Gait, waddling
Waddling gait, a distinctive ducklike walk, is an important sign of muscular dystrophy, spinal muscle atrophy or, rarely, congenital hip displacement. It may be present when the child begins to walk or may appear only later in life. The gait results from deterioration of the pelvic girdle muscles—primarily the gluteus medius, hip flexors, and hip extensors. Weakness in these muscles hinders stabilization of the weight-bearing hip during walking, causing the opposite hip to drop and the trunk to lean toward that side in an attempt to maintain balance. (See Identifying gait abnormalities, pages 358 and 359.)
Typically, the legs assume a wide stance and the trunk is thrown back to further improve stability, exaggerating lordosis and abdominal protrusion. In severe cases, leg and foot muscle contractures may cause equinovarus deformity of the foot combined with circumduction or bowing of the legs.
History and physical examination
Ask the patient (or a family member if the patient is a young child) when the gait first appeared and if it has recently worsened. To determine the extent of pelvic girdle and leg muscle weakness, ask if the patient falls frequently or has difficulty climbing stairs, rising from a chair, or walking. Also, find out if he was late in learning to walk or holding his head upright. Obtain a family history, focusing on problems of muscle weakness and gait and on congenital motor disorders.
Inspect and palpate leg muscles, especially in the calves, for size and tone. Check for a positive Gowers’sign, which indicates pelvic muscle weakness. (See Identifying Gowers’ sign.) Next, assess motor strength and function in the shoulders, arms, and hands, looking for weakness or asymmetrical movements.
Medical causes
Congenital hip dysplasia
Bilateral hip dislocation produces a waddling gait with lordosis and pain.
Muscular dystrophy
In Duchenne’s muscular dystrophy, waddling gait becomes clinically evident by ages 3 to 5. The gait worsens as the disease progresses, until the child loses the ability to walk and needs a wheelchair, usually between ages 10 and 12. Early signs are usually subtle: delay in learning to walk, frequent falls, gait or posture abnormalities, and intermittent calf pain. Common later findings include lordosis with abdominal protrusion, a positive Gowers’sign, and equinovarus foot position. As the disease progresses, its effects become more prominent; they commonly include rapid muscle wasting beginning in the legs and spreading to the arms (although calf and upper arm muscles may become hypertrophied, firm, and rubbery), muscle contractures, limited dorsiflexion of the feet and extension of the knees and elbows, obesity and, possibly, mild mental retardation. If kyphoscoliosis develops, it may lead to respiratory dysfunction and, eventually, death from cardiac or respiratory failure.
In Becker’s muscular dystrophy, waddling gait typically becomes apparent in late adolescence, slowly worsens during the third decade, and culminates in total loss of ambulation. Muscle weakness first appears in the pelvic and upper arm muscles. Progressive wasting with selected muscle hypertrophy produces lordosis with abdominal protrusion, poor balance, a positive Gowers’sign and, possibly, mental retardation.
In facioscapulohumeral muscular dystrophy, which usually occurs late in childhood or during adolescence, waddling gait appears after muscle wasting has spread downward from the face and shoulder girdle to the pelvic girdle and legs. Earlier effects include progressive weakness and atrophy of facial, shoulder, and arm muscles; slight lordosis; and pelvic instability.
Spinal muscle atrophy
In Kugelberg-Welander syndrome, waddling gait occurs early (usually after age 2) and typically progresses slowly, culminating in total loss of ambulation up to 20 years later. Related findings may include muscle atrophy in the legs and pelvis, progressing to the shoulders; a positive Gowers’sign; ophthalmoplegia; and tongue fasciculations.
In Werdnig-Hoffmann disease, waddling gait typically begins when the child learns to walk. Reflexes may be absent. The gait progressively worsens, culminating in complete loss of ambulation by adolescence. Associated findings include lordosis with abdominal protrusion and muscle weakness in the hips and thighs.
Special considerations
Although there’s no cure for waddling gait, daily passive and active muscle-stretching exercises should be performed for both arms and legs. If possible, have the patient walk at least 3 hours each day (with leg braces if necessary) to maintain muscle strength, reduce contractures, and delay further gait deterioration. Stay near the patient during the walk, especially if he’s on unfamiliar or uneven ground. Provide a balanced diet to maintain energy levels and prevent obesity. Because of the grim prognosis associated with muscular dystrophy and spinal muscle atrophy, provide emotional support for the patient and his family.
Patient counseling
Caution the patient against long, unbroken periods of bed rest, which accelerate muscle deterioration. As indicated, refer him to a local chapter of the Muscular Dystrophy Association. Suggest genetic testing and counseling for the parents if they’re considering having another child.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
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