Gowers’ sign refers to the use of hands and arms to “walk” up the body from a squatting or sitting position due to proximal lower limb and pelvic girdle muscle weakness.

• In children: Classic sign in Duchenne or Becker muscular dystrophy.

• In adults: May be observed as irregular contraction of the iris when illuminated in tabes dorsalis (rarely relevant to mobility).

This assessment focuses primarily on the pediatric muscular dystrophy context.

Pathophysiology

• Duchenne/Becker muscular dystrophy:

  • Genetic mutations in the dystrophin gene → defective sarcolemmal stability.

  • Weakness predominates in proximal muscles of the pelvic girdle and thighs.

• Functional consequence: Child cannot rise from the floor without compensatory maneuvers:

  • Hands on knees → pushing up → walking hands along thighs → standing upright.

• Adult tabes dorsalis variant: Impaired pupillary reflex (Argyll Robertson variant) may be seen as an ocular Gowers’ sign.

Examination Technique

1. Patient positioning: Ask the patient (child) to sit or lie on the floor.

2. Instruction: Request the patient to stand up without support.

3. Observation:

   • Positive Gowers’ sign: child uses hands to “climb” up legs due to proximal weakness.

   • Note sequence of compensatory movements and any difficulty with rising.

4. Documentation: Record presence, severity, and symmetry of the sign.

Clinical Features

Differential Diagnosis

Pediatric Considerations

• Early detection is critical for genetic counseling and management.

• Observe rise from floor, chair, or low surfaces.

• Assess muscle strength in upper and lower limbs.

Geriatric/Adult Considerations

• Gowers’ sign is rarely observed in adults except as an ocular manifestation in tabes dorsalis.

• Adult proximal myopathies may mimic pediatric forms; differentiate by history and lab/genetic tests.

Limitations

• Mild proximal weakness may not produce an obvious Gowers’ sign.

• Cooperation and understanding of instructions are essential.

• Must distinguish from lower limb orthopedic conditions that impede rising.

Patient counseling

• Explain that difficulty rising is due to muscle weakness, not laziness or pain.

• Discuss the importance of physical therapy, mobility aids, and monitoring.

• Genetic counseling is essential for familial muscular dystrophies.

Conclusion

Gowers’ sign is a hallmark clinical feature of proximal muscle weakness, most notably in Duchenne and Becker muscular dystrophies. Careful observation of rising maneuvers, combined with neurological and musculoskeletal assessment, aids early diagnosis, guides management, and informs prognosis.

References

1. Bushby K, et al. Diagnosis and management of Duchenne muscular dystrophy, part 1: diagnosis, and pharmacological and psychosocial management. Lancet Neurol. 2010;9(1):77–93.

2. Emery AE. Muscular Dystrophy. 5th ed. Oxford: Oxford University Press; 2008.

3. Ropper AH, Samuels MA. Adams and Victor’s Principles of Neurology. 11th ed. New York: McGraw-Hill; 2021.

4. Dubowitz V. Muscle Disorders in Childhood. 2nd ed. London: Saunders; 2007.