So what do these dogs tell us?

These are pedographs of a 12 year old male who was brought into the office last week by his mother with knee pain, bilaterally, R > L and bilateral hip pain.

Clinical findings are a left tibial and femoral leg length deficiency of over 1 cm; bilateral internal tibial torsion in excess of 40 degrees; no femoral retro or ante torsion.

Gait evaluation revealed moderate rear and midfoot pronation. He leaned to the left during stance phase on the left. Arm swing had bilateral symmetry.

So, what can you tell us about internal tibial torsion?

The tibial torsion angle is measured by looking at the angle of the tibial plateau and the intermaleolar line (see middle picture above). The distal tibia begins in utero having an angle of 0 degrees in the infant an “untwists” to 22 degrees by adulthood (see far right). Tom Michaud does a great job talking about this in this book “Human Locomotion: The conservative Management of Gait Related Disorders”. When it moves less than the requisite amount (possibly due to biomechanical. genetic or environmental influences), you get internal tibial torsion. This means the foot is pointed inward when the knee is in the coronal plane (ie facing straight forward)

Time for a quick pedograph case:

This person presented with arch pain and occasional forefoot pain.

Note the increased size (length) of the heel print with blunting at the anterior most aspect. The midfoot impression is  increased, revealing collapsing medial longitudinal arches. The forefoot print has increased pressures over the 2nd metatarsal heads bilaterally, and the 1st on the left. She claws with toes 2-4 bilaterally.

This demonstrates poor intrinsic stability of the foot (as evidenced by the increased heel impression and midfoot collapse) and well as decreased ankle rocker (as evidenced by the increased forefoot pressures).

We also see increased ink under the distal second digit (esp on the right). This suggests some possible incompetence of the first ray complex and big toe, which is represented by the medial ink presentation under the great toe (suggesting a pinch callus, which is seen when there is spin of the foot and insufficient great toe anchoring and push off).  When the great toe function is compromised, we tend to see increased activity of the 2nd digit long flexors, represented well here by increased ink under the 2nd toe.

The pedograph truly does provide a window to the gait cycle!

We remain: Gait Geeks