, such as a child no longer able to do up buttons on clothes due to finger pain or swelling or a toddler wanting to be carried up and down stairs.
- Regression can manifest as the child becoming 'clumsy'; it is important to ask about activities at home, school and play and consider walking, running, handwriting and ability on stairs.
- Joint swelling may be subtle and easily missed.
- Inflammatory joint or muscle disease can be indolent.
- Referral to paediatric rheumatology is strongly recommended if joint pathology is suspected.