So, What’s going on here?
In the top left view, you are seeing the left foot in a neutral posture with the knee in the (relative) midline. Notice how the foot adducts? This person has INTERNAL TIBIAL TORSION. They also have hammer toes and a cavus (high) arch.
In the top right, the foot is again in a neutral posture and the R foot is adducted EVEN FARTHER. Again, internal tibial torsion along with hammer toes and a cavus foot. For a hint, look at the tibial tuberosity; it should line up with an imaginary line drawn through the 2nd metatarsal.
In the middle left picture I am fully internally rotating the R leg. Hmm, no internal rotation of the hip (note the knee goes little beyond midline). You need 4 degrees of internal rotation of the hip to walk normally and most folks have 40 degrees. This person has FEMORAL RETROTORSION.
In the middle right picture I am fully internally rotating the L leg. Hmm, no internal rotation of the hip here either; in fact, even less than the right. Again, FEMORAL RETROTORSION.
In the bottom two pictures, the goniometer is aligned with the ASIS and tibial tuberosity. I am not sure if you can see it, but it is 18 degrees on the left and 20 on the right. Normally the Q angle is between 8 and 12 degrees. This person has developed compensatory GENU VALGUS.
Does it surprise you he has pain on the outside of his feet? How about knee pain?
So what does this mean?
- he will have a decreased progression angle of the feet
- he will externally rotate the feet to allow a more normal progression angle and “create” the internal rotation of the hip needed
- this will place the knee out side the saggital plane and create a potential conflict at the knee
- he will stress the ligaments at the medial knee secondary to his valgus deformity
- he will increase the pressure on the lateral condles of the femur and lateral tibial plateau, leading to early degeneration
So what do you do?
- normalize, to the best of his (and your) abilities, foot and lower extremity mechanics with manipulation, exercise, etc
- ensure he has an adequate foot tripod with the tripod and EHB exercises
- In his case, construct an orthotic, which will correct rearfoot pronation and yet not push the knee outside the saggital plane, by having a forefoot valgus post in place
- educate him about proper footwear with an adequate toe box and not too much torsional rigidity (ie no motion control features)
- follow him at regular intervals to make sure he doesn’t fall off the turnip truck