Video case: The King’s Preference: Short and Sweet. A quick and easy case demonstrating the patellar tracking struggles with external tibial torsion.
Our favorite functional evaluation piece of equipment as well as our favorite piece of therapy equipment is the Total Gym. Here we clearly demonstrate, to us and the client, in partial weight bearing load, the effects of external tibial torsion.
Remember, the knee is sort of the King of all joints when it comes to the lower extremity. The knee is a sagittal plane hinge, and so all it wants to do is hinge forward, freely without binding from deficits at the hip or knee. But we cannot ignore the simple fact that pre-pubescent kids the long bone derotation process is still undergoing, and in adults the process may have been corrupted or insufficient.
In this case it should be obvious that the knee is sagittal and free to hinge when the foot is at a large foot progression angle. This allows the knee to hinge cleanly. But when the foot is corrected to the sagittal plane, as you see in the second half of the video, the knee tracks inward and this can cause patellofemoral pain syndromes, swelling, challenges to the menisci (and possible eventual tears) and challenges to the ACL and other accessory restraints. Additionally, this medial drift is a longer and more difficult challenge to the eccentric phase external rotators such as the gluteus maximius not to mention many of the other muscles and their optimal function.
So, the next time you see a large foot progression angle in a client or in their walk (duck footed if you will) try to resist the natural urge to tell them to corrrect the foot angle. They are likely doing it to keep the King happy. And furthermore, be careful on your coaching recommendations during squats, olympic lifts, lunges and running. Just because you do not like the way the foot looks doesn’t mean you should antagonize the King of joints.
External tibial torsion, its not something you want to see, but when you do see it, you have to know its degree, its effects at the knee, hip and foot as well as how it might impact hip extension, pelvic neutrality, foot strike, foot type, toe off and so many other aspects.
Whoever said gait analysis was easy was a liar. And if all they use is a video camera and fancy analysis software they have show up with only part of the team. And if they said they were an expert in gait only a few years into practice, you had better also look for a jester’s hat somewhere hiding in the corner. After all, the King would want to know !
Shawn and Ivo, your court jesters for the last 3+ years. Maybe we will get a promotion from the King someday soon !