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?

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.) 

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

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)

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