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

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
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.

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.

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°). more cool stuff on torsions here

Wow, cool stuff, eh?

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

Now THERE”S some internal tibial torsion!

So, this gent came in to see us with L sided knee pain after it collapsed with an audible “pop” during a baseball game. He has +1/+2 laxity in his ACL on that side. He has subpatellar and joint line pain on full flexion, which is limited slightly to 130 (compared to 145 right)

 We know he has internal torsion because a line drawn from the tibial tuberosity dropped inferiorly does not pass through or near the plane of the 2nd metatarsal (more on tibial torsions here)

What would you do? Here’s what we did:

  • acupuncture to reduce swelling
  • took him out of his motion control shoes (which pitch him further outside the saggital plane)
  • gave him propriosensory exercises (1 leg balance: eyes open/ eyes closed; 1 legged mini squats, BOSU ball standing: eyes open/eyes closed)
  • potty squats in a pain free range
  • ice prn
  • asked him to avoid full flexion

Is it any wonder he injured his knee? Imagine placing the FOOT in the saggital plane, which places the knee FAR outside it; now load the joint an twist, OUCH!

What would you do? This is what we did.


This 7 year old girl is brought in by her mother because of knee misalignment while skiing, L > R. No history of trauma; normal term birth with no complications. No knee pain. Of incidental note, she is deaf in the left ear.

Exam findings:

She has bi-lat. external tibial torsion, left much worse than right (40 degrees transmallolear angle vs 22 degrees. for info on measuring torsions, click here). remember, you should be able to draw a line from the tibial tuberosity down through the 2nd metatarsal head. 

She has a 5mm anatomical leg length deficiency on the right (see top above left).

She has femoral antetorsion right side with very little external rotation, approximately 10 degrees,  internal rotation is in excess of 50.  Left side has normal femoral versions (for a review of femoral versions and torsions, click here).  See last 2 pictures which are full internal and external rotation respectively.

She has a mild uncompensated forefoot varus (cannot really see from the pictures, you will need to take our word for it) with a relatively cavus arch to her foot(see center and last picture on right.

Neurologically, she appeared to have integrity with respect to sensation, motor strength and deep tendon reflexes in the lower extremities.


Pathomechanical alignment as described.  Severe left external tibial torsion. MIld to moderate right. Femoral antetorsion right.


We are going to build her a medium heel cup full length modified UCB orthotic inverting the cast bi-lat. left greater than right.  We gave her  balance and coordination exercises, heel walking, lift/spread/reach and one leg balancing. She will follow up for a dispense.  Her mother will try to get a better fitting ski boot as the one she has currently is two sizes too big. She will return for a dispense. She should consider wearing the orthotics in everyday footwear as well. We will do a follow up post in a few weeks. 

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This is part 2 of a 2 part post; with the video from the case previously discussed

please note the following in the video:

  • body lean to left during left stance phase (to clear right longer leg)
  • circumduction of right lower extremity  (to clear right longer leg)
  • lack of arm swing bilaterally (cortical involvement)
  • patient looking down while walking (decomposition of gait)
  • shortened step length (decomposition of gait)
  • increased tibial varum bilaterally

ASSESSMENT:  This patient’s short leg and internal tibial torsion impediments to her full recovery. She has increased tibial varum noted which is complicating the picture. This is causing pathomechanics and an abductory moment not only at the knee but also in the lumbar, thoracic and cervical spines.

WHAT DID WE DO?:                    

  • We attempted to do the one leg standing exercise. She needed to hold on and did not feel stable on the left hip while performing this.  This is probably more of confidence rather than ability issue. 
  • We gave her the stand/sit exercise to try to improve gluteal recruitment.
  • We also gave her the lift/spread/reach exercise to attempt to strengthen her feet.
  • A full-length 5 mm lift was cut for the left shoe  She felt more stable when walking on this.
  • She was treated with IC, PIR and manipulative therapy and neuromuscular stim of the knee as well as left hip area above, below and at the joint line of the knee as well as gluteus medius and minimus.   
  • We may need to consider building a more aggressive orthotic with a forefoot varus post depending upon her progress and response to care  

 The Gait Guys. Making it real, each and every post here on the blog.

special thanks to SZ for allowing us to publish her case, so others can learn

Wow! What would you do?

This is part 1 of a 2 part post. Look for the other one a few minutes after this one with a video up top for the conclusion

PRESENTING PROBLEM: This 54 YO female patient presents with with left sided knee pain.  She had a total knee replacement (TKR) done in 2011.  She’s had a significant amount of discomfort on the medial aspect of the knee since then. She had an MRI of the hip done thinking the problem was there, and found nothing.   She is walking with a bad limp, left leg is half inch shorter than the right.  Pain is worse at night, changes with weather. 

She has knee pain on the lateral aspect (points to tibial plateau and joint line) with swelling that goes down to the ankle left side.  She has been wearing a “Good Feet” OTC orthotic on the left side which she states helps quite a bit.

Generally speaking, stretching and analgesics make the discomfort better.    Ibuprofen 400 mg. b.i.d. can take the edge off  Soft sided brace (neoprene sleeve) makes a difference as well. The hard sided brace gives her difficulty.

WORK HISTORY: She works for a preschool.  Her job involves standing and getting up and down a lot.  

FAMILY HISTORY:  She has left sided lid ptosis, this evidently is familial.  

PHYSICAL EXAM:  She stood 5’ 1” and weighed approx. 150 pounds.

Viewing the knees bi-lat., the left knee is markedly externally rotated.

She does have a left short leg; tibial and femoral.  She has bilateral tibial torsion (look at the tibial tuberosities and drop a line straight down; it should pass through the 2nd metatarsal head) and marked internal tibial torsion on the left side (>60 degrees) with femoral retrotorsion (less than 8 degree angle of femoral head with the shaft) on this side.  There is no rotation of the thigh or leg past zero degrees midline. .  She had 10 degrees of tibial varum on the left hand side.  Her Q-angle is 10 degrees on that side.  There is plantar flexion inversion of the foot.  Left lower extremity has less sensation secondary to the her TKR  surgery.

Gait evaluation reveals a fair amount of midfoot pronation noted on the left hand side in addition to an intoed gait.  She has to lean her body over to the left to get the right leg to clear.

Some mild weakness noted of hip abduction musculature left hand side gluteus medius, middle and anterior fibers. Knee stability tests were negative.

Neurologically, otherwise, she had full integrity with respect to sensation, motor strength and deep tendon reflexes in the upper and lower extremities.

Please see part 2 of this post for additional info including our assessment and what WE did.

 The Gait Guys. Making it real, each and every post here on the blog.

special thanks to SZ for allowing us to publish her case, so others can learn

More on the “little guy”

We have been following this little guy for some time now. If you have not been keeping up, perhaps you should read herehere and here 1st. 

So, what do we see in these latest pictures?

Top left: neutral view.

  • He enjoys flip flops; probably not the best thing for a developing kiddo, in light of the excessive engagement of the posterior compartment (and reciprocal inhibition of the anterior compartment)
  • he has some tibial varum (ie bowleggedness) L > R
  • he has some developmental genu valgum whnich appears to be improving (need a Q angle review? click here)
  • no tibial torsion present on L: for a review on torsions, click here
  • still some external tibial torsion present on R (see section below on middle shots)

Top right and bottom: full internal rotation of R thigh: compare with bottom: full internal rotation of L thigh

  • he has adequate internal rotation (4 degrees needed) but not as great as left side (see bottom shot); this represents some improvement since we started
  • he has generous internal rotation of the left thigh

Middle Left: full external rotation of right thigh

  • note the position of the knee and the position of the foot; external tibial torsion is present. for a review of torsions, click here.
  • he has limited external rotation of the right thigh (compared with the left. The knee should fall more outside the saggital plane

Middle right: full external rotation of the left thigh

  • note the position of the knee and the position of the foot; internal tibial torsion is present. 
  • he has generous external rotation of the left thigh (compared with the left)

of other significant note: most of his calcaneal valgus has resolved; longitudinal arches are improved.

What now?

  • He continues to develop normally and continues to improve since his original presentation to the office
  • Having the child continue to walk barefoot
  • Continue to wear shoes with little torsional rigidity, to encourage additional additional intrinsic strength to the feet
  • He should continue to limit “W” sitting, as this will tend to increase the genu valgus present
  • We reviewed 1 leg balancing “games” and encouraged continuing agility activities, like balance beam, hopping, skipping and jumping on each leg individually
  • added in using a push and pedal bike
  • added in heel walking exercises

Ivo and Shawn. Bald. Good looking. Extraordinary Gait Geeks. Taking the world of gait literacy by storm with each and every post.