External tibial torsion or femoral retrotorsion?

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This young lad presents to your office complaining of bilateral knee discomfort at the medial aspect, just below the patella, particularly when ascending and descending stairs and hills. You narrow it down to abnormal patellar tracking and 2 possibilities of who is driving the bus, but which is it?

Torsions of an extremity are said to exist when they measure two or more standard deviation‘s outside of normal. In external tibial torsion, the shaft of the tibia over rotates more than it’s 1.5° per year from zero at birth to greater than 19°. You are left with a foot that is has an increased progression angle and a center of gravity falls medial to the foot causing abnormal patellar tracking.

Femoral retro torsion is said to exist when the head of the femur over reduces from its 35° angle at birth to less than 8° resulting in severely limited internal rotation of the hips bilaterally. The lower extremity is often externally rotated to compensate.

An easy differential for the 2 is to drop a plumbline from the tibial tuberosity through the foot. This line normally passes through the second or between the second and third metatarsal‘s. If it falls medial to that it is eternal tibial torsion and lateral to that most likely internal tibial torsion or potentially a metatarsus varus or forefoot adductus.

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Another differential would be to perform “Craigs test” and measure how much internal and external rotation of the femur there is at the femoral acetabular articulation.

An easier way to put it is; those with femoral retrotorsion have less hip internal rotation and often increased amounts of external rotation; often they can’t even get past zero, never mind the requisite 4-6 degrees for normal gait. Those with increased internal rotation and diminished external rotation most likely have femoral antetorsion.

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So, Which is it? When his knees are Straightahead, his feet point out; when his feet are straightahead, his knees point inward. A plumbline from the tibial tuberosity passes medial to the second metatarsal. Looking at the pictures, you can see that he is external tibial torsion along with a sandal thong deformity that we talked about last week.

Dr Ivo Waerlop, one of The Gait Guys.

#externaltibialtorsion #outturnedfoot #increasedprogressionangle #kneepain #thegaitguys

We’ve told you once and we will tell you again…

Folks with femoral retro torsion often experience lower back pain with twisting movements

This left handed hydrology engineer Presented to the office with an acute onset of lower back pain following “swinging a softball bat”. He comments that he always “hit it out of the park“ and hit “five home runs“ in the last game prior to his backs demise.

note the internal tibial torsion. drop a plumbline from the tibial tuberosity. it should pass through the 2nd met or between the 2nd and 3rd met shafts

note the internal tibial torsion. drop a plumbline from the tibial tuberosity. it should pass through the 2nd met or between the 2nd and 3rd met shafts

note the internal tibial torsion. drop a plumbline from the tibial tuberosity. it should pass through the 2nd met or between the 2nd and 3rd met shafts

note the internal tibial torsion. drop a plumbline from the tibial tuberosity. it should pass through the 2nd met or between the 2nd and 3rd met shafts

He presented antalgic with a pelvic shift to the left side, flexion of the lumbar spine with 0° extension and a complete loss of the lumbar lordosis. He could not extend his lumbar spine past 0° and was able to flex approximately 70. Lateral bending was approximately 20° on each side. Neurological exam negative. Physical exam revealed bilateral femoral retro torsion as seen above. Note above the loss of internal rotation at the hips of both legs, thus he has very limited internal rotation of the hips. Femoral retroversion means that the angle of the neck of the femur (also known as the femoral neck angle) is less than 8°, severely limiting internal rotation of the hip and often leading to CAM lesions.

Stand like you’re in a batters box and swing like you’re left handed. What do you notice? As you come through your swing your left hip externally rotates and your right hip must internally rotate. He has no internal rotation of the right hip and on a good day, the lumbar spine has about 5° of rotation with half of that occurring at the lumbosacral junction. Guess what? The facet joints are going to become compressed!

bisect the calcaneus. the line should fall though the 2nd metatarsal or between the 2nd and 3rd met shafts

bisect the calcaneus. the line should fall though the 2nd metatarsal or between the 2nd and 3rd met shafts

bisect the calcaneus. the line should fall though the 2nd metatarsal or between the 2nd and 3rd met shafts

bisect the calcaneus. the line should fall though the 2nd metatarsal or between the 2nd and 3rd met shafts

Now combine that with bilateral 4 foot adductus (see photos above). His foot is already in supination so it is a poor shock observer.

Go back to your “batters box“. Come through your swing left handed. What do you notice? The left foot goes into a greater amount of pronation in the right foot goes into a greater amount of supination. Do you think this is going to help the amount of internal rotation available to the hip?

When folks present with lower back pain due to twisting injuries, make sure to check for femoral torsions. They’re often present with internal tibial torsion, which is also present in this individual.

Remember a while ago we said “things occur in threes”. That goes for congenital abnormalities as well: in this patient: femoral retro torsion, internal tibial torsion and forefoot adductus.

What do we do? Treat locally to reduce inflammation and take steps to try to improve internal rotation of the hips bilaterally as well as having him externally rotate his right foot when he is in the batteries box to allow him to "create" more internal rotation of the right hip.

Dr Ivo Waerlop, one of The Gait Guys

#internalrotation #hipproblem #femoraltorsion #femoralversion #retroversion #retrotorsion #thegaitguys

Femoral Anteversion?

image source: Byun HY, Shin H, Lee ES, Kong MS, Lee SH, Lee CH. The Availability of Radiological Measurement of Femoral Anteversion Angle: Three-Dimensional Computed Tomography Reconstruction.  Ann Rehabil Med . 2016;40(2):237-43.

image source: Byun HY, Shin H, Lee ES, Kong MS, Lee SH, Lee CH. The Availability of Radiological Measurement of Femoral Anteversion Angle: Three-Dimensional Computed Tomography Reconstruction. Ann Rehabil Med. 2016;40(2):237-43.

 

Here is a free, full text article that talks about using 3D CT for a precise measurement of things like femoral and tibial torsions and versions. Remember that this will directly influence the amount of internal and external rotation of the hip, which will have a direct influence on gait. Remember you need 4-6 degrees of internal and external rotation to ambulate normally

Dr Ivo Waerlop, one of The Gait Guys

Byun HY, Shin H, Lee ES, Kong MS, Lee SH, Lee CH. The Availability of Radiological Measurement of Femoral Anteversion Angle: Three-Dimensional Computed Tomography Reconstruction. Ann Rehabil Med. 2016;40(2):237-43.

#gait, #measurement, #femoraltorsion, #femoralversion, #antetorsion, #anteversion, #retrotorsion, #retroversion

link to free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4855117/

 

Do you know your Torsions? If so, then you here is what you need to know about twisted people...

Are you twisted? Are your patients/clients twisted? You know about tibial torsions from yesterday but do you know about femoral torsions?

To go along with yesterdays post, here is some more info on femoral torsions. If you missed it, click here

The degree of version is the angle between an imaginary line drawn through the condyles of the femur and an imaginary line drawn through the head and neck of the femur. This is often referred to as the femoral neck angle or FNA.

IMAGE SOURCE: Michael T Cibulka; Determination and Significance of Femoral Neck Anteversion,  Physical Therapy , Volume 84, Issue 6, 1 June 2004, Pages 550–558,  https://doi.org/10.1093/ptj/84.6.550

IMAGE SOURCE: Michael T Cibulka; Determination and Significance of Femoral Neck Anteversion, Physical Therapy, Volume 84, Issue 6, 1 June 2004, Pages 550–558, https://doi.org/10.1093/ptj/84.6.550

Beginning about the 3rd month of embryological development (Lanz and Mayet 1953) the femoral neck angle reaches 60 degrees and decreases, with growth, to about 40 degrees (with an average of 30-60 degrees) at birth. It then decreases 25-30 degrees by adulthood to 8-20 degrees with males being at the lower and females at the upper end of the range.

The FNA angle, therefore, diminishes about 1.5 degrees a year until about 15 years of age. Femoral neck anteversion angle is typically symmetrical from the left side to the right side.

What causes torsion in the first place? By the sixth month in utero, the lumbar spine and hips of the fetus are fully flexed, so perhaps it is positional. Other sources say it coincides with the degree of osteogenesis. There is a growing consensus that muscular forces are responsible, particularly the iliopsoas or possibly the medial and lateral hip rotators.

Additional changes can occur after birth, particularly with sitting postures. “W” sitting or “cross legged” sitting have been associated with altering the available range of motion and thus the FNA, with the range increased in the direction the hip was held in; W sitting causing increased internal rotation and antetorsion and cross legged causing external rotation and retro torsion.

image source: T Michaud, with permission

image source: T Michaud, with permission

As discussed previously, there are at least 3 reasons we need to understand torsions and versions, They can alter the progression angle of gait, they usually affect the available ranges of motion of the limb and they can alter the coronal plane orientation of the limb.

  1. fermoral torsions often alter the progression angle of gait. In femoral antetorsion torsion, the knees often face inward, resulting in an intoed gait and a decreased progression angle of the foot. This can be differentiated from internal tibial torsion (ITT) by looking at the tibia and studying the position of the tibial tuberosity with respect to the foot, particularly the 2nd metatarsal. In ITT, the foot points inward while the tibial tuberosity points straight ahead. In an individual with no torsion, the tibial tuberosity lines up with the 2nd metatarsal. If the tibial tuerosity and 2nd met are lined up, and the knees still point inward, the individual probably has femoral ante torsion. Remember that a decreased progression angle is often associated with a decreased step width whereas an increased angle is often associated with an increased step width.

  2. Femoral torsions affect available ranges of motion of the limb. We remember that the thigh leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance (most folks have 40 degrees) If it is already fully internally rotated (as it may be with femoral retro torsion), that range of motion must be created or compensated for elsewhere. This, much like internal tibial torsion, can result in external rotation of the affected lower limb to create the range of motion needed.

  • Femoral retro torsion results in less internal rotation of the limb, and increased external rotation.

  • Femoral ante torsion results in less external rotation of the limb, and increased internal rotation.

          3. femoral torsions usually do not effect the coronal plane orientation of the lower limb,      since the “spin” is in the transverse or horizontal plane.

The take home message here about femoral torsions is that no matter what the cause:

  • FNA values that exist one to two standard deviations outside the range are considered “torsions”

  • Decreased values (ie, less than 8 degrees) are called “retro torsion” and increased values (greater than 20 degrees) are called “ante torsion”

  • Retro torsion causes a limitation of available internal rotation of the hip and an increase in external rotation

  • Ante torsion causes an increase in available internal rotation of the hip and decrease in external rotation

  • Femoral ante torsion will be perpetuated by “W” sitting (sitting on knees with the feet outside the thighs, promoting internal rotation of the femur)

  • Femoral antetorsion will be perpetuated by sitting cross legged, which forces the thigh into external rotation.

Michael T Cibulka; Determination and Significance of Femoral Neck Anteversion, Physical Therapy, Volume 84, Issue 6, 1 June 2004, Pages 550–558, https://doi.org/10.1093/ptj/84.6.550

http://www.clinicalgaitanalysis.com/faq/torsion.html

Souza AD, Ankolekar VH, Padmashali S, Das A, Souza A, Hosapatna M. Femoral Neck Anteversion and Neck Shaft Angles: Determination and their Clinical Implications in Fetuses of Different Gestational Ages. Malays Orthop J. 2015;9(2):33-36.

image from: http://boneandspine.com/what-is-anteversion-and-retroversion/

image from: http://boneandspine.com/what-is-anteversion-and-retroversion/

Femoral versions and torsions?

While searching for something else, we ran across this post. A pretty good lay discussion and explanation about femoral torsions. Technically, versions are NORMAL variations or limb rotations that are within accepted limits and TORSIONS are pathological, when it measures 2 or greater standard deviations from the mean and is considered pathological. Femoral versions are the angular difference between the transcondylar and transcervical axes. The femur is normally anteverted (1). 

We liked the last section talking about how to compensate for them and "acceptable" work arounds and biomechanics. 

https://b-reddy.org/2013/05/09/talking-about-hip-retroversion/

1. Staehli L in: Fundamentals of Pediatric Orthopedics Lippincott Williams & Wilkins, Jun 15, 2015 p 144

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Twisted, Part 4

 

Hopefully you have been keeping us with us. If you missed the 1st 3 of this series, go back 3 weeks and start reading again, or do a search on the blog page for “torsion”.

The final chapter of developmental versions involves the femur. The degree of version is the angle between an imaginary line drawn through the condyles of the femur and an imaginary line drawn through the head and neck of the femur. This is often referred to as the femoral neck angle or FNA.

Beginning about the 3rd month of embryological development (Lanz and Mayet 1953) and reaches about 40 degrees (with an average of 30-60 degrees) at birth. It then decreases 25-30 degrees by adulthood to 8-20 degrees with males being at the lower and females at the upper end of the range.

The FNA angle, therefore, diminishes about 1.5 degrees a year until about 15 years of age. Femoral neck anteversion angle is typically symmetrical from the left side to the right side.

What causes torsion in the first place? By the sixth month in utero, the lumbar spine and hips of the fetus are fully flexed, so perhaps it is positional. Other sources say it coincides with the degree of osteogenesis. There is a growing consensus that muscular forces are responsible, particularly the iliopsoas  or possibly the medial and lateral hip rotators.

Additional changes can occur after birth, particularly with sitting postures. “W” sitting or “cross legged” sitting have been associated with altering the available range of motion and thus the FNA, with the range increased in the direction the hip was held in; W sitting causing increased internal rotation and antetorsion and cross legged causing external rotation and retro torsion.

As discussed previously, there are at least 3 reasons we need to understand torsions and versions, They can alter the progression angle of gait, they usually affect the available ranges of motion of the limb and they can alter the coronal plane orientation of the limb.

1. fermoral torsions often alter the progression angle of gait.  In femoral antetorsion torsion, the knees often face inward, resulting in an intoed gait and a decreased progression angle of the foot. This can be differentiated from internal tibial torsion (ITT) by looking at the tibia and studying the position of the tibial tuberosity with respect to the foot, particularly the 2nd metatarsal. In ITT, the foot points inward while the tibial tuberosity points straight ahead. In an individual with no torsion, the tibial tuberosity lines up with the 2nd metatarsal. If the tibial tuerosity and 2nd met are lined up,  and the knees still point inward, the individual probably has femoral ante torsion. Remember that a decreased progression angle is often associated with a decreased step width whereas an increased angle is often associated with an increased step width. See the person with external tibial torsion in the above picture?

2. Femoral torsions affect available ranges of motion of the limb. We remember that the thigh leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance (most folks have 40 degrees) If it is already fully internally rotated (as it may be with femoral retro torsion), that range of motion must be created or compensated for elsewhere. This, much like internal tibial torsion, can result in external rotation of the affected lower limb to create the range of motion needed.

Femoral retro torsion results in less internal rotation of the limb, and increased external rotation.

Femoral ante torsion results in less external rotation of the limb, and increased internal rotation.

3. femoral torsions usually do not effect the coronal plane orientation of the lower limb, since the “spin” is in the transverse or horizontal plane.

The take home message here about femoral torsions is that no matter what the cause:

  •  FNA values that exist one to two standard deviations outside the range are considered “torsions”

  • Decreased values (ie, less than 8 degrees) are called “retro torsion” and increased values (greater than 20 degrees) are called “ante torsion”
  • Retro torsion causes a limitation of available internal rotation of the hip and an increase in external rotation

  • Ante torsion causes an increase in available internal rotation  of the hip and decrease in external rotation
  • Femoral ante torsion will be perpetuated by “W” sitting (sitting on knees with the feet outside the thighs, promoting internal rotation of the femur)

  • Femoral antetorsion will be perpetuated by sitting cross legged, which forces the thigh into external rotation.

 

Stay tuned for a case tomorrow to test your learning over the last few weeks.

 

We remain: Bald, good looking and intelligent…The Gait Guys

 

 

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