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Copyright 198 by he ownol o Bone and oinr Surgery l ~ o p o r a
u d
The Development of Mature Gait*BY DAVI D H . SUTHERLAND, M . D .
~ ,ICHARD OLSHEN, P H . D . ~ ,ES COOPER, B.A. .,A N D
S A V IO L.-Y. WOO,P H . D . ~ ,A N DIEGO, ALIFORNIAFrom the
Gait Analysis Laboratory, Children s Hospital and Health Center,
Son Diego
A m c r To determine the normal gait patternsin childhood, gait
studies were performed on 186 nor-mal children between the ages of
one and seven years.Rotations of the lower-extremity joints in the
sagittal,frontal, and transverse planes; step length;
cadence;walking velocity; and duration of single-limb stance
(aspercentage of the gait cycle) were analyzed throughouta walking
cycle using high-speed movies, a Graf-Pensonic digitizer, a
computer, and a plotter as well aselectromyograms.
The sagittal-plane angular rotations in childrenfrom two years
on are very similar to those of normaladults. Subjects less than
two years old have greaterknee flexion and more ankle dorsiflexion
during stancephase, and their knee-flexion wave (stance-phase
kneeflexion after foot-strike and subsequent knee extensionprior to
toe-off) is diminished. Also, external rotationof the hip in these
younger subjects is pronounced.
Reciprocal arm-swing and heel-strike are presentin most children
by the age of eighteen months. Sincethese commonly accepted
indicators of gait maturityare present very early, we measured
other gait deter-minants and found that the five important
determi-na4ts of a mature gait are duration of single-limbstance,
walking velocity, cadence, step length, and theratio of pelvic span
to ankle spread. As maturity ad-vances, cadence decreases while
walking velocity andstep length increase. Importan factors in the
develop-ment of a mature pattern of these determinants are
in-creasing limb length and greater limb stability, man-ifested by
the increasing duration of single-limb stance(an index of limb
stability). A mature gait pattern asdetermined by these criteria is
well established at theage of three years.CLINICALELEVANCEiven
these normative data,it will be possible to compare the gait
patterns of ab-normal children with the patterns of normal
childrenof the same age, and thus to acquire a better
under-standing of the pathomechanics of gait disorders
inchildhood.
The usual sequence of events in human neuromuscu-* Supportedby
National Institutes of Health Grant No. HDO 8520.Dr. Olshen's
research supported in part by National Science FoundationGrant MCS
76-08314 to the University of California, San Diego.t University of
California, San Diego, California 92093.Children's Hospital and
Health Center, 8001 Frost Street, SanDiego, California 92123.
lar maturation and the development of locomotor skill
arefamiliar. The infant is thought to acquire the ability to sitat
approximately six months, to crawl at nine months, towalk with
support at one year, to walk without support atfifteen months, and
to run at eighteen months18. At theinception of independent
walking, the toddler steps with awide base and hyperflexion of the
hips and knees, holdsthe arms in abduction and the elbows in
extension, andmoves in a staccato manner13. Following this early
ex-ploratory phase of walking, gradually the width of the
basediminishes, the movements become smoother, reciprocalarm-swing
appears, step length and walking velocity in-crease, and an adult
pattern of walking emerges. There isgeneral agreement that the
development of walking skill iscompleted by the age of five years
13*17.1g,ut som e authorsh av e fo un d e vid en ce of ea rlie r g
ait m a t ~ r a t i o n ~ . ~ . ' ~ . ~Both learning and maturation
of the central nervoussystem contribute to the evolution of mature
gait. Manyauthors have commented on the relationship between
thedevelopment of mature gait and maturational changes inth e
nervou s ~ y s t e m l ~ . ' ~ .he course of maturation of
thecentral nervous system progresses in a cephalocaudalmanner4.5 8
11 12.15 1e.le
While many excellent studies of gait maturation inchild ren have
been r e p ~ r t e d ~ , ~ , ' ~ , ' ~ ,ery few mea-surements of
the angular rotations of the limb segmentswere included, and those
reported were for a relativelysmall number of subjects. W ith the
current development ofgait analysis and its increasing application
to the study ofpathological gai t, there is a critical need for
normative datafor children who are on e to seven years old. The
objectivesof the present study were: (1 ) to outline the changes in
gaitfrom the age of first walking to seven years; (2) to
definemature gait in terms of specific gait parameters; and (3)
toprovide a substantial data base to m ake it possible to co m-pare
children who have gait problems with normal childrenof the same
age.
MethodsSubjects Studied
One hundred and eighty-six normal children werestudied, of whom
169 (91 per cent) were white. The re-mainder were Spanish,
Oriental, and black. Their agesranged from one to seven years. The
distribution by sexand age is shown in Table I. Each child was
studied withinthirty days of the date when his or her birthday
corre-sponded to the age group indicated.336 TH JOURNAL OF BONE AND
JOINT SURGERY
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T H E D E V E L O P M E N T OF M A T U R E G A I T 353tween limb
length and free-speed step length may be evi-dence of delayed
neuromuscular maturation.
As we have shown, the joint motions during gait ofnormal
children, whether mature or immature, are notcharacteristic. They
differ only slightly from those ofadults. Marked changes in
joint-angle measurements ascompared with normal measurements
indicate disease orinjury of the motor-skeletal system, not
immaturity. Forexample, a patient with spastic diplegia and
severehamstring-muscle contractures will show increased kneeflexion
throughout stance phase .
While normative da ta for children a re of great impor-tance, we
do not wish to imply that the presence of a ma-ture gait pattern in
a normal child can only be establishedby using elaborate laboratory
techniques. T he presence ofheel-strike and reciprocal movements of
the upper andlower extremities can be observed quite easily. Also,
it isnot difficult to differentiate visually betwee n th e wide
baseof the toddler and the narrow base of suppo rt of the
maturewalker. It is more difficult to determine the normal
rela-tionship between step length, caden ce, an d walking
veloc-ity, but two observers with a stopwatch can measure walk-ing
velocity and cadence and calculate step length. Withthese simple
observations and m easurem ents, i t is usually
possible to separate immature and mature walkers. A highlevel of
sophistication can be achieved by using the Ran-ch o Foot-Switch
Stride Analyze r'? This system measureswalking velocity, stride
length, cadence, and duration ofsingle-limb stance.The real value
of norm ative data is that they providenormal performance standards
for children that permitcomparison w ith pathological gaits2 '. It
is no longer neces-sary to compare the walking pattern of a child
who has apathological gait with the pattern of a normal adult.
Wecan now compare the gait patterns of children,
whetherpathological or unknown, with the patterns of normalchildren
of the same age.
Our understanding of gait disorders in children willbe improved
by a clear understanding of the developmentof mature gait. Accurate
measurements of gait parametersthroughout the development of mature
gait provide aframew ork on which we can build an understanding of
thephys io log ical even t s in human locomot ion and
thepathomechanics of gait disorders.
NOTE: The photographic measurement system was developed at San
ranc~sco h r~n e r sHospital for Crippled Children by one of us (D
. H . S . ) and John Hagy. Expansion of the mea-surements and
refinementsof the technique have come about through collaboration
between thegait laboratories of San Diego Children's Hospital and
Health Center and the San ranciscoShnner s Hospital for Crippled
Children. The piezoelecvic force-plate was developed at
ShrinersHospital.
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VOL. 62-A, NO. 3 APRIL 1980
