Motor development. DMD usually presents in early childhood with delayed milestones, including delays in sitting and standing independently. The mean age of walking is approximately 18 months (range 12-24 months). The first symptoms of DMD as identified by parents are typically: general motor delays (42%); gait problems, including persistent toe-walking and flat-footedness (30%); delay in walking (20%); learning difficulties (5%); and speech problems (3%). The mean age of diagnosis of boys with DMD without a family history of DMD is approximately four years ten months (range: 16 months - 8 years) [ Bushby 1999 , Zalaudek et al 1999 ]. Proximal weakness causes a waddling gait and difficulty climbing stairs, running, jumping, and standing up from a squatting position [ Li et al 2012 ]. Boys use the Gower maneuver to rise from a supine position, using the arms to supplement weak pelvic girdle muscles. The calf muscles are hypertrophic and firm to palpation. Occasionally there is calf pain. DMD is rapidly progressive, with affected children being wheelchair bound by age 12 years.
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