Take a look at these pics for a moment, then come back and read.
Ready? Lets see how much you remember about torsions and versions. Take a look at this child that was brought in by their parent (legs were too short to drive themselves : ) ) They were wondering if the child needed orthotics. What do we see?
top left photo: legs are in a neutral position. note the position of the knee (more specifically the tibial tuberosity and patellae can sometimes fake you out. ( OK, maybe not you, but they can sometimes fake SOME people out). The plane of the 2nd metatarsal is LATERAL to the tibial tuberosity, This is EXTERNAL TIBIAL TORSION; it appears greater on the (patients) right (look also at the left lower leg in the center picture as well, it has less torsion). Note also the lower longitudinal arches bilaterally (they are typically higher in non-weightbearing but in children this young they are typically lower in the early stages).
top right photo: I am fully internally rotating the right lower leg and hip. Note the position of the knee; it does not rotate as much as you would expect (normally 40 degrees) when compared to the distance the foot seems to have travelled. This hip is RETRO-TORSIONED (remember we are born anteverted about 40 degrees, which decreases approximately 1.5 degrees per year to puberty, resulting in an 8-12 degree angle in the adult. If you need a review, go back and read the February 27th post). Go back and read our 5 part series on Versions and Torsions (“Are you Twisted ?”).
Center photo: I am fully externally rotating the right leg. Note that range of motion is much greater than internal rotation and exceeds 40 degrees. This supports the previous paragraph, retro-torsion.
Bottom left: I am fully internally rotating the left lower leg. It appears normal with about 40 degrees (or more) of internal rotation. This femur is NORMAL or has NORMAL FEMORAL VERSION.
Bottom right: I am externally rotating the left leg. Motion appears to mimic internal rotation and is approximately equal. This supports the previous paragraph as NORMAL FEMORAL VERSION.
- External tibial torsion, R > L
- flattened longitudinal arches
- Right femoral retrotorsion
- Left femoral version, NORMAL
Well, what do you think? Are orthotics going to help this kiddo? No, probably not, they may even make the problem worse, by slowing derotation of the talar head, forcing them into more permanent varus of the forefoot.
How did you do? Can you see now why torsions and versions (the degree of “twistedness” of a limb is so important? They help you understand skeletal development and help you to make clearer decisions.
The Gait Guys. Twisted in a good way. Versioned but not torsioned.
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