External tibial torsion and lower back pain

How can external tibial torsion and lower back pain possibly be related? Let’s take a quick look at the anatomy and see how.

knees neutral, note external rotation of the right foot and decreased progression angle

knees neutral, note external rotation of the right foot and decreased progression angle

Remember the external tibial torsion is present if we drop a plumbline from the tibial tuberosity and it passes between the first and second metatarsals or more medially. This increases the progression angle of the foot. This occurs due to “over rotation" of the lower extremity during development, often exceeding the 1.5 degrees per year of external rotation per year up to age 15 or occurring for a longer period of time, up to skeletal maturity. It can be uni or bilateral.

note when the foot is neutral, the knee points inward

note when the foot is neutral, the knee points inward

Often, due to the increased progression angle, people will try to "straighten their feet" (ie, decrees their progression angle) to move forward in the sagittal plane. This places the knees to the inside of the sagittal plane which causes medial knee fall and sometimes increased mid and forefoot pronation. This results in increased medial spin of the thigh bilaterally which increases the lumbar lordosis. Combine this with a sway back or anterior pelvic tilt and you have increased pressure on the lumbar facet joints. The facets are designed to carry approximately 20% of the load put in these circumstances are often called upon to carry the much more. This often results in facet imbrication and lower back pain. You can strengthen the abdomen all you like but if you do not change the attitude of the foot, a will often develop lower back pain, especially when the abs fatigue. Now think about if the deformity is unilateral; this will often cause asymmetrical rotation of the pelvis in a clockwise or counter clockwise direction.

So, what can you do you?

Since external tibial torsion is a "hard deformity", we can influence how the bone grows before skeletal maturity but after that will not change significantly with stretching or exercise.

  • You can teach them to walk with an increase in progression angle (ie “duck footed”). This will often keep the knee in the sagittal plane and can be surprisingly well tolerated

  • You can use a foot leveling orthotic or arch support to bolster the arch and change the mechanics of the foot, causing external rotation of the tibia which will often result in a decrease in progression angle in compensation while still keeping the knee in the sagittal plane

  • You could place a full length varus wedge in the shoe which, by inverting the foot, externally rotates the tibia which the person will often compensates for by decreasing there progression angle to keep the knee and the sagittal plane

Dr Ivo Waerlop, one of The Gait Guys

#tibialtorsion #lowbackpain #LBP #progressionangle

Sometimes it’s OK for “toes in“ squats

We hear from folks and also read on a lot of blogs and articles about whether your toes should be in or out for squats or other types of activities. The real answer is “it depends”.

What it depends on is the patient’s specific anatomy. That means we need to pay attention to knees and hips and things like femoral and tibial torsion‘s. It’s paramount to keep the knees in the sagittal plane, no matter what the lower extremity orientation is.

When somebody has external tibial torsion (i.e. when you drop a plumbline from there to view tuberosity it passes medial to the line between the second and third or second metatarsal) then having your feet and externally rotated position places the knees in sagittal plane. Having the patient go “toes in” with this type of anatomy will cause both knees to for medially and create patellofemoral tracking issues.

Likewise, like the patient in the video, (Yes, I know I say “external tibial torsion“ at the beginning of the video but the patient has internal tibial torsion as you will see from the remainder of the video) when somebody has internal tibial torsion (I.e. when you drop a plumbline from the tibial tuberosity it passes lateral to the second metatarsal or a line between the second and third metatarsal) you would need to point the toes inward to keep the knees in the sagittal plane as demonstrated in the video. You can also see in the video when her feet are placed “toes out“ they fall outside sagittal plane laterally which creates patellofemoral tracking issues like it was in this particular patient.

So, knees in or knees out? It depends…

Dr. Ivo Waerlop, one of The Gait Guys

#internaltibialtorsion #externaltibialtorsion #kneepain #kneesin #kneesout #squats #thegaitguys

The amazing power of compensation. Coming to a patient in your office… Maybe today

This gal has had a right sided knee replacement. She has an anatomical right short leg, a forefoot supinatus, an increased Q angle and a forefoot adductus. So, what’s the backstory?

When we have an anatomical short leg, we will often have a tendency to try to “lengthen“ that extremity and “shorten” the longer extremity. This is often accomplished through pelvic rotation although sometimes can be with knee flexion/extension or change in the Q angle. When the condition is long-standing, the body will often compensate in other ways, such as what we are seeing here.


The fore foot can supinate in an attempt to lenthen the extremity. Note how the right extremity forefoot is in varus with respect to the rearfoot, effectively lengthening the extremity. As you can see from the picture, this is becoming a “hard“ deformity resulting in a forefoot varus.


Over time, the forefoot has actually “adducted “ as you can see, again in an attempt to lengthen the extremity. Remember that supination is plantar flexion, abduction and inversion, all three which are visible here.

You will also see that the Q angle is less on the right side (se above), effectively lengthening that extremity, but not quite enough as we can see from the picture :-)

Dr Ivo Waerlop, one of The Gait Guys

#forefootadductus #shortleg #kneereplacement #tkr #forefootvarus #gait #thegaitguys

Some more really subtle things...How sharp are YOUR eyes?

As I study this video more and more (yep, we just keep looking at things because we are that nerdy and that paranoid that we missed something) I saw at least 3 very subtle findings. 

Watch the video of this right handed physical therapist who had L knee reconstruction (MCL/ACL with hamstring allograft) a few (hundred) times and see what you come up with, then come back and read this. We lie to slow things down and even frame by frame it with the slow motion feature or space bar to stop it. As background to the clinical exam, he has limited hip and knee extension on the left, 4/5 weakness of the quadratus femoris. His popliteus tests strong and 5/5. He has right sided back pain with L sided knee pain at the joint line and just inferior and medial. the treadmill is at a 2% grade at 2 mph.

Notice how he has a pelvic drift to the right during stance phase on that side. Why do you think? Remember, he has had a left sided knee surgery that left him with limited knee extension on that side. This creates a functional short leg on that side (the left), so he needs to get the longer (right) leg around. We don’t always see lateral movement of the pelvis on the longer leg side, but our guess is he is trying to “shorten” the longer leg side; lateral translation in the coronal plane is one strategy to accomplish that.

Now look at the left side. Can you see the subtle hip hike to clear the right leg? How about the small amount of circumduction? Sometimes folks will employ more than one strategy to get around a long leg, but ususally one will predominate, but not in this case. 

Did you catch the abductory twist of the right heel? The longer leg side needs to go through a greater range of motion of ankle dorsiflexion which will store more potential energy in the tricep surae as well as long flexors of the toes, that energy needs to go somewhere!

Now think about step length. It will often be shortened on the shorter leg side. He still needs to move forward the same amount, so he uses the right arm to help propel his center of mass forward. Do you see the increased arm swing? 

And why does he abduct his right arm so much? Where is his center of mass at left foot strike? It is all the way to the right, because of the “short leg”, correct? How can you counterbalance that? Abducting the arm would certainly accomplish that. Why does it go across the body? It is no longer needed to be that lateral during stance phase on the right, but he still needs to use it to propel himself forward with the shortened step length we talked about before. 

Mental gymnastics, running through what runs through our minds and why things may appear the way that they do. A great lesson in knowing what is supposed to happen and when in the gait cycle

Dr Ivo Waerlop, one of The Gait Guys

#kneepain #lowbackpain #gaitanalysis #thegaitguys #visualgaitanalysis

Right-sided knee pain in a cyclist...due to his hip?

This 54-year-old pilot presented to our office with pain on the outside of his right knee while cycling with his wife who is currently training for the triple bypass. The discomfort comes on later in the ride and is largely lateral. He thought it may be due to a seat position so he raised his seat up but then shortly developed lower back discomfort. Lowered the seat back down and presents to the office today. He is currently on a 54 cm Pierello road bike with a straight top tube.

Physical exam revealed him to have moderately limited internal rotation of the right hip which was approximately 5 degrees external rotation; left side had approximately 5 degrees of internal rotation. There was no significant leg length discrepancy or internal tibial torsion. Musculature, save for the long extensors the toes tests 5/5 and strong. Hip extension is 0 degrees bilaterally 5 flexion approximately 120 degrees with tightness mostly in the iliopsoas and some in the rectus femoris. Knee stability tests are unremarkable. Some patellofemoral discomfort with compression on the right. Palpable tightness in the right IT band.

X-rays revealed degenerative changes at the inferior aspect of the right acetabulum with a small spur an osteophyte formation.

His seat height was set so that at bottom dead center with the seat tube he had a 30 degree bend in his knee. Seat fore and aft position placed the knee over pedal spindle behind central axis of the pedal. His pedal stroke, seen on the video, reveals moderate internal rotation and medial displacement of the knee on the right side.

So what is going on?

It’s all about how folks compensate. This gent has very limited internal rotation of the right hip. Due to the nature of cycling, he is REALLY TRYING to get his 1st MTP down to the pedal to generate power. This is not unusual among cyclists, which is why what you think should be happening in gait does not always transfer over to cycling. in doing so, he MUST rotate SOMETHING forward (in this case his pelvis) medially to create the internal rotation needed. From this scenario, you can see how the posturing would increase knee valve and offer a mechanical advantage to the vastus lateralis, causing patello femoral dysfunction and knee pain.

So we did we do?

  • Moved his seat forward so that a line drawn from between the patella and tibial tuberosity fell through the center axis of the pedal

  • Angled his cleat so that he is able to have a greater progression angle moving forward, bringing his knee more into the sagittal plane

  • Began working on the hip to increase internal rotation working on the gluteus minimus, vastus lateralis and biceps femoris as well as hip capsule and ilio/ischio/pubofemoral ligaments

Dr Ivo Waerlop, one of The Gait Guys

#kneepain #cycling #hipproblem #femoralretrotorsion #thegaitguys #torsion

Have you seen this?

Patterns. That’s what it’s about a lot of times. Dr Allen and I are always looking for patterns or combinations of muscles which work together and seem to cause what appear to be predictable patterns; like a weak anterior compartment and a weak gluteus maximus, or a weak gluteus medius and contralateral quadratus lumborum.

Here is an interesting story and a new combination that at least I have never seen before

I had a 11-year-old right footed soccer player from my son’s soccer team coming to see me with bilateral posterior knee pain which began during a soccer game while he was “playing up” on his older brothers team. He did need to do a lot of jumping as well as cutting. He is generally a midfielder/Forward. Well experienced player and “soccer is his life“.

My initial thoughts were something like a gastroc dysfunction or a Baker’s cyst. On examination, no masses or definitive swelling noted behind either knee. He did have tenderness to moderate degree over the right plantaris and tenderness as well as 4/5 weakness of the left popliteus. There was a loss of long axis extension of the talo crural articulations bilaterally with the loss of lateral bending to the right and left at L2-L3.

If you think about the mechanics of the right footed kicker (and try this while kicking a soccer ball yourself) it would be approximately as follows: left foot would be planted near the ball and the tibia/femur complex would be internally rotating well the foot is pronating and the popliteus would be eccentrically contracting to slow the rotation of the femur and the tibia. The right foot will be coming through and plantarflexion after a push off from the ball of the foot firing the triceps surae and plantaris complexes. He would be “launching“ off of the right foot and landing on his left just prior to the kick, causing a sudden demand on the plantar flexors; with the plantaris being the weak link. As the kicking leg follows through, the femur of the stance phase leg needs to externally rotate (along with the tibia) at a faster rate than the tibia (otherwise you could injure the meniscus) the popliteus would be contracting concentrically. A cleat, because it increases the coefficient of friction with the ground would keep the foot on the ground solidly planted and The burden of stress would go to the muscles which would be extremely routine leg and close chain which would include the semimembranosus/tendinosis  complex as well as the vastus medialis and possibly gracilis and short adductor, along with the popliteus.

I have to say and all of my years of practice I’ve never seen this combination type of injury before involving these two muscles specifically and am wondering if anyone else has seen this?

Dr Ivo Waerlop, one of The Gait Guys

#footproblem #gait #thegaitguys #soccerinjury #bilateralkneepain #popliteus #plantaris

image credit: https://commons.wikimedia.org/wiki/File:Slide2ACCA.JPG

image credit: https://commons.wikimedia.org/wiki/File:Slide2ACCA.JPG

Knee braces and long legs?

Knee brace fixed at a zero to 5 degree flexion angle, creating a long leg? 

We know that the knee is supposed to flex during stance phase, usually around 20-25 degrees (depending on speed and weight, increases in bot increases the flexion requirement) to create dampening from vertical oscillation of the pelvis. What happens if they cannot flex? This creates a virtual "long leg" on that side this will usually result in:

  • Increased vertical translation of the pelvis upward on the braced side and

  • A compensation to make up for this "long leg; circumduction in this case,  but it could be any of the other compensations that we have talked about in posts here on the blog. 

work arounds? They are tough as each can create their own set of problems

  • allow more flexion in the knee on the braced side (not always possible)

  • place a full length sole lift on the opposite side to make up for the difference

  • use crutches

  • use a skateboard : )

we are sure you have some as well that you would LOVE to share with us

Dr Ivo Waerlop, one of The Gait Guys

#shortleg #LLD #compensations #legbrace #gaitproblem #thegaitguys


K ShamaeiGS SawickiAM Dollar Estimation of quasi-stiffness and propulsive work of the human ankle in the stance phase of walking - PloS one, 2013 - journals.plos.org

MORAIS FILHO, Mauro César; REIS, Renata Albertin dos  and  KAWAMURA, Cátia Myuki.Evaluation of ankle and knee movement pattern during maturation of normal gait. Acta ortop. bras. [online]. 2010, vol.18, n.1 [cited  2019-04-25], pp.23-25.

Motion control Shoes + Internal Tibial Torsion = Knee Pain

Thinking about putting a motion control shoe under that foot to control pronation? You had better make sure you make friends with the knee, as it will often (depending on the compensation) be placed OUTSIDE the SAGGITAL PLANE. Like Dr Allen has said many times before , the knee is basically a hinge joint placed between 2 ball and socket joints, and it is usually the one to start grumbling...

Learn more as Dr Ivo Waerlop of The Gait Guys explains in this brief video

#gait #Gaitanalysis #gaitguys #thegaitguys #kneepain #motioncontrolshoes #internaltibialtorsion


Does Manual Therapy help with OA?

Footnotes 7 - Black and Red.jpg

The answer is yes, at least according to this lit review.

The “data crunching” found that manual therapy, defined as any hands on treatment rendered, with (and without) exercise therapy resulted in reducing pain, improving function, ROM and physical performance in patients with knee OA, at least in the short term. 

Anwer et al., Effects of orthopaedic manual therapy in knee osteoarthritis: a systematic review and meta-analysis. J Physiother 104 (2018) 264-276.

Shoe causing knee pain? You decide… 


This gentleman presented with left-sided knee pain at the medial collateral ligament. His left foot was planted when he rotated to the left. Take a close look at the shoes in the picture. If you look closely, you will notice the right shoe is tilted on its axis due to a rear foot to forefoot deformity (forefoot supinatus)and the left shoe upper was assembled canted on its axis, Most likely in manufacturing defect. Can you see the subtle valgus in the left shoe rearfoot?

Think of the implications of a shoe with this orientation. Putting the rearfoot in valgus “prepronates“ the foot, causing medial rotation of the tibia and femur and increase valgus stress on the knee, stressing the medial collateral ligament and stabilizing complex. This will most likely manifest itself as anterior rotation of the ilium on the left-hand side with relative posterior rotation on the right and a clockwise Pelvic distortion pattern. With the foot planted on the left side and it being pre-pronated, can you see how the rotation to the left leaves a greater amount of external rotation that must occur to just get the foot to neutral, never mind supination for stability and pushoff?
What about the popliteus having to work on time to assist and extra rotation and the appropriate femoral/tibial rotation ratios to spare the medial meniscus?

These are the kind of things to keep us awake at night…

And why does this guy have hip pain?

line up the center of the heel counters with the outsoles, and what do you see?

line up the center of the heel counters with the outsoles, and what do you see?

can you see how the heel counter is centered on the outsole, like it is supposed to be

can you see how the heel counter is centered on the outsole, like it is supposed to be

notice how the heel counter of the shoe is canted medially on the outsole of the shoe, creating a varus cant

notice how the heel counter of the shoe is canted medially on the outsole of the shoe, creating a varus cant

Take a guy with lower back and left sided sub patellar pain that also has a left anatomically short leg (tibial) and bilateral internal tibial torsion and put him in these baby’s to play pickleball and you have a prescription for disaster.

Folks with an LLD generally (soft rule here) have a tendency to supinate more on the short leg side (in an attempt to make the limb longer) and pronate more on the longer leg side (to make the limb shorter). Supination causes external rotation of the lower limb (remember, we are trying to make the foot into a rigid lever in a “normal” gait cycle). this external rotation with rotate the knee externally (laterally). Folks with internal tibial torsion usually rotate their limb externally to give them a better progression angle (of the foot) so they don’t trip and fall from having their feet pointing inward. This ALSO moves the knee into external rotation (laterally), often moving it OUTSIDE the saggital plane. In this case, the knee, because of the difference in leg length AND internal tibial torsion AND the varus cant of the shoe, has his knee WAY OUTSIDE the saggital plane, causing faulty patellar tracking and LBP.

Moral of the story? When people present with a problem ALWAYS TAKE TIME TO LOOK AT THEIR SHOES!

Recalcitrant medial knee pain? Have you heard about the "Problematic Pes"...

image source: https://commons.wikimedia.org/wiki/File:Slide2DADE.JPG

image source: https://commons.wikimedia.org/wiki/File:Slide2DADE.JPG

Recalcitrant knee pain just below the medial tibial plateau? Worse with sprints, hills and after running a while? It may be the pes anserine insertion(s).

Made up of the tibial insertions, from anterior to posterior, of the sartorius, gracilis and semitendinosis which lie superficial to the distal tibial insertion of the superficial medial collateral ligament. This structure is named from the way it looks, like a goose's foot (anserine pes), rather than its anatomical location. The pes anserine bursa lies below it and between the MCL and hamstring tendons and can be subject to compressive forces if compromised in some way, by injury or pathomechanics

The muscles of the pes anserine arise from three different compartments in the thigh. The sartorius originates from the anterior compartment,  the gracilis from the medial compartment and the semitendinosus, the posterior compartment. Their varied origins, paths, and actions, as these muscles approach their insertion all add stability to the medial aspect of the knee.

During an ideal gait cycle, the sartorius fires from toe off through nearly terminal swing, the semitendinosus from mid swing through nearly loading response, with a brief firing at toe off  and gracilis tonically throughout stance phase with bursts from terminal swing through initial contact and again from pre swing to initial swing.

image source: Tom Michaud, with permission

image source: Tom Michaud, with permission

We remember that the abdominals should initiate thigh flexion with the iliopsoas, rectus femoris, tensor fascia lata and sartorius perpetuating the motion. Sometimes, when the abdominals are insufficient, we will substitute other thigh flexors, often the psoas and/or rectus femoris, but sometimes sartorius, especially in people with excessive midfoot pronation. Think about all of the medial rotation occurring at the knee during excessive midfoot pronation and when overpronation occurs, the extra compensatory external rotation that must occur to try and bring the knee back into the sagittal plane. The sartorius is positioned perfectly for this function, along with the semitendinosus which assists and external rotation and closed chain with the innocent pes anserine bursa directly beneath. This is complemented by the compressive forces of this gracilis firing because of the increased coronal plane motion occurring at the pelvis.

Call it pes anserinus bursitis or pes anserine tendinitis but they both add up to medial knee pain when the thigh needs help flexing.

Look to this troublesome trio the next time you have recalcitrant medial knee pain.



Gupta, Aman & Saraf, Abhinesh & Yadav, Chandrajeet. (2013). ISSN 2347-954X (Print) High-Resolution Ultrasonography in PesAnserinus Bursitis: Case Report and Literature Review. 1. 753-757. 


 Michaud T: in Foot Orthoses and Other Forms of Conservative Foot Care Williams & Wilkins, 1993 Pp. 50-55

 Michaud T: in Human Locomotion: The Conservative Management of Gait-Related Disorders 2011

Podcast 138 (for real). Are you fighting your own gait/running neurology?

1. Running with the extensors. Convergence and divergence of neurons.
2. Fighting your gait neurology. The lies about the Bird dog rehab exercise.
3. ACL and ACL rehab. Surgery or no sugery. Wise? Risks ? How social media discussions might just be getting it wrong.
4. Cross over gait and lateral heel strike and ensuing problems at great toe off. A failure to medial foot tripod high gear toe off ?
5. Are the hip flexors actually hip flexors in gait ? what are your high knee drills doing? Anything good?

Key words: acl, analysis, cross, extensor, flexors, gait, heel, hip, instability, knee, over, plri, pools, problems, running, strike, surgery

Links to find the podcast:

iTunes page: https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2

Direct Download:http://traffic.libsyn.com/thegaitguys/pod_138_real_-_82818_2.12_PM.mp3

Permalink URL:http://thegaitguys.libsyn.com/podcast-138-for-real

Libsyn URL: http://directory.libsyn.com/episode/index/id/6978817

Our Websites:




Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).

Our podcast is on iTunes and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.

QL and Patellofemoral Pain?

photo credit: https://www.t-nation.com/training/training-disasters

photo credit: https://www.t-nation.com/training/training-disasters

"Subjects with PFP(patello femoral pain) have a higher prevalence of MTrPs (Myofascial trigger points) in bilateral GMe (gluteus medius)) and QL (quadratus lumborum) muscles. They demonstrate less hip abduction strength compared with controls, but the TPPRT (trigger point pressure release therapy, AKA ischemic compression) did not result in an increase in hip abduction strength. "

It is not surprising that when the hip is involved, the knee will be involved. As Dr. Allen often likes to say "the knee is basically in joint between 2 ball and socket joints ".

The gluteus medius and quadratus lumborum, along with the adductors are coronal plane stabilizers of the pelvis. They both have rotational components to their function as well affecting the hip directly for the former and lumbar spine for the latter. You can see our other QL articles about this here and here.

It is not much of a stretch to imagine that dysfunction of these muscles could result in trigger points and/or dysfunction of the knee (or foot for that matter ) could cause trigger points in these muscles.

Here is an article (1) examining trigger points in the gluteus medius and quadratus lumborum which, if you are familiar with Porterfield and DeRosa's work (2), are intimately linked during gait. We found it interesting that skin nick compression did not increase hip abduction strength where we find dry needling and intramuscular therapy often do.

Don't overlook these muscles and this important relationship.



  1. Roach, Sean et al.Prevalence of Myofascial Trigger Points in the Hip in Patellofemoral Pain Archives of Physical Medicine and Rehabilitation , Volume 94 , Issue 3 , 522 - 526link to free full text article: http://www.archives-pmr.org/article/S0003-9993(12)01079-9/fulltexthttp://www.archives-pmr.org/article/S0003-9993(12)01079-9/fulltext

  2. J. Porterfield, C. DeRosa (Eds.) Mechanical low back pain. 2nd ed. WB Saunders, Philadelphia; 1991


The Q angle and Kids: The Basics

Screen Shot 2017-05-01 at 3.37.08 PM.png

Genu valgum in kids: What you need to know

We have all seen this. The kid with the awful “knock knees”.  It is a Latin word “which means “bent” or “knock kneed”. It appears to have 1st been used in 1884.

This condition, where the Q angle angle exceeds 15 degrees, usually presents maximally at age 3 and should resolve by age 9. It is usually physiologic in development due to obliquity of the femur, when the medial condyle is lower than the lateral. Normal development and weight bearing lead to an overgrowth of the medial condyle of the femur. This, combined with varying development of the medial and lateral epiphysies of the tibial plateau leads to the valgus development. Gradually, with increased weight bearing, the lateral femoral condyle (and thus the tibial epiphysis) bear more weight and this appears to slow, and eventually reverse the valgum.

Normal knee angulation usually progresses from 10-15 degrees varus at birth to a maximal valgus angle of 10-15 degreesat 3-3.5 years (see picture).  The valgus usually decreases to an adult angle of 5-7 degrees.  Remember that in women, the Q angle should be less than 22 degrees with the knee in extension and in men, less than 18 degrees. It is measured by measuring the angle between the line drawn from the ASIS to the center of the patella and one from the center of the patella through the tibial tuberosty, while the leg is extended.

Further evaluation of a child is probably indicated if:

  • The angle is greater than 2 standard deviations for their age (see chart) 
  • If their height is > 25th percentile 
  • If it is increasing in severity 
  • If it is developing asymmetrically

Management is by serial measurement of the intermalleolar distance (the distance between ankles when the child’s knee are placed together) to document gradual spontaneous resolution (hopefully). If physiologic genu valgum persists beyond 7-8 years of age, an orthopaedic referral would be indicated but certainly intervention with attempts at corrective exercises and gait therapy should be employed. Persistence in the adult can cause a myriad of gait, foot, patello femoral and hip disorders, and that is the topic on another post.

Promotion of good foot biomechanics through the use of minimally supportive shoes, encouraging walking on sand (time to take that trip to the beach!), walking on uneven surfaces (like rocks, dirt and gravel), gentle massage (to promote muscle facilitation for those muscles which test weak (origin/insertion work) and circulation), gait therapeutic exercises and acupuncture when indicated, can all be helpful.

Varus anyone?

Varus anyone?

Does patello femoral pain have anything to do with rearfoot varus? Perhaps, according to this study:

" A small but significant increase in rearfoot varus was found in the patellofemoral pain group compared with the control group (8.9 vs. 6.8 degrees; p = .0002). These results suggest that increased rearfoot varus may be a contributing factor in patellofemoral pain and should be assessed when evaluating the events at the subtalar joint and the lower extremity. In addition, it has been demonstrated that consistent rearfoot measurements can be obtained by an individual clinician."

Powers CM, Maffucci R, Hampton S. Rearfoot posture in subjects with patellofemoral pain. J Orthop Sports Phys Ther. 1995 Oct;22(4):155-60.

Unless you have ownership....

Compliance is often the issue ...especially in younger folks

Just say no to the exercise video. You need:

  • understanding on the patients part of the pathology and the importance of the rehab
  • buy in on the patients part
  • a way to monitor progress with objective outcomes

a nice review article in LER, full text here

additionally, this was covered in a great PODcast by David Pope here: http://physioedge.com.au/physio-edge-039-patellofemoral-pain-adolescents-dr-michael-rathleff/

The Knee and Macerating Menisci

Take a good look at the above 2 slides.

Notice that, during pronation, there is a medial rotation of the lower leg and thigh. We remember that, during pronation, the talus plantar flexes, adducts, and everts. This anterior translation and medial rotation of the talus causes the tibia and subsequently the femur to follow. This, if everything is working right, results in medial rotation of the knee.

From the slides, it should also be evident that the medial condyle of the femur and a medial tibial plateau are larger than the lateral. This allows for an increased amount of internal and external rotation of the knee. We remember that the meniscus, like a washer, is between the tibia and femur. We if you think about this kinematically, it would make sense that the tibia, during pronation (which occurs from initial contact to mid stance) would have to rotate faster than the femur otherwise the meniscus would be caught "in between". If there is a mismatch in timing, the meniscus is "caught in the middle", which causes undue stress and can cause fraying, degeneration, etc.

Likewise, during supination (from mid stance to pre swing) the femur must externally rotate faster then the tibia, otherwise we see this same "mismatch". This is a scenario we commonly see in folks who over pronate at the mid foot and remain in pronation for too omg a period of time. 

We think of pronation as being initiated from the movement described above by the talus, and it is attenuated by the popliteus muscle as well as some of the deep flexors of the foot, which fire mostly during stance phase. You will notice that the popliteus  is eccentrically contracting at this point.

Supination, initiated by swing phase of the opposite leg and momentum, is assisted by concentric contraction of the popliteus muscle, internal rotation of the pelvis on the stance phase leg, contraction of the vastus medialis, deep flexors of the foot and peroneii.

Taking moment to "wrap your head around" this concept. Now you can see how complicated it can be when we started to throw in femoral and tibial torsions as well as possibly some orthotic therapy. For example, in an individual with internal tibial torsion, if you do not valgus post the forefoot of the orthotic, the knee is placed at outside the sagittal plane in external rotation further by the orthotic and this thwarts the function of his mechanism, leaving the meniscus holding the bag. 

Know your anatomy and know what is supposed to be firing when, your patients and clients knees depend on it!