External Tibial Torsion: A Video showing the effects on the knee, foot and hip.
Tibial torsion is measured as the angular difference between the tibial plateau and the distal malleoli. Here we have put 2 blue dots on the tibia, one at the middle of the tibial plateau and one at the half-way bisection of the malleoli (“ankle bones”). You can see that the dots clearly do not rest on the same vertical plane, they are nowhere close in this case ! This is tibial torsion. And since the lower dot is outside the upper dot, this is EXTERNAL TIBIAL TORSION. It is one of the factors which determine the progression angle of the foot (see our post here). It is easily seen here that, the foot will follow the lower dot because that is where the foot is attached to the ankle mortise joint. This is thus what is referred to as an “increased or excessive” Foot Progression Angle. Some will loosely, and humorously, refer to this as being “Duck Footed”. (But we have never seen a duck with external tibial torsion so who knows how this came about ! :-)
Normally, the angle is 0 degrees in an infant leaving the feet straight or slightly “in-toed”, and the tibia “unwinds” with growth, leaving the angle in adults at approximately 22 degrees. Angles in excess of 25 degrees are considered external tibial torsion; angles less than 15 degrees, internal tibial torsion.
In this case video it is critical to note a few things:
1- at the beginning we coached the client to straighten the feet forward so we could see the effects of the tibial torsion on the knees. In External Tibial Torsion, as in this case, the knees will always drift inwards (this is why these clients will always turn out the feet so that the knees and patella can track forward in the normal hinge progression that is necessary for gait. A case of external tibial torsion like this case will never see them walking with the feet straight forward (0 degree foot progression angle) because they will knock the knees together and the patella will track incorrectly and develop knee tracking pain.
2- you should be able to see that the client cannot dorsiflex the ankle sufficiently at the start because of the binding of the ankle into the torsioned distal tibia-fibula ankle mortise joint. The client gets “locked out” and cannot squat more than a few degrees. Be sure to notice this. These clients should not be pigeon-holed into how they do squats and lunges (“Straighten your feed lad!” should not be your recommendation, they just won’t be able to do much if they do. They will cheat !)
3. The second set of squats show them with the feet turned out excessively. They are able to get down further now, but the knees are now tracking too far outside and not forward. This was too much accommodation for the external tibial torsion.
4. The 3rd set are done (at 0:28 seconds into the video) with a more reasonable foot alignment. Reasonable for this client but far too much for someone who does NOT have external tibial torsion. You can see that the single planar hinge joint knee (the joint with the least tolerance) now moves nicely forward towards the camera. So, they will walk with the feet at this progression angle because this is where the external tibial torsion has left the knees to rest in the sagittal (forward) plane. Here the client will have minimal if any knee issues. However, one can only imagine what their ankles and feet and hips will think of all this !
To discern tibial torsions from femoral torsions, observe the orientation of the tibial tuberosity (the upper blue dot) with respect to the foot; in tibial torsion, there is a large difference. If this angle is withing the 15-25 degree range, then the torsion lies in the femur (femoral retro torsion and ante torsion…the subject of another post).
So, if you are training, coaching or rehabing a client are you aware of issues like these ? Are you attempting to drive skill, endurance and strength into your clients into a lower limb plane that is reasonable for their bony alignment? Maybe you were not even aware of these issues at all ? Lets hope not. You just cannot pigeon-hole all of your clients into a similar paradigm. It just isn’t that simple. Not if you do not want to injure someone. We get alot of these cases, sadly.
We discuss this in more detail in our Shoe Fit program that is soon to launch, but we also presented several 1 hour slide presentations on www.onlineCE.com in the recent months if you wanted to take those lectures.
Shawn and Ivo, two twisted fellas. Torsioned dudes. One is internally torsioned, the other external……… we cancel eachother out !