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Independent ambulation is a critical gross motor skill achieved early in childhood. Various neurologic disorders can manifest in infancy such that normal gait development is limited or delayed. In progressive neurologic conditions, children may never acquire independent walking or may regress, leading to loss of ambulation. Before discussing different abnormal gait phenomenologies, a brief review of normal gait development is provided. Included in this chapter is also a summary of nonneurologic causes for gait problems. Finally, as we discuss neurologic differential diagnoses for gait disorder, it is important to recognize that gait dysfunction often coexists with other abnormal neurologic symptoms in the context of global assessment of neurologic disorders in children and adolescents.


Most gestationally full-term toddlers will walk unassisted by about 15 months of age. By age 3 years, children’s gait pattern is mature. The gait cycle starts and ends with the ipsilateral heel striking the ground successively. Throughout the cycle, each leg alternates between the stance phase (~60%) when the foot is in contact with the ground and the swing phase (~40%). After heel strike, the foot rolls and lifts off at the toes to initiate the swing phase. Truncal posture is upright with head midline and arms reciprocally swinging at the side along with the contralateral leg. The distance between lateral aspects of both feet should approximate the width of the trunk.

As young infants learn to walk, they initiate the gait cycle by striking the ground with the entire plantar surface. Abducted arms along with a wide base help infants to maintain balance. There is pronounced flexion at the hip and knees. Legs are externally rotated. During stance phase, legs are fully extended at the knee. This gait pattern gradually matures with narrowing of the base. Heel strike develops around 18 months of age. Legs gradually start to rotate internally at the end of the swing phase. Full knee extension at midstance transitions to slight knee flexion to allow for smoother gait. Arms eventually are adducted and exhibit reciprocal swing. Gradually as children age, cadence (steps per minute) decreases while stride length and velocity increase.


Normal gait requires proper function of musculoskeletal and multiple neurologic systems (eg, visual, sensory, coordination, motor). Therefore, the assessment of a child with gait problems requires a detailed physical examination including a full neurologic exam.

Valuable insight into the cause of gait deviation without use of formal and expensive gait analysis equipment can be accomplished by observing the child walk in anterior, posterior, and lateral views, and describing movement and position of the swinging and stance limb across the foot, knee, and hip joints (Table 7–1). It is also important to note symmetry in step length and efficiency of walking pattern with either presence or absence of excessive body motion or ...

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