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Abnormal gait

Abnormal gait patterns seen in musculoskeletal disease.

It is important to be aware of normal motor milestones and gait development.

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, 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. 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 and other features to suggest muscle disease are available

Description

Potential causes

Antalgic gait

Due to pain on the affected side. May present with limp or non-weight bearing

A stiff leg gait may be observed with arthritis at the knee(s)

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

Trendelenberg gait

Results from hip abductor muscle weakness. Whilst weight-bearing on ipsilateral side, the pelvis drops on 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 disease, Slipped Capital Femoral Epiphysis, developmental dysplasia of the 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 gait

("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, and can be seen in leg length discrepancy.
  • Unilateral spasticity (e.g. hemiplegic cerebral palsy).

Waddling gait

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

Spastic gait

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 gait

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 gait ("equinus")

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 lysosomal storage disease such as mucopolysaccharidoses in the context of tip toe gait, joint contractures, and especially if seen in carpal tunnel syndrome, hearing problems, recurrent upper airway infections, glue ear and recurrent herniae.

High Steppage gait

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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