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

Holy twisted tibias Batman! What is going here in this R sided knee pain patient?

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In the 1st picture note this patient is in a neutral posture. Note how far externally rotated her right foot is compared to the left. Note that when you drop a plumbline down from the tibial tuberosity it does not pass-through or between the second and third metatarsals. Also note the incident left short leg

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In the next picture both of the patients legs are fully externally rotated. Note the large disparity from right to left. Because of the limited extra rotation of the right hip this patient most likely has femoral retro torsion. This means that the angle of her femoral head is at a greater than 12° angle. We would normally expect approximately 40° of external Rotation. 4 to 6° is requisite for normal gait and supination.

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In the next picture the patients knees are fully internally rotated you can see that she has an excessive amount of internal rotation on the right compare to left, confirming her femoral antetorsion.

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When this patient puts her feet straight (last picture), her knees point to the inside causing the patello femoral dysfunction right greater than left. No wonder she has right-sided knee pain!

Because of the degree of external tibial torsion (14 to 21° considered normal), activity modification is imperative. A foot leveling orthotic with a modified UCB, also inverting the orthotic is helpful to bring her foot somewhat more to the midline (the orthotic pushes the knee further outside the sagittal plane and the patient internally rotate the need to compensate, thus giving a better alignment).


a note on tibial torsion. As the fetus matures, The tibia then rotates externally, and most newborns have an average of 0- 4° of internal tibial torsion. At birth, there should be little to no torsion of the tibia; the proximal and distal portions of the bone have little angular difference (see above: top). Postnatally, the tibia should twist outward (externally) a total of 15 degrees until adult values are reached between ages 8 and 10 years of 23° of external tibial torsion (range, 0° to 40°).

Wow, cool stuff, eh? Dr Ivo Waerlop, one of The Gait Guys

#tibialtorsion #tibialversion #kneepain #thegaitguys #gaitanalysis

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

Low Back Pain? Check for Femoral Retrotorsion on the Same Side

note the right sided leg length discrepancy

note the right sided leg length discrepancy

right tibia is anatomically shorter

right tibia is anatomically shorter

more internal rotation available on the left side at the hip. Note the internal tibial torsion as well

more internal rotation available on the left side at the hip. Note the internal tibial torsion as well

very little internal rotation available at the right hip

very little internal rotation available at the right hip

This right handed concrete worker presented to our office with right-sided lower back pain. He was lifting a bag of concrete moving from left to right which she estimates weighing between 60 and 80 pounds. He did this repetitively throughout the day and subsequently developed right sided lower back pain. The pain is in the suprailiac region and is described as dull, achey. Is exacerbated by right rotation and right lateral bending.

His exam found him to have a right sided anatomical leg length discrepancy, tibial left (see above) and femoral retro torsion on the right with no internal rotation of the hip past 0 degrees (see picture of full internal rotation of the right hip and cmpare it with the left); left side had approximately 10 degrees internal rotation. He also has bilateral internal tibial torsion, R > L. Palpation findings revealed tightness in the lumbar multifidus and quadratus lumborum with a loss of lateral bending to the right at L2 through L4 and a loss of flexion about the right sacroiliac joint. Lower extremity reflexes were 2+ with bilateral symmetry; sensation to vibration was intact at the distal phalanges; motor strength was strong and graded as 5/5.

Think about the implications of his right-sided leg length discrepancy first. This places his foot and a relative supinated posture compared to the left. Remember that supination is plantar flexion, inversion and adduction.

His femoral retro torsion on the right limits his internal rotation at the hip. When his foot planted with a diminished progression angle secondary to the internal tibial torsion, and he has to rotate from left to right, very little, if any motion, can occur at the right hip and therefore must occur in the lumbar spine. Remember the lumbar spine has very limited range of motion begin with with most of that occurring at the L5-S1 junction, depending upon its anatomy. Now superimpose a long lever load and rotary force. Back pain!

We instructed him on proper lifting technique and also talked about keeping the shoulders and hips in the same plane when lifting or load. If he does need to lift a load and spin unilateral on his right lower extremity, we asked him to externally rotate the right lower extremity. He was treated with manipulation and neuromuscular acupuncture.

If you have somebody with unilateral lower back pain, think about the implications if they have any femoral torsion or version present

Dr. Ivo Waerlop, one of The Gait Guys.

#lowbackpain #LBP #femoralretrotorsion #femoral #torsion #gait #gaitanalysis #thegaituys

Got a kid that "toes in"?

image source: W Phillips https://somepomed.org/articulos/contents/mobipreview.htm?38/8/39046

image source: W Phillips https://somepomed.org/articulos/contents/mobipreview.htm?38/8/39046

Photo Credit: Illustration based off Jake Pett, B.F.A. and Stuart Pett,  M.D illustration for International Association for Dance Medicine and  Science 2011

Photo Credit: Illustration based off Jake Pett, B.F.A. and Stuart Pett, M.D illustration for International Association for Dance Medicine and Science 2011

image courtesy: T Michaud

image courtesy: T Michaud

Got a kid that "toes in" during gait? Are you seeing this?

  • smaller foot progression angle

  • greater knee adduction

  • more internally rotated and flexed hips

  • greater anterior pelvic tilt

Wondering what could be causing it?

We start life with the hips anteverted (ie, the angle of the neck of the femur with the shaft of the femur is > 12 degrees; in fact at birth it is around 35 degrees) and this angle should decrease as we age to about 8-12 degrees). When we stand, the heads of our femurs point anteriorly; it is just a matter of how much (ante version or ante torsion) or how little (retro version or retro torsion) that is.

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 angle of the femur neck to its shaft 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.

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:

  • the angle of the femur neck to shaft 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.

 

Great paper here

link to full text: http://onlinelibrary.wiley.com/doi/10.1002/jor.22746/abstract;jsessionid=AC848D963DCA526402D71260BDFC91F6.f04t04

Dr Ivo, one of the Gait Guys

#gait,#gaitanalysis,#femoralneckangle, #femoraltorsion, #antetorsion, #retrotorsion, #toein

 

So, you do weighted carries?

METHODS:

Participants were instructed to ascend and descend a three-step staircase at preferred pace using a right leg lead and a left leg lead for each load condition: no load, 20% body weight (BW) bilateral load, and 20% BW unilateral load. L5/S1 contralateral bending, hip abduction, external knee varus, and ankle inversion moments were calculated using inverse dynamics.

 

Nothing earthshaking here (1) , but a few takeaways:

  • Asymmetric loading of L5-S1 will most likely become more significant if the individual has a L5-S1 facet tropism, where one (or both) of the facets is (are) facing saggitally, as loading will be be even greater.  This has been associated with disc derangement (2) and degeneration (3).

 

  • The body does seem to adjust for the load, but it takes at least to the second step. We need to make sure the proprioceptive feedback loops (joint and muscle mechanoreceptors and their associated pathways) are functioning well. Manipulate, mobilize, facilitate, inhibit as appropriate.

 

  • The increased varus moment and hip abduction on the unweighted side are most likely to move the center of gravity more to the midline, which makes sense. This may become problematic with folks with increased internal tibial torsion, especially with femoral retroversion/torsion as they already have limited internal rotation available to them at the hip

 

 

 

 

 

 
1. Wang J, Gillette JC. Carrying asymmetric loads during stair negotiation: Loaded limb stance vs. unloaded limb stance. Gait Posture. 2018 Jun 19;64:213-219. doi: 10.1016/j.gaitpost.2018.06.113. [Epub ahead of print]
2. Chadha M, Sharma G, Arora SS, Kochar V. Association of facet tropism with lumbar disc herniation. European Spine Journal. 2013;22(5):1045-1052. doi:10.1007/s00586-012-2612-5.
3. Berlemann U, Jeszenszky DJ, Buhler DW, Harms J (1998) Facet joint remodeling in degenerative spondylolisthesis: an investigation of joint orientation and tropism. Eur Spine J 7: 376-380.

 

Abstract

BACKGROUND:

Individuals often carry items in one hand instead of both hands during activities of daily living. Research Question The purpose of this study was to investigate low back and lower extremity frontal plane moments for loaded limb stance and unloaded limb stance when carrying symmetric and asymmetric loads during stair negotiation.

METHODS:

Participants were instructed to ascend and descend a three-step staircase at preferred pace using a right leg lead and a left leg lead for each load condition: no load, 20% body weight (BW) bilateral load, and 20% BW unilateral load. L5/S1 contralateral bending, hip abduction, external knee varus, and ankle inversion moments were calculated using inverse dynamics.

RESULTS:

Peak L5/S1 contralateral bending moments were significantly higher when carrying a 20% BW unilateral load as compared to a 20% BW bilateral load for both stair ascent and stair descent. In addition, peak L5/S1 contralateral bending moments were significantly higher during step one than for step two. Peak external knee varus and hip abduction moments were significantly higher in unloaded limb stance as compared to loaded limb stance when carrying a 20% BW unilateral load.

SIGNIFICANCE:

General load carriage recommendations include carrying less than 20% BW loads and splitting loads bilaterally when feasible. Assessment recommendations include analyzing the first stair step and analyzing both the loaded and unloaded limbs.

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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 Why does this gal have so much limited external rotation of her legs? 

 We have discussed torsions and versions here on the blog many times before. We rarely see femoral antetorsion. She came in to see us with the pain following a total hip replacement on the right.

 Note that she has fairly good internal rotation of the hips bilaterally but limited external rotation. This is usually not the case, as most folks lose internal rotation. We need 4 to 6° internal and external rotation to walk normally. This poor gal has very little external rotation available to her.

Have you figured out what’s going on with hips yet? She has a condition called femoral ante torsion.   This means that the angle of the femoral neck is in excess of 12°. This will allow her to have a lot of internal rotation but very little external rotation.  She will need to either “create” or “borrow” her requisite external rotation from somewhere. In this case she decreases her progression of gait (intoed), and borrows the remainder from her lumbar spine.

 So what do we do? We attempt to create more external rotation. We are accomplishing this with exercises that emphasize external rotation, acupuncture/needling of the hip capsule and musculature which would promote external rotation (posterior fibers of gluteus medius,  gluteus maximus, vastus medialis, biceps femoris). A few degrees can go a very long way as they have in this patient. 

confused? Did you miss our awesome post on femoral torsions: click here to learn more.

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 Every foot has a story. 

 This is not your typical “in this person has internal tibial torsion, yada yada yada” post.  This post poses a question and the question is “Why does this gentleman have a forefoot adductus?”

The first two pictures show me fully internally rotating the patients left leg. You will note that he does not go past zero degrees and he has femoral retroversion. He also has bilateral internal tibial torsion, which is visible in most of the pictures. The next two pictures show me fully internally rotating his right leg, with limited motion, as well and internal tibial torsion, which is worse on this ® side

 The large middle picture shows him rest. Note the bilateral external rotation of the legs. This is most likely to create some internal rotation, because thatis a position of comfort for him (ie he is creating some “relief” and internal rotation, by externally rotating the lower extremity)

 The next three pictures show his anatomically short left leg. Yes there is a large tibial and small femoral component. 

 The final picture (from above) shows his forefoot adductus. Note that how, if you were to bisect the calcaneus and draw a line coming forward, the toes fall medial to a line that would normally be between the second and third metatarsal’s. This is more evident on the right side.  Note the separation of the big toe from the others, right side greater than left. 

Metatarsus adductus deformity is a forefoot which is adducted in the transverse plane with the apex of the deformity at LisFranc’s (tarso-metatarsal) joint. The fifth metatarsal base will be prominent and the lateral border of the foot convex in shape . The medial foot border is concave with a deep vertical skin crease located at the first metatarso cuneiform joint level. The hallux (great toe) may be widely separated from the second digit and the lesser digits will usually be adducted at their bases. ln some cases the abductor hallucis tendon may be palpably taut just proximal to its insertion into the inferomedial aspect of the proximal phalanx (1)

Gait abnormalities seen with this deformity include a decreased progression angle, in toed gait, excessive supination of the feet with low gear push off from the lesser metatarsals. 

 It is interesting to note that along with forefoot adductus, hip dysplasia and internal tibial torsion are common (2) and this patient has some degree of both. 

 His forefoot adductus is developmental and due to the lack of range of motion and lack of internal rotation of the lower extremities, due to the femoral retrotorsion and internal tibial torsion.  If he didn’t adduct the foot he would have to change weight-bearing over his stance phase extremity to propel himself forward. Try internally rotating your foot and standing on one leg and then externally rotating. See what I mean? With the internal rotation it moves your center of gravity over your hip without nearly as much lateral displacement as would be necessary as with external rotation. Try it again with external rotation of the foot; do you see how you are more likely displace the hip further to that side OR lean to that side rather than shift your hip? So, his adductus is out of necessity.

Interesting case! When you have a person with internal torsion and limited hip internal rotation, with an adducted foot, think of forefoot adductus!


1.  Bleck E: Metatarsus adductus: classification and relationship to outcomes of treatment. J Pediatric Orthop 3:2-9,1983.

2. Jacobs J: Metatarsus varus and hip dysplasia. C/inO rth o p 16:203-212, 1960

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All that is twisted is not tibial

Last week we posted on measuring tibial torsions (click here to read that post). This week we are posting on measuring the other, often over looked torsion: “femoral torsion”.

Perhaps you have read some of our posts on femoral torsion, particularly this one.

We remember that as hip (thigh) flexion increases, the amount of internal rotation of the femur decreases. This is due largely to the direction of the hip capsule ligaments (ishiofemoral, iliofemoral and pubeofemoral ligaments) “spiraling” from their attachment from the femur to the innominate. This may seem like a subtle detail until you thing about how much hip flexion occurs when we do a squat, and what exactly, is the position of our feet.

We start life with the hips anteverted (ie, the angle of the neck of the femur with the shaft of the femur is > 12 degrees; in fact at birth it is around 35 degrees) and this angle should decrease as we age to about 8-12 degrees). When we stand, the heads of our femurs point anteriorly; it is just a matter of how much (ante version or ante torsion) or how little  (retro version or retro torsion) that is. If you are a precise person and would really like to geek out on the difference between versions or torsions, check out this post here

Measurement is important, because the more retro torsion you have (ie, the smaller the angle is), the less internal rotation of the femur you will have available to you. An important fact if you are planning on squatting. 

An easy way to do this is by approximating the angle of the femoral neck by performing “Craig’s Test”. Have your patient/client/athlete lie prone with their knee flexed 90 degrees. Palpate the greater trochanter (the bump on the side of the hip that the gluteus medius muscles attach to) with one hand while using the other hand to grasp around the ankle and internally and externally rotate the femur (we like to use the right hand on the right trochanter for the patient/client/athletes right leg). Note the position of the tibia when the greater trochanter is parallel to the table (see diagram above from Tom Michaud’s most excellent text: Human Locomotion: the conservative management of gait related disorders, available by clicking here). The smaller the angle, the more retro version/torsion present). 

This is also a convenient way to estimate the amount of internal and external rotation of the femur available. One source states that internal rotation of greater than 70 degrees and external rotation of less than 25 degrees means that there is excessive femoral ante torsion present (1).

Craig’s Test: a convenient way to measure torsions of the femur. Important if you squat! Brought to you by The Gait Guys: Uber Gait Geeks Extrodinaire. 

(1) Staheli LT. Rotational problems in the lower extremity. Orthop Clin North Am, 1987; 18:503-512

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How do you measure tibial torsion anyway?

With all the talk on the Crossfit blog about the knees out debate, we though we would shed some light on measuring torsions, beginning with tibial torsion, since this does not seem to have been taken account of in the discussion and we feel it is germane. 

Yo may have seen some of our other posts in tibial torsion here or here; this post will serve to help you measure it. 

Looking at the top left picture: we can see that the axis of the tibial plateau and the transmalleolar axis (an imaginary line drawn through the medial and lateral malleolus) are parallel at birth (net angle zero) and progress to 22 degrees at skeletal maturity, resulting from the outward rotation of the tibia of about 1-1.5 degrees per year. This results in a normal external tibial version of about 17-18 degrees (you subtract 5 degrees for the talar neck angle, talked about in the link above). Note that this is the normal or ideal angle we would expect (hope?) to see. Go 2 standard deviations in either direction and we have external and internal tibial torsions.

You can go about taking this measurement in may ways; we will outline 2 of them. 

  1. In the upper left picture, we see an individual who has their knee flexed to 90 degrees over the side of a table while seated. This represents the tibial plateau angle. You the use a protractor to measure the angle between the tibial plateau and an imaginary line drawn through the medial and lateral malleoli. This is the transmalleolar angle. You then subtract 5 degrees from this number (remember the talar neck angle?) to get the angle of tibial version (or torsion).
  2. In the lower left and right pictures, we have the patient supine with the knees pointed upward and tibial plateau flat on the table. Then, working from inferiorly, use a goniometer to measure the angle of the transmalleolar axis. Again, we subtract 5 degrees for the talar neck.

We would encourage you to read up on torsions. This post, which we wrote over a year ago, is probably one of the most important ones on tibial torsions. 

Torsions. Important stuff, especially when you are talking about the axis of the knees in activities like a squat. Remember, the knee is a hinge between 2 multiaxial joints (hip and ankle) and will often take the brunt of the (patho)mechanics, as it has fewer degrees of freedom of movement. If you have external tibial torsion and you push your knees (angle your feet) out further, you are moving the knees outside the saggital plane. You have better have a very competent medial tripod! If you have internal tibial torsion, angling the feet out may be a good idea. Know your (or your patients/clients/athletes) anatomy!

The Gait Guys. Bald, Good Looking and Twisted. Here to help you navigate your way through better biomechanics. 

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You can only “borrow” so much before you need to “pay it back”

How can feet relate to golf swing?

This 52 year old right handed gentleman presented with pain at the thoracolumbar junction after playing golf. He noticed he had a limited amount of “back swing” and pain at the end of his “follow through”.

Take a look a these pix and think about why.

Hopefully, in addition to he having hairy and scarred legs (he is a contractor by trade), you noted the following

  • Top left: note the normal internal rotation of the right hip; You need 4 degrees to walk normally and most folks have close to 40 degrees. He also has internal tibial torsion.
  • Top right: loss of external rotation of the right hip. Again, you need 4 degrees (from neutral) of external rotation of the hip to supinate and walk normally.
  • Top center:normal internal rotation of the left hip; internal tibial torsion
  • 3rd photo down: limited external rotation of the left hip, especially with respect ti the amount of internal rotation present; this is to a greater degree than the right
  • 4th and 5th photos down: note the amount of tibial varum and tibial torsion. Yes, with this much varum, he has a forefoot varus.

The brain is wired so that it will (generally) not allow you to walk with your toes pointing in (pigeon toed), so you rotate them out to somewhat of a normal progression angle (for more on progression angles, click here). If you have internal tibial torsion, this places the knees outside the saggital plane. (For more on tibial torsion, click here.) If you rotate your extremity outward, and already have a limited amount of range of motion available, you will take up some of that range of motion, making less available for normal physiological function. If the motion cannot occur at the knee or hip, it will usually occur at the next available joint cephalad, in this case the spine.

The lumbar spine has a limited amount of rotation available, ranging from 1.2-1.7 degrees per segment in a normal spine (1). This is generally less in degenerative conditions (2).

Place your feet on the ground with your feet pointing straight ahead. Now simulate a right handed golf swing, bending slightly at the waist and  rotating your body backward to the right. Now slowly swing and follow through from right to left. Note what happens to your hips: as you wind back to the right, the left hip is externally rotating and the right hip is internally rotating. As you follow through to the left, your right, your hip must externally rotate and your left hip must externally rotate. Can you see how his left hip is inhibiting his back swing and his right hip is limiting  his follow through? Can you see that because of his internal tibial torsion, he has already “used up” some of his external rotation range of motion?

If he does not have enough range of motion in the hip, where will it come from?

he will “borrow it” from a joint more north of the hip, in this case, his spine. More motion will occur at the thoracolumbar junction, since most likely (because of degenerative change) the most is available there; but you can only “borrow” so much before you need to “Pay it back”. In this case, he over rotated and injured the joint.

What did we do?

  • we treated the injured joint locally, with manipulation of the pathomechanical segments
  • we reduced inflammation and muscle spasm with acupuncture
  • we gave him some lumbar and throacolumbar stabilization exercises: founders exercise, extension holds, non tripod, cross crawl, pull ups
  • we gave him foot exercises to reduce his forefoot varus: tripod standing, EHB, lift-spread-reach
  • we had him externally rotate both feet (duck) when playing golf

The Gait Guys. Helping you to store up lots “in your bank” of foot and gait literacy, so you can help people when they need to “pay it back”, one case at a time.

(1) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223353/

(2) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705911/

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Remember this kiddo?

We have been following the natural development of this little guy for some time now. For a review, please see here (1 year ago) and here (2 years ago) for our previous posts on him.

In the top 2 shots, the legs are neutral. The 3rd and 4th shots are full internal rotation of the left and right hips respectively. The last 2 shots are full external rotation of the hips.

Well, what do you think now?

We remember that this child has external tibial torsion and pes planus. As seen in the supine photo, when the knees face forward, the feet have an increased progression angle (they turn out). We are born with some degree / or little to none, tibial torsion and the in-toeing of infants is due to the angle of the talar neck (30 degrees) and femoral anteversion (the angle of the neck of the femur and the distal end is 35 degrees).  The lower limbs rotate outward at a rate of approximately 1.5 degrees per year to reach a final angle of 22 degrees….. that is of course if the normal de rotation that a child’s lower limbs go through occurs timely and completely.

He still has a pronounced valgus angle at the the knees (need a review on Q angles? click here). We remember that the Q angle is negative at birth (ie genu varum) progresses to a maximal angulation of 10-15 degrees at about 3.5 years, then settles down to 5-7 degrees by the time they have stopped growing. He is almost 4 and it ihas lessend since the last check to 15 degrees.

His internal rotation of the hips should be about 40 degrees, which it appears to be. External rotation should match; his is a little more limited than internal rotation, L > R. Remember that the femoral neck angle will be reducing at the rate of about 1.5 degrees per year from 35 degrees to about 12 in the adult (ie, they are becoming less anteverted).

At the same time, the tibia is externally rotating (normal tibial version) from 0 to about 22 degrees. He has fairly normal external tibial version on the right and still has some persistent internal tibial version on the left. Picture the hips rotating in and the lower leg rotating out. In this little fellow, his tibia is outpacing the hips. Nothing to worry about, but we do need to keep and eye on it.

What do we tell his folks?

  • He is developing normally and has improved significantly since his original presentation to the office
  • Having the child walk barefoot has been a good thing and has provided some intrinsic strength to the feet
  • He needs to continue to walk barefoot and when not, wear shoes with little torsional rigidity, to encourage additional intrinsic strength to the feet
  • He should limit “W” sitting, as this will tend to increase the genu valgus present
  • We gave him 1 leg balancing “games” and encouraged agility activities, like balance beam, hopping, skipping and jumping on each leg individually

We are the Gait Guys, promoting gait and foot literacy, each and every post.

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Holy Hand Grenades! What kind of shoe do I put these feet in?

Take a look at these feet. (* click on each of the photos to see the full photo, they get cropped in the viewer) Pretty bad, eh? How about a motion control shoe to help things along? NOT! OK. but WHY NOT? Let’s take a look and talk about it.

To orient you:

  • top photo: full internal rotation of the Left leg
  • 2nd photo: full internal rotation of the Right leg
  • 3rd photo: full external rotation of the Left leg
  • last photo: full external rotation of the Right leg

Yes, this gal has internal tibial torsion (yikes! what’s that? click here for a review).

Yes, it is worse on the Left side

Yes, she has a moderate genu valgus, bilaterally.

If someone has internal tibial torsion, the foot points inward when the knee is in the saggital plane (it is like a hinge). The brain will not allow us to walk this way, as we would trip, so we rotate the feet out. This moves the knee out of the saggital plane (ie. now it points outward).

What happens when we place a motion control shoe (with a generous arch and midfoot and rearfoot control) under the foot? It lifts the arch (ie it creates supination and it PREVENTS pronation). This creates EXTERNAL rotation of the leg and thigh, moving the knee EVEN FURTHER outside the saggital plane. No bueno for walking forward and bad news for the menisci.

Another point worth mentioning is the genu valgus. What happens when you pick up the arch? It forces the knee laterally, correct? It does this by externally rotating the leg. This places more pressure/compression on the medial aspect of the knee joint (particularly the medial condyle of the femur). Not a good idea if there is any degeneration present, as it will increase pain. And this is no way to let younger clients start out their life either.

So, what type of shoe would be best?

  • a shoe with little to no torsional rigidity (the shoe needs to have some “give”)
  • a shoe with no motion control features
  • a shoe with less of a ramp delta (ie; less drop, because more drop = more supination of the foot (supination is plantarflexion, inversion and adduction)
  • a shoe that matches her sox, so as not to interfere with the harmonic radiation of the colors (OK, maybe not so much…)

Sometimes giving the foot what it appears to need can wreak  havoc elsewhere. One needs to understand the whole system and understand what interventions will do to each part. Sometimes one has to compromise to a partial remedy in one area so as not to create a problem elsewhere. (Kind of like your eye-glass doctor. Rarely do they give you the full prescription you need, because the full prescription might be too much for the brain all at once.  Better to see decent and not fall over, than to see perfectly while face down in the dirt.) 

Want to know more? Consider taking the National Shoe Fit Certification Program. Email us for details: thegaitguys@gmail.com.

We are the Gait Guys, and yes, we like her sox : )

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Holy Late Cretaceous Therapods. Those Veliciraptors were twisted!

The dinosaur made famous by Jurassic Park (We never understood why they put this dinosaur in the movie, the Jurassic period was many millions of years earlier, but that’s another story).

Dr Ivo was able to take some pictures of a rare, preserved skeleton from Mongolia at the dinosaur museum in Fruita, CO, while visiting with his family.

These bad boys (and girls) were fast predators, and one of the things that made them that way, was the fact that they were built for speed!

Take a look at theses hips! Note the extreme retro torsioned angle of the femur heads. We remember that femoral retro torsion limits internal rotation of the hips (OK, so you don’t remember? click here for a review).

Now lets think about this. Externally rotate your thigh and lower leg. What do you notice? Hopefully you notice it puts your foot in more supination. This makes it into a more rigid lever, better for pushing off and better for sprinting!

Have you ever seen a sprinter? do they run on their toes? Is their foot more supinated? Ever see a velociraptor run? Check out this sequence from the “Dinosaur Planet” series. Remember, only their toes are on the ground and the thing that looks like a backwards knee is actually their ankle. 

Since their legs are so close to the body, there is little need for internal rotation, so why not maximize the effect and assist in supination?

Wow! Are you finally convinced that torsions are cool? After all, they appear to have been around for at least the last 75 million years and probably longer. 

The Gait Guys. Quarternary Geeks of the Cenozoic Era. Yes, we study dinosaur gait too…

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Hmmm. We are fully internally rotating this gentleman’s lower leg (and thus hip) on each side. What can you tell us?

Look at the upper picture. Does the knee go past midline? NO! So we have limnited internal rotation of the hip. What are the possible causes?

  • femoral retro torsion
  • tight posterior capsule of hip
  • OA of hip
  • tight gluteal group (max or posterior fibers of medius)
  • labral derangement

Now line up the tibial tuberosity and the foot. What do you see? The foot is externally rotated with respect to the leg. What are the possible causes?

  • external tibial torsion
  • subtalar valgus
  • fracture/derangement causing this position

Now look at the bottom picture. Awesome forearm and nice choice of watch. Good thing we didn’t wear Mickey Mouse!

Look at upper leg. Hmm. Same story as the right side.

Look at the lower leg and line up the tibial tuberosity and the foot. What do you see? The foot is internally rotated with respect to the leg. What are the possible causes?

  • internal tibial torsion
  • subtalar varum
  • fracture/derangement causing this position

So this individual will have very different lower leg mechanics on the right side compared to the left (external torsion right, internal left). We refere to this as “windswept” biomechanics, as it looks like the wind came in from the right and “swept” the feet together to the left.

What will this look like? Most likely increased pronation on the right and supination on the left. What may we see?

  • calcaneal (rearfoot) valgus on right
  • calcaneal (rearfoot) varum on the left
  • bilateral knee fall to midline
  • knee fall to midline on right occurring smoother than on left
     (the patient has an uncompensated forefoot varus bilaterally; he is already partially pronated on the right, so it may appear to be less abrupt)
  • toeing off in supination more pronounced on the left (due to the internal torsion and forefoot varus)

The Gait Guys. Increasing your foot and gait IQ with each and every post.

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What can we learn from a trip to the museum and ancient pachyderms?

Lessons from the Denver Museum of Science and the “Mammoths and Mastodons” exhibit.

Leave it to gait nerds to notice stuff like this. These are the things that keep us up at night.


Look carefully at the last 2 pictures, especially the femurs. Besides their grandious size, what do you see. Femoral anterversion! The angle of the femur head with the shaft of the femur is quite large. We remember from our discussion of anteversion previously (see here); that femoral anteversion allows a greater amount of internal rotation of the head of the femur in the acetabulum (ie the ball in the socket).

Now look at the top picture. Besides a cross over gait that Dr Allen was quick to point out. What do you see?  Ok…tremendous glutes : ). What else? Look at the second picture for a hint. You got it! Internal rotation of the legs.


Think about how pachyderms are put together compared to say, reptiles, specifically lizards. The legs are UNDER the body in the former and STICK OUT from the body in the latter. Watch them walk. The latter swing their tails and the former have the legs under their center of mass.

Extrapolate this to human gait (We know, it’s a stretch, but you have a great imagination). Some people have their weight under their body (ie, they have sufficient internal rotation of the hips to allow this; many of these folks have more anteverision than retroversion. also remember that we are speaking versions, NOT torsions here). Think about retroverted folks. Wider stance, wider gait, just like reptiles.

Ok, maybe this was a stretch, but it was cool, no?

The Gait Guys. Comparing pachyderms to humans….reallly.

all material copyright 2013 The Gait Guys/The Homunculus Group. All rights reserved.

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So, What’s going on here?

Remember torsions and versions? If not, click here, here, here and here for a review. 

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
The Gait Guys. Making it real, every day, every post, every PODcast.
all material copyright 2013 The Gait Guys/ The Homunculus Group.