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, page 274.)

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 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

Developmental dysplasia of the hip.Bilateral hip dislocation produces a waddling gait with lordosis and pain.

Muscular dystrophy.With Duchenne's muscular dystrophy, waddling gait becomes clinically evident between ages 3 and 5. The gait worsens as the disease progresses, until the child loses the ability to walk and requires the use of a wheelchair, usually between ages 10 and 12. Early signs are usually subtle: a 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. Serious complications result when kyphoscoliosis develops, leading to respiratory dysfunction and, eventually, death from cardiac or respiratory failure.

With 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.

With facioscapulohumeral muscular dystrophy, which usually occurs late in childhood and 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.With Kugelberg-Welander syndrome, waddling gait occurs early (usually after age 2) and typically progresses slowly, culminating in the 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.

With 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.

Nursing considerations

▪ Perform passive and active muscle-stretching exercises to the arms and legs.

▪ Encourage the patient to walk at least 3 hours each day (with leg braces, if necessary) to maintain muscle strength, reduce contractures, and delay further gait deterioration, if possible.

▪ Stay near the patient during ambulation, to provide support if necessary.

▪ 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 teaching

▪ Caution the patient about long, unbroken periods of bed rest, which accelerate muscle deterioration.

▪ Refer the patient to a local Muscular Dystrophy Association chapter, as indicated.

▪ Suggest genetic counseling for parents, if they're considering having more children.

Pictures

Book Source Details

• Book Title: Nursing: Interpreting Signs and Symptoms
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Nursing: Interpreting Signs and Symptoms Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-668-7

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