Internal Tibial Torsion

Tibial Torsion – Podiatry, Orthopedics, & Physical Therapy

Internal Tibial Torsion | Johns Hopkins Medicine

TIBIAL TORSION
By: Robert H. Sheinberg, D.P.M., D.A.B.F.A.S., F.A.C.F.A.S. 

INTERNAL TIBIAL TORSION

It is a rotation of the lower leg bone (tibia) excessively inwards relative to the upper leg bone (femur).

It may also be due to an internal twist of the lower portion of the lower leg bone (tibia) relative to the upper portion of the lower leg bone (tibia). Usually noticed between the ages of 2 and 4.

It is the most common cause of in toe in the 2 to 4-year-old age group and the condition usually resolves by age 8.

CAUSE:

  • Intrauterine position.
  • Excessive medial ligamentous and muscular tightness around the knee region.
  • Sitting and sleeping postures may perpetuate the problems but generally do not cause them.

SIGNS AND SYMPTOMS:

  • When viewing the child standing, the foot and lower leg appear to be rotated internally. If there is an isolated problem, the kneecaps appear to be straight, thus distinguishing this condition from femoral anteversion in which the kneecaps are pointed in.
  • When walking or running the feet excessively turn in occasionally causing tripping and falling. During running the kneecaps continue to stay straight.
  • At the end of the day when fatigue sets in the in toe appear to be worse. Maybe asymmetrical (one side worse than the other).
  • May appear to be bowlegged (because the musculature in the calf is rotated towards the outside of the lower leg).
  • Could be associated with metatarsus adductus in an infant.

CLINICAL EXAMINATION:

Examining the child with the patient sitting, standing and walking is important. When the child is sitting the rotation of the lower leg bone is measured against the upper leg bone.

When the rotation of the lower leg bone is excessively in with very little rotation out, this is indicative of internal tibial torsion.

Observation of the kneecaps is important in helping to rule out femoral anteversion or to determine if there is a component of a hip problem associated with it.

TREATMENT:

  • Observation of gait and reassurance to the parents that the condition usually resolves by age 8 is provided.
  • Abnormal sitting and sleeping postures which tend to perpetuate the deformity need to be changed.
  • A child that is tripping and falling or has a posture that is excessively turning in will benefit from a cast that goes above the knee. During the cast application, the lower leg bone is gently rotated externally relative to the upper leg bone. This helps to stretch the ligamentous and musculotendinous structures around the knee. The cast may be utilized for 2-6 weeks. This will rapidly help the normal physiologic unwinding process of the lower leg bone relative to the upper leg bone.
  • Night splinting is utilized following cast removal to maintain the correction.
  • Counter rotational splints and a Denis Browne bar may also be helpful. They may not help as much in the unwinding process as much as they will help prevent abnormal sleeping postures that could perpetuate the deformity.
  • Orthotics and gait plates may also be utilized to help to move the foot towards external rotation during gait. They are also beneficial in preventing abnormal compensation, which could put stress on the arch.
  • It is rare that an operation is performed for this condition. If the deformity is excessive causing tripping and falling and there is a significant cosmetic concern, surgery on the lower portion of the lower leg can be performed to externally rotate the foot

Below is a clinical demonstration of in-toeing with the knee being held in rectus position by the clinician, the tibia lies in an internally rotated position causing the foot to follow by in-toeing.

Often, children will sit on their feet, as shown below, which promotes an in toe gait

Standing In toe with the knee straight (Right Leg). This is true tibial torsion causing in toe (Below)

EXTERNAL TIBIAL TORSION

External tibial torsion is usually a common cause of an out toe gait. The lower leg bone (tibia) rotates excessively to the outside when comparing it to the upper leg bone (femur).

CAUSE:

  • Hereditary.
  • Not usually due to in utero position as the fetus’ tibia is usually rotated internally.
  • Tight ligament and tendon structures (hamstrings, iliotibial band).
  • Can be caused by a true twist of the lower portion of the lower leg bone (tibia) relative to the upper portion of the lower leg bone (tibia).

SIGNS AND SYMPTOMS.

  • Commonly seen when children begin to walk. Becomes more apparent between the ages of 4 and 7.
  • If the hip is normal the knee appears to be straight when watching the child walk but yet the foot and lower leg turn to the outside.
  • Usually associated with a flatfoot deformity.
  • Poor push off power during running.
  • The child may lack coordination during activity.
  • Premature fatigue with activity.
  • Runs poorly as the child runs through the midfoot and not over the ball of the foot as in a normal gait.
  • Usually more commonly seen in one leg more than the other.
  • Can be associated with knee Pain (patellofemoral instability).

CLINICAL EXAMINATION:

  • With the knee flexed at 90 degrees, the lower leg bone (tibia) is rotated in and out relative to the upper leg bone (femur).
  • The tibia will rotate excessively towards the outside of the body and very little rotation will go towards the inside.
  • Must also examine the hips for femoral retroversion (upper leg bone rotates excessively out with limited motion turning in).
  • Must rule out flatfoot deformity which would be made worse by the lower leg position (external tibial torsion).

X-RAYS:

  • If the deformity is significant x-rays may be taken. The lower leg bone (transmalleolar axis) is measured relative to the upper leg bone (bicondylar axis of the proximal tibia). In an adult, it is approximately 14 degrees external.

TREATMENT:

  • Full lower extremity examination to rule out other coexisting problems.
  • If the foot is flat orthotics are necessary for the foot to prevent the creation of or worsening of a flatfoot deformity. It will also help to bring the foot slightly up and in, lessening some of the appearances of the deformity.
  • If associated with excessively tight ligaments and tendons around the knee a short course of immobilization in a cast above the knee may be of some benefit. When a cast is applied the lower leg bone (tibia) is gently rotated internally relative to the upper leg bone (femur). This causes a gentle stretch on the ligament and tendon structures around the knee area. The cast may be necessary for up to 8 weeks depending on the degree of the problem.
  • Following cast removal night splinting of the leg to hold the lower leg (tibia) in internal rotation relative to the upper leg (femur) may be of some benefit.
  • If the condition causes problems with gait, pain in the knee or is of significant cosmetic concern, surgery can be performed at the lower leg (above the ankle growth plate) to take some of the rotation the lower leg bone (tibia). Surgery should not be performed until the child is 10 or older.

Below is a casting technique used on smaller children to help stretch out soft tissue structures to allow rotation of the tibia to align the foot with the knee and femur. 

Source: http://www.southfloridasportsmedicine.com/tibial-torsion.html

Pigeon toe: Treatment, causes, and age groups

Internal Tibial Torsion | Johns Hopkins Medicine

Seeing a child’s toes point inward may cause concern for a parent. However, this common and painless condition, known as pigeon toe or pediatric intoeing, is common in children up to the age of 8 years.

It can happen in one or both feet. The condition usually corrects itself without treatment.

Pigeon toe often develops in the womb or due to genetic anomalies, so a person can do very little to prevent it.

No evidence exists to support any type of shoe that claims to help prevent or, in most cases, treat pigeon toe or that learning to walk in bare feet can help redirect pigeon toes.

Share on PinterestPigeon toe is common and easy to treat.

It is easy to treat most cases of pigeon toe.

The most common treatments are time, allowing a child to grow normally, and reassurance. Normally, little or no further intervention is necessary.

In the rare case that the feet require further medical intervention, practitioners will often suggest one of the following:

  • molds or casts that correct the foot shape
  • surgery to correct the positioning of the bones that cause pigeon toe

A doctor or therapist may recommend additional therapies that focus on parts of the legs and hips. If they feel any weakness in those areas, it may be linked to the pigeon toe.

As most cases of pigeon toe resolve on their own over time, most doctors do not recommend much intervention in the early stages. They mostly recommend that monitoring and observation are effective first steps.

Are children with pigeon toe able to exercise

Children with pigeon toe can exercise normally, and the condition rarely causes pain.

The most common issue is that children with in-turned feet may trip more regularly than other children during exercise. This tendency usually resolves before treatment has fully corrected the toes.

In most cases, simple walking, running, and other activities that occur naturally in children are the best daily exercises.

There are three potential causes of pigeon toe.

Metatarsus varus or metatarsus adductus

In this condition, the foot has a curved, half-moon appearance. The front of the foot is angled in toward the middle, while the back of the foot and ankle are normal. This type of pigeon toe normally results from the position the child took in the womb.

Metatarsus varus is fairly common in babies who were breech in utero, meaning that they were facing the wrong way in the womb. It also occurs more often in children whose mothers had low levels of amniotic fluid. For some people with the condition, there may be a family history.

This condition is usually “flexible” and the foot can be easily straightened. This resolves as the child gets older, and no further treatment should be required. If the foot position is “fixed” and does not improve, further treatment is occasionally necessary.

If desired, a parent can also gently stretch the feet of the infant a few times a day to help correct the shape, though this is not necessary.

Internal tibial torsion

Internal tibial torsion is caused by an inward twisting of the lower legbone, or the tibia. It is initially not noticeable but often becomes apparent at about the same time as a child’s first steps.

Children with internal tibial torsion do not usually feel any pain, but parents often report that their child experiences frequent falls.

As the child grows older, this type of pigeon toe almost always corrects itself without treatment, and the child does not normally require any therapy, bracing, or casting.

If it does not resolve by the time a child reaches 9 or 10 years of age, internal tibial torsion may require surgery. The procedure involves cutting through and reattaching the twisted bone to straighten the foot.

Femoral anteversion

This type of pigeon toe is very common and occurs in 10 percent of children.

The upper leg bone, known as the femur, experiences too much rotation inward at the hip joint. This is ly due to stress on the hips before birth, though the true cause is unknown.

This type of intoeing normally clears by the age of 8 years. If symptoms continue after this age, consult an orthopedic surgeon to determine whether the child needs corrective surgery.

Share on PinterestIntoeing can be observable from birth. However, there is often very little to worry about.

In children with pigeon toe, the feet and toes often can appear different in children of various ages.

Pigeon toeing may appear as follows:

Infants: The front of the foot and toes often bend in towards the middle of the foot. The outer part of the baby’s feet will often have a half-moon shape. This frequently occurs in both feet.

Toddlers aged from 1 to 3 years: A child in this age group that has pigeon toeing may appear bowlegged. The pigeon toeing most commonly seen in toddlers is normally the result of tibial torsion, in which the shinbone rotates inward.

Children between 3 and 10 years: Femoral anteversion is the most frequent cause of pigeon toeing in this age group. Children with this often prefer to sit in a “w” position, where their knees appear to go inward. There is no harm in allowing your child to sit in this position if they prefer it.

Pigeon toe presents slightly differently as children start to walk and as they get older. Very often, the cause is due to the leg, not the foot, and the child’s toes appear to point towards each other.

When to see a doctor

There is normally no need to see a doctor immediately. However, if pigeon toe is still apparent by the time a child reaches 8 years, or if it causes the child to fall more often than normal, consult a healthcare professional. Most parents seek medical advice regarding pigeon toe as part of their child’s routine exams.

Share on PinterestThe doctor will sometimes but not always take an x-ray of the feet to diagnose pigeon toe.

A diagnosis of pigeon toe depends on the type.

To diagnose the condition, the doctor carries out a simple physical exam. In some cases, X-rays, and other imaging may be necessary, but this is uncommon.

For metatarsus varus or metatarsus adductus, diagnosis can take place very early, sometimes during the post-birth examination. A simple physical examination should be enough. The doctor should also rule out issues with the hip that may be causing the intoeing.

Internal tibial torsion does not usually occur until the child starts to walk, so the earliest diagnosis may happen just before 1 year of age. A doctor will diagnose this by watching a child walk and by examining the child’s legs. If the doctor reaches a diagnosis, they may measure the legs.

A doctor most often diagnoses femoral anteversion between the ages of 4 and 6 years. This will normally start with a physical examination and review the medical history of the child and family.

Whatever the diagnosis, pigeon toe should give no great cause for concern as it is painless and often resolves without treatment.

Pigeon toe is a harmless, painless, and common orthopedic condition that occurs in young children.

The toes point inward instead of straight ahead. There are three different causes of pigeon toe, and the type dictates the level of treatment necessary to correct the problem.

However, a child would be able to exercise and live a full, happy life without impaired movement or uneven gait.

Source: https://www.medicalnewstoday.com/articles/315061

The distal femur is a reliable guide for tibial plateau fracture reduction: a study of measurements on 3D CT scans in 84 healthy knees

Internal Tibial Torsion | Johns Hopkins Medicine

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Internal Tibial Torsion – Podiatry, Orthopedics, & Physical Therapy

Internal Tibial Torsion | Johns Hopkins Medicine

INTERNAL TIBIAL TORSION
By:  Robert H. Sheinberg, D.P.M., D.A.B.F.A.S., F.A.C.F.A.S.

It is a rotation of the lower leg bone (tibia) excessively inwards relative to the upper leg bone (femur).

  It may also be due to an internal twist of the lower portion of the lower leg bone (tibia) relative to the upper portion of the lower leg bone (tibia).  Usually noticed between the ages of 2 and 4.

  It is the most common cause of intoe in the 2 to 4-year-old age group and the condition usually resolves by age 8.

 CAUSE:

  • Intrauterine position.
  • Excessive medial ligamentous and muscular tightness around the knee region.
  • Sitting and sleeping postures (picture below) may perpetuate the problems but generally do not cause them. 

SIGNS AND SYMPTOMS:

  • When viewing the child standing, the foot and lower leg appear to be rotated internally.  If there is an isolated problem, the kneecaps appear to be straight, thus distinguishing this condition from femoral anteversion in which the kneecaps are pointed in. 
  • When walking or running the feet excessively turn in occasionally causing tripping and falling.  During running the kneecaps continue to stay straight. 
  • At the end of the day when fatigue sets in the intoe appears to be worse.  May be asymmetrical (one side worse than the other). 
  • May appear to be bowlegged (because the musculature in the calf is rotated towards the outside of the lower leg). 
  • Could be associated with metatarsus adductus in an infant.

CLINICAL EXAMINATION:

Examining the child with the patient sitting, standing and walking is important.  When the child is sitting the rotation of the lower leg bone is measured against the upper leg bone.

  When the rotation of the lower leg bone is excessively in with very little rotation out, this is indicative of internal tibial torsion.

  Observation of the kneecaps is important in helping to rule out femoral anteversion or to determine if there is a component of a hip problem associated with it.

TREATMENT:

  • Observation of gait and reassurance to the parents that the condition usually resolves by age 8 is provided.
  • Abnormal sitting and sleeping postures which tend to perpetuate the deformity need to be changed.
  • A child that is tripping and falling or has a posture that is excessively turning in will benefit from a cast that goes above the knee.  During the cast application the lower leg bone is gently rotated externally relative to the upper leg bone.  This helps to stretch the ligamentous and musculotendinous structures around the knee.  Cast may be utilized for 2-6 weeks.  This will rapidly help the normal physiologic unwinding process of the lower leg bone relative to the upper leg bone.
  • Night splinting is utilized following cast removal to maintain the correction.
  • Counter rotational splints and a Denis Browne bar may also be helpful.  They may not help as much in the unwinding process as much as they will help prevent abnormal sleeping postures that could perpetuate the deformity.
  • Orthotics and gait plates may also be utilized to help to move the foot towards external rotation during gait.  They are also beneficial in preventing abnormal compensation, which could put stress on the arch.
  • It is rare that an operation is performed for this condition.  If the deformity is excessive causing tripping and falling and there is a significant cosmetic concern, surgery on the lower portion of the lower leg can be performed to externally rotate the foot. 

Clinical photograph of an infant with internal tibial torsion. The leg (below the knee) appear deviated internally and slightly rotated internally as well.

The photograph below depicts an adolscent child with the similar type of structural changes with internal deviation of the tibia with interna rotation causing the feet to also turn inward.

Source: http://www.southfloridasportsmedicine.com/internal-tibial-torsion.html