Find written content here https://medical-notes-revise-in-1-minute.com An examination of each component of the three phases of ambulation is essential in diagnosing various neurologic disorders and evaluating patient progress during rehabilitation and recovery from the effects of neurologic disease, a musculoskeletal injury or disease process, or a combination of these conditions. #gait #examine gait #evaluating patient

1. EXAMINATI
ON OF GAIT

2. •Begin by introducing yourself to the parent and
patient, getting an impression of the child’s cognition,
and any problems with speech or eye contact.
•Also, gain an impression of whether the parents
have any gait/neurological problems themselves.

3. FIRST 30
SECONDS just
observe

4. •Stand back, quickly scan the room for orthoses (e.g., ankle-foot
orthoses [AFOs]), other aids, and
•scan the child for signs of neurological disorders, such as a large
head, obvious eye signs (e.g., squint, ptosis or nystagmus),
abnormal posturing (e.g., hemiplegic), abnormal movements (e.g.,
tremor, fasciculations), and asymmetry (e.g., growth arrest with
hemiplegia, rib asymmetry with scoliosis).

5. •Then, with the child’s lower limbs adequately exposed (watch how the
child undresses), Inspect the limbs very carefully. Note the muscle bulk
(look systematically at buttocks, thighs, and calves for any wasting or
any enlargement of calves [calf pseudohypertrophy in DMD]),
contractures, and any deformities of the feet (e.g., talipes, pes cavus).
•Look for skin signs such as neurocutaneous stigmata or scars of
procedures (e.g., tendon releases, ventriculoperitoneal shunts).

6. ASK THE CHILD
FOR A WALK IN
STRAIGHT LINE

7. Normal gait. This
is the initial
screening
procedure. Note
any characteristic
pattern of the
gait; for
example,
circumduction with hemiplegia,
scissors (+/– crouching) gait with spastic
diplegia,
wide-based with cerebellar pathway
dysfunction,
waddling with proximal myopathies (pelvic girdle
weakness, giving bilateral Trendelenburg gait),
steppage gait with foot drop (paralyzed ankle and foot
dorsiflexors), unilateral Trendelenburg gait with a unilateral
dislocated hip,
antalgic gait (limp from painful limb pathology) with
orthopedic problems.
(If no obvious recognizable pattern is seen, then look at each
component of the gait in turn, focusing on the pelvis, hips, knees,
and feet, or in the reverse order, and describe what you see.)

8. Heel-toe walking. This
tests for cerebellar
pathway problems. If the
child is over two years and
cannot walk steadily, this
may be due to pathology in
the cerebellar vermis, but
it may also be due to
weakness or sensory
deficits.

9. After walking tandem in a
straight line, it is useful to
get the child to turn
around quickly (‘as fast as
you can’) and walk back
the other way. If the child
stumbles with a quick
turn, this can be the first
sign of vermal pathology.

10. Walking on heels. This tests for strength
of dorsiflexion (L5) or contractures of the
calf muscles. It is often difficult to do this
in many conditions (e.g., CP, anterior
horn cell disease, peripheral
neuropathies, DMD). This is a useful test
in the school-aged child, but not
necessarily younger. (By 2.5 years, 60%
of children can walk on their heels; by
four years, most children can walk on
their heels, by five years, almost all
children can walk on their heels.)

11. Walking on toes. This tests for the
strength of plantar flexion (S1). It
is usually possible for children
with CP or DMD to do this well,
but children with lesions affecting.
S1 (e.g., low lumbar
myelomeningocele [MMC],
peripheral neuropathies, anterior
horn cell disease) may find it
impossible. (By two years, 90% of
children can walk on their tip-
toes.)

12. Walking on outsides of feet. This is
the Fog test. Maintaining the
position of marked inversion
brings out signs of subtle
hemiplegia with the mildly
hemiplegic child. Adopting either a
frank hemiplegic posture or
demonstrating a notable
asymmetry in arm and leg
positioning. Walking on the insides
of the feet (marked eversion), often
called the ‘reverse Fog,’ has similar
significance. Again, it is the
finding of asymmetry that is

13. Running. This also
accentuates findings such as
hemiplegia and proximal
weakness (in the latter, a child
may seem to be miming a run
in slow motion). Only ask the
child to run if there is
adequate room to do so and if
the child is over two years old.
(By 18 months, 80% of
children can run; by two
years, 97% of children can
run.)

14. Standing on each foot. By
inspecting from behind and noting
the position of the pelvis, by iliac
crest position, this allows detection
of any proximal instability and
positive Trendelenburg’s sign. This
test is useful in children over three
years old. (By 2.5 years, about 50%
of children can stand on one foot for
over 6 seconds; by three years, 95%
of children can manage this.)

15. Hopping on each foot. This
assesses for unilateral
weakness and balance, in
school-aged children,
especially over 7. (By 3.5
years, 50% of children can hop
for 3 meters. By five years,
92% of children can hop this
distance. By seven years
almost all children can
manage this.)

16. Standing with feet together. With eyes open, this tests
for truncal (cerebellar) ataxia. With eyes closed, this
checks for Romberg’s sign (falling due to dorsal
column pathology and removal of visual input). The
Romberg test, standing with feet together, is often
combined withholding the upper limbs extended out
in front of the child, with fingers extended, looking for
parietal (proprioceptive) drift when eyes are closed,
which occurs with contralateral parietal lesions,
where the arm may drift away from the previous
position, moving down (or up) because of unawareness
of its position without visual reinforcement (a form of
hemineglect).

17. Bending forwards and touching toes.
This is to screen for scoliosis, which
can occur with numerous
neuromuscular disorders. The back
should be inspected carefully for
midline scars (e.g., MMC repair),
hairy patches, or lipomas. Scoliosis
can be the cause or effect of
neurological disorders. The degree of
scoliosis may reflect the severity of
lower motor neuron (LMN) disorders
such as spinal muscular atrophies
(SMAs), myopathies, DMD, or upper
motor neuron (UMN) disorders such
as CP.

18. Squatting and then rising from
the squatting position.
Maintaining a squatting position
tests more peripheral strength.
This may be difficult in cases
with peripheral neuropathy.
Arising from the squatting
position tests for proximal
weakness. (By 12 months, 95% of
children can squat.)

19. Lying on the floor and then
rising from this position. This
is called Gowers’ maneuver, to
elicit Gowers’ sign, which
occurs with proximal
weakness, classically
associated with DMD; If a
child over two years old does
not sit bolt upright quickly,
this suggests some proximal
weakness.

20. The next step is to examine the
lower limbs, and look for
Common findings include
hemiplegia, spastic diplegia, and
muscle disorders.