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Gover’s sign

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Gower's sign muscular dystrophy clinical significance mechanism

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Gower's Sign

Gower's Sign - sequential illustrations showing a child rising from the floor using hands to walk up thighs
Figure: Gower sign - child must use hands to rise from sitting position. (From Campbell's Operative Orthopaedics, 15th ed.)

Definition

Gower's sign (also "Gower maneuver") is a clinical indicator of proximal lower limb muscle weakness, first described in 1879 by neurologist Sir William Richard Gowers in patients with Duchenne muscular dystrophy (DMD). The patient, unable to extend at the hips and knees from sitting/lying, compensates by using their hands to "walk up" their own legs - pushing off the floor, then pushing on the thighs - to achieve a standing position.

Mechanism

The weakness affects proximal muscles before distal ones. Specifically:
  • Gluteus maximus (hip extensors) and quadriceps are predominantly weak
  • The child cannot extend the hips and knees against gravity alone
  • To compensate, the child presses their hands into the floor, raises hips high into the air ("butt-first maneuver"), forming a triangle with hips at the apex and hands+feet at the base, then "walks" both hands up the thighs to push the trunk upright
This entire process is the Gower maneuver, and it can be broken into component parts to document disease severity:
  • Degree of initial turn (>90 degrees?)
  • Unilateral vs bilateral hand support on thigh
  • Whether support is transitory or sustained
  • Whether a butt-first prone crawl maneuver is needed
  • Bradley and Daroff's Neurology in Clinical Practice, block 6

Classical Association: Duchenne Muscular Dystrophy (DMD)

Gower's sign is most classically associated with DMD, an X-linked recessive condition caused by absence of dystrophin. Key features in DMD:
FeatureDetail
OnsetSigns appear between ages 3-6 years
GaitWaddling Trendelenburg gait, toe-walking, lumbar lordosis
Calf musclesPseudohypertrophy - firm, rubbery feel due to fat/fibrosis infiltration
CK level50-100x normal (dramatically elevated)
ProgressionWheelchair by ~12 years (with steroids + physio)
InheritanceX-linked recessive; ~1/3 sporadic (new mutations)
Apparent improvement may occur between ages 2-6 as natural developmental gains temporarily outpace muscle weakness - this is illusory.
  • Campbell's Operative Orthopaedics, 15th ed. 2026, p. 1725
  • Bradley and Daroff's Neurology in Clinical Practice, block 29

Other Causes of Gower's Sign

Gower's sign is not exclusive to DMD - it occurs in any condition with pelvic girdle or proximal lower limb weakness:
  • Other muscular dystrophies (Becker, limb-girdle, Emery-Dreifuss)
  • Inflammatory myopathies (polymyositis, dermatomyositis - notably, dermatomyositis in children shows Gowers' sign with symmetric limb girdle weakness)
  • Spinal muscular atrophy (SMA)
  • Glycogen storage diseases (e.g., Pompe disease)
  • Congenital myopathies
  • Myasthenia gravis (severe cases)
  • Rheumatology, 2-Volume Set (Elsevier, 2022), block 14 and 21

Three Described Gower's Signs

As noted by StatPearls (NCBI), three Gower's signs exist in the literature:
  1. Gower's sign (1879) - The classic maneuver described above (rising from the floor by climbing up the thighs) - indicator of proximal muscle weakness
  2. Gower's sign in tabes dorsalis - Loss of knee jerk reinforcement by hand clenching, indicating posterior column disease
  3. Gower's hemianopic pupillary sign - Pupil contracts to diffuse light but not to a beam shone from the blind side; related to optic tract lesions
The first is by far the most clinically relevant and commonly tested.

Grading of Severity (Gower Maneuver)

SeverityDescription
Mild (1-4 pts)Prolonged/strained rise; one-hand support on thigh; hand on floor without thigh support
Moderate (5-7 pts)Prone crawl position + 1-2 hands on thigh
Severe (8-10 pts)Prone crawl + >2 hand-on-thigh maneuvers; needs additional aid; unable to rise

Associated Signs in DMD (Physical Examination)

  • Meryon sign - child slides through examiner's arms when lifted under the chest (shoulder girdle weakness)
  • Trendelenburg gait - waddling, from gluteus medius weakness
  • Thomas test - hip flexion contracture (later disease)
  • Ober test - hip abduction contracture (later disease)
  • Calf pseudohypertrophy - firmer than normal to palpation

Investigations to Confirm

  • Serum CK - dramatically elevated (50-100x normal); first-line test
  • DNA analysis (dystrophin gene mutation) - confirmatory
  • Muscle biopsy - variable fiber size, internal nuclei, split fibers, degenerating/regenerating fibers, fibrofatty infiltration; dystrophin staining absent
  • EMG - myopathic pattern
  • Campbell's Operative Orthopaedics, 15th ed. 2026; Miller's Review of Orthopaedics, 9th ed.
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