Change the foot, change the knee (and vice versa). A video case of External Tibial Torsion.

Here is a perfect example of external tibial torsion. Are you treating and training people and messing with their orthotics, squat knee-foot posturing or making gait/running/jumping changes or recommendations? If you are doing all of this and you do not know about tibial torsions, then shame on you, go apologize to these people right now. You could be causing them mechanical grief. Go buy them ice cream (even if they are “paleo”), that fixes most unintentional human mistakes. 

This is a classic presentation of external tibial torsion. This is an anatomic problem, you cannot fix this intrinsically, but you can help extrinsically. You teach these people about this issue and why the foot and the knee cannot cooperate. You teach them why their feet are spun out (increased foot progression angle) while their knee tracks straight forward sagittally. You teach them why they might heel strike far laterally and why their pronation phase might be abrupt. As in this video, you teach them why they might fashionably choose to narrow the foot progression angle (foot turned in) while at the same time having to bear weight on the lateral foot (in supination to externally spin the tibia) to keep the knee tracking sagittally. You teach them why this will be impossible to do in pumps (inversion sprain ouch) and why over time this will anger many joints and tendons. You teach them that without this accommodation they will track the knee inside the sagittal plane (as seen in the video).  You teach them why they might be at greater risk of having foot prontation issue pathologies, why they might have limited internal hip rotation, why orthotics likely do not do much for them (yes, there are exceptions), why certain shoes are a challenge for them while others are magical and why over time their once beautiful arch has begun to “fall” and be less prominent as they attenuate the plantar tissues.  

As you get good with this gait and biomechanics stuff, you should readily see and understand all of the issues discussed here today in a mere flash of instant brilliance so you know what to offer your client, in understanding and remedy options. As you have seen in this video, when left to their own devices, they naturally allow the knee to find the sagittal plane in a nice forward hinge. In this posture the foot is excessively progressed outward. Again, this is because of the tibial long bone torsion. This is their anatomy, this is not functional in this case. You cannot fix this, you help them manage this, first with their awareness, then with your brilliance.  You may implement exercises and gait strategies to help them become aware of mechanical issues and how to protect the foot-ankle, the knee and the hip. You teach them why they might have a tendency towards anterior pelvis posturing or sway back type postures. You teach them why, in some cases, they choose knee hyperextension as a comfortable yet lazy stance postural habit. You teach them why some shoes are “happy” shoes for them, and why others are pure evil.

A foundational principle we teach here at The Gait Guys is that the knee is a simple hinge between two multiaxial joints on either side of the knee, the hip and the foot-ankle complex. The knee really can only flex and extend, and when the mechanics above and below are challenged the knee has little depth to its abilities to tolerate much of anything except simple sagittal hinging. You can see that the foot posturing and tibial torsion rule the roost here in this video. You should learn in time that managing this case above and below the knee is where the pot of gold is found. You will learn in time that taping the knee is often futile, yet a worthy experiment both for you and the client in the discovery process, but that a life time of taping is not logical. External tibial torsion, although affording the knee that sagittal hinge plane, can narrow its range of safe sagittal mechanics and it is up to you to  help them learn and discover that razor’s edge safely and effectively when the torsion is large.  You should also discuss with them that as they plastically tissue adapt over the years (ie. pronate more and lose more arch integrity), this razor’s edge may widen or narrow for the knee mechanics as well as the hip and foot-ankle complex.  

For your reading pleasure, a classic example of how to interrogate a safe sagittal knee progression was discussed in this blog video piece we wrote recently, linked here.

Look and you shall find, but only if you know what you are looking for.

* Please now know that you should never off the cuff tell someone to turn inwards their outwardly spun foot. But if you do, have ice cream on hand, just in case.

Need more to spin your head ? Think about whether their IT band complex is going to be functioning normally.  Oy, where is that ice cream !

Shawn Allen, one of the gait guys

Falling hard; Using supination to stop the drop.

“One thing, affects all things. One change necessitates global change. The more you know, the more you will see (and understand).  The more you know, see and understand, the more responsible you will and should feel to get it right and the more global your approach should become. If your head does not spin at times with all the issues that need to be juggled, you are likely not seeing all the issues you should be seeing.” -Dr. Allen (from an upcoming CME course)

This is a case that has been looked at before but today with new video. This is a client with a known anatomic short leg on the right (sock-less foot) from a diseased right hip joint.  

In this video, it is clear to see the subconscious brain attempting to lengthen the right leg by right foot strike laterally (in supination) in an attempt to keep the arch and talus as high as possible.  Supination should raise the arch and thus the resting height of the talus, which will functionally lengthen the leg.  This is great for the early stance phase of gait and help to normalize pelvis symmetry, however, it will certainly result in (as seen in this video) a sudden late stance phase pronation event as they move over to the medial foot for toe off. Pronation will occur abruptly and excessively, which can have its own set of biomechanical compensations all the way up the chain, from metatarsal stress responses and plantar fasciitis to hip rotational pathologies.  It will also result in a sudden plummet downwards back into the anatomic short leg as the functional lengthening strategy is aborted out of necessity to move forward.  

This is a case where use of a full length sole lift is imperative at all times. The closer you get to normalizing the functional length, the less you need to worry about controlling pronation with a controlling orthotic (controlling rate and extent of arch drop in many cases). Do not use a heel lift only in these cases, you can see this client is already rushing quickly into forefoot loading from the issues at hand, the last thing you should be doing is plantarflexing the foot-ankle and helping them get to the forefoot even faster !  This will cause toe hammering and gripping and set the client up for further risk to fat pat displacement, abnormal metatarsal loading, challenges to the lumbricals as well as imbalances in the harmony of the long and short flexors and extensors (ie. hammer toes). 

How much do you lift ?  Be patient, go little by little. Give time for adaptation. Gauge the amount on improved function, not trying to match the right and the left precisely, after all the two hips are not the same to begin with. So go with cleaner function over choosing matching equal leg lengths.  Give time for compensatory adaptation, it is going to take time.  

Finally, do not forget that these types of clients will always need therapy and retraining of normal ankle rocker and hip extension mechanics as well as lumbopelvic stability (because they will be most likely be dumping into anterior pelvic tilt and knee flexion during the sudden forefoot loading in the late midstance phase of gait). So ramp up those lower abdominals (especially on the right) !  

Oh, and do not forget that left arm swing will be all distorted since it pairs with this right limp challenge. Leave those therapeutic issues to the end, they will not change until they see more equal functional leg lengths. This is why we say never (ok, almost never) retrain arm swing until you know you have two closely symmetrical lower limbs. Otherwise you will be teaching them to compensate on an already faulty motor compensation. Remember, to get proper anti-phasic gait, or better put, to slow the tendency towards spinal protective phasic gait, you need the pelvic and shoulder “girdles” to cooperate. When you get it right, opposite arm and leg will swing together in same pendulum direction, and this will be matched and set up by an antiphasic gait.

One last thing, rushing to the right forefoot will force an early departure off that right limb during gait, which will have to be caught by the left quad to dampen the premature load on the left. They will also likely have a left frontal plane pelvis drift which will also have to be addressed at some point or concurrently. This could set up a cross over gait in some folks, so watch for that as well.

“One thing, affects all things. One change necessitates global change. The more you know, the more you will see (and understand).  The more you know, see and understand, the more responsible you will and should feel to get it right and the more global your approach should become. If your head does not spin at times with all the issues that need to be juggled, you are likely not seeing all the issues you should be seeing.” -Dr. Allen (from an upcoming CME course)

Shawn Allen, one of the gait guys.

Salsa Dancing for Age related Functional Deficits.

Don’t dismiss it until you have tried it. For 3 years we did it here at The Gait Guys (and salsa was one of our favorites), so we know what it is all about … . the foot work, the amount of core stability needed, hip stability, lower abdominal skills, balance, proprio, vestibular accommodation etc. Dancing is no joke, and no you are not too cool to do it. Here in America we are the exception, not the rule. In most countries, after dinner, they push the tables to the sides and people dance the night away. In many countries, men dance. Looking to impress guys? Take some lessons. Looking to get your elderly clients active, set them up with your local dance studio and improve their health. 

– random thoughts from Dr. Allen

Their study’s conclusions: “Salsa proved to be a safe and feasible exercise programme for older adults accompanied with a high adherence rate. Age-related deficits in measures of static and particularly dynamic postural control can be mitigated by salsa dancing in older adults. High physical activity and fitness/mobility levels of our participants could be responsible for the nonsignificant findings in gait variability and leg extensor power.” – Granacher et al.

Difference between adult and infant gait compensation.

We highly doubt the infants compensated to the point of “recovering symmetrical gait”. It just isn’t possible seeing as there was frank asymmetry in leg length. However, it is quite possible they accomodated quicker with a more reasonable compensation, that MAY have appeared to have less limp. We did not do the study, but over a beer we might guess that the investigators might agree that our verbiage is closer to accurate. None the less, cool stuff to cogitate. We are very appreciative of this study, there is something to take from this study.

“The stability of a system affects how it will handle a perturbation: The system may compensate for the perturbation or not. This study examined how 14-month-old infants-notoriously unstable walkers-and adults cope with a perturbation to walking. We attached a platform to one of participants’ shoes, forcing them to walk with one elongated leg. At first, the platform shoe caused both age groups to slow down and limp, and caused infants to misstep and fall. But after a few trials, infants altered their gait to compensate for the platform shoe whereas adults did not; infants recovered symmetrical gait whereas adults continued to limp. Apparently, adult walking was stable enough to cope with the perturbation, but infants risked falling if they did not compensate. Compensation depends on the interplay of multiple factors: The availability of a compensatory response, the cost of compensation, and the stability of the system being perturbed.”- From the Cole et all study (reference below)

– thoughts by Shawn Allen


Infant Behav Dev. 2014 Aug;37(3):305-14. doi: 10.1016/j.infbeh.2014.04.006. Epub 2014 May 20.Coping with asymmetry: how infants and adults walk with one elongated leg.Cole WG1, Gill SV2, Vereijken B3, Adolph KE4.