Foot Progression Angle Exaggeration: External Tibial Torsion

Take a look at the tibial tuberosity and then where you think the 2nd metatarsal head would be. What do you see? The 2nd metatarsal is lateral to the tibial tuberosity. You are looking at external tibial torsion. 

Lets see how this external tibail torsion behaves during a knee bending. Observe the medial drift of the knee during weight bearing knee flexion. Many folks would say that the problem here is the increased foot prontation, but that is not where the problem lies, that is where many of the forces are funneling though. The client is pronating more because the external tibial torsion that is creating this appearance has put the knee inside the foot tripods region of stability.

In external tibial torsion there is an external torsion or a “twist” along the length of the tibia (diaphysis or long section). This occurs in this example to the degree that the ankle joint (mortise joint) can no longer cooperate with sagittal knee joint.  When taking a client with external tibial torsion and pre-postioning their foot in a relatively acceptable/normal foot progression angle there is a conflict at the knee, meaning that the knee cannot hinge forward in its usual sagittal plane. In this case with the foot progression angle smaller than what this client would posture the foot, the knee the knee will be forced to drift medially.

Are you looking for torsions of the lower limb in your clients ?

Are you forcing them into foot postures that look better to  you but that which are conflicting to your clients given body mechanics ?  Would you correct this client’s foot turn out (increased progression angle) ? IF you did you would likely cause them knee pain in time.  Would you put them into a stability shoe to try and control the pronation ? Again, you are likely to draw their knee outside the saggital knee hinge that is presently pain free. There is more to shoe fit that just looking at the foot. First do no harm is our mantra ! 

Remember, telling someone to turn their foot in or out because it doesn’t appear correct to your eyes can significantly impair either local or global joints , and often both. Torsions can occur in the talus, the tibia and the femur.

Furthermore, torsions can have an impact on foot posturing at foot strike and affect the limbs loading response, from foot to core and even arm swing can be altered.  Letting your foot fall naturally beneath your body does not mean that you have the clean anatomy to do so without a short term or long term cost. 

This is some of the toughest stuff you will deal with clinically. The fence is narrow, if you do to little correction you fall off the fence into the wrong yard and create problems. If you do to much correction you get the same result. These torsional issues are a delicate balancing act many times. You first have to know what you have, then you have to know where the fix is, and then how much is safe.  Tricky stuff. This is exactly why in some folks a stability shoe can be magic or tragic and in others dropping into zero drop minimalism can be magic or tragic.  

Want more on torsion and versions ?  Type the words into the search box on our blog. We have plenty of good info for you.

Shawn and Ivo, The Gait Guys

Limitations: The powers of observation will help you.

Physical examination, FMS, DNS, gait analysis … . . these are all very important tools for the coach, trainer, therapist, clinician.  They will all offer information and lead the “therapy giver” in a direction for intervention.  But when something doesn’t match up with the basic standard protocols, you have to go outside the standard box.  We have all been there and today is just a little reminder not to get caught up in the “proceedures” and merely running through protocol without an engaged brain putting the pieces together.  

Here we see 2 classic examples of deviations from the mean, the client on the left has drifted further outside the frontal plane because of tibial varum and a little genu varus.  The client on the right has imploded deep into the frontal plane via rigid pes planus foot collapse and genu valgum.  These will both affect your physical screenings for these clients. And keep in mind, and this is probably the most important point of today’s blog post, either client may have good or bad strategies around their anatomy.  In other words, some clients will have great compensations to limit further functional pathology, and some will have poor compensation strategies, and thus, both will have different physical exam findings, different screenings and different neuromotor patterns embedded deep into their CPGs (central pattern generators).   Put yet another way, all of the scenarios discussed may/will have varying screening assessment outcomes but for different reasons.  If you know the cause of these faults and the impaired neuro-recruitment patterns that are likely, your assessments will make more sense, and so will your exercise/therapy/rehab prescriptions.  If you do not understand the fundamental differences (ie long bone torsions or various femoral-neck shaft angles, foot types such as an uncompensated forefoot valgus etc) , one could prescribe therapies that will not address the underlying problems, rather they might address the compensations and strategies found with these client’s challenges.

It can get sloppy messy.  Wear a bib.

Dig for the roots, don’t mow the grass…… Shawn and Ivo, The Gait Guys

Photo: Where is your knee joint hinge point ?  Say that 4 times fast.

Here is a photo of 4 elite runners. We suspect it is an 800m race  because #100 is Ahmed Bile who is the son of Olympian and world champion Abdi Bile.

In this photo you can see that Ahmed #100 has a significantly large foot progression angle (large foot turn out) and this likely represents external tibial torsion or femoral antetorsion while #454 has a neutral foot turn out as does #232.  #46 has a modest foot progression angle. Grossly, #46 also has the patella right over the foot and so tibial torsion is not likely. Now, move up to observe their knee progression. All of them have a forward (sagittally) oriented knee progression. How can that be? Well, it is simple if you know your torsional issues. After all, the knee is a hinge and if you are running forward your knee pretty much should hinge forward as well.  Now, there is much room for conversation here and debate but we are just trying to make and observation and a point. To a large extent the knee rules the roost in the lower limb in terms of sagittal progression because it is the joint with the least number of tolerances. The knee only hinges in flexion and extension where as the hip and ankle/foot have frontal and axial planes they can notably tap into when the sagittal is challenged.  Again, look at #100 and our point is made.

Look at the 2 fellas in the middle (454 and 232). they have a internally (medially) postured knee/thigh yet their foot progression angle is mostly neutral and the knees are hinging forward.  Does #454 have internal tibial torsion? It could be (hint, look at his right trailing leg, specifically the patella and foot postures) but the left limb looks cleaner although adducted suggesting he might like the cross-over gait or it is more external tibial torsioned. Where as the 2 outer fellas, 100 and 46, are more neutrally oriented knees/thighs (one could make the case that #100 has a more externally oriented femur) yet increased progression foot progression angle in an environment of a forward hinging knee.

So what gives ? Torsions. Yes, we are soapboxing on torsions again. Torsions in the tibia, torsions in the femur. Versions are normal expressed angles, tibial torsions are abnormal.

Now, as life would have it, look over the right shoulder of #100. See the fella in the red headband? Ya, that guy losing.  He has the cleanest lines of the bunch. How is that for cruel irony ?  Sometimes it ain’t what you got, it is what you do with what you got.  Unless of course he is actually wincing in pain and trailing behind because he got spiked by #100 and that hideously frontal plane splayed foot !

Lastly, this wouldn’t be an official Gait Guys post if we did not preach to remember that “what you see is not the problem, what you see in a gait analysis is the person’s compensatory strategy around their deficits”. And here we see deficits. Our observations today are merely just that, observations. Now someone has to get them on a table and examine them and confirm our observations, prove them wrong and/or discover the joint, muscular and motor pattern deficits that created these observations.  Or, someone has to confirm that all parts are working and that they were at the end of the line when the straight long bones were first handed out.  

Today’s Lesson:  Get in line, and get in line early. (just kidding of course)

The Gait Guys.  Calling it they way we see it, but reserving the right to plead the 5th or change our minds after an examination.  We would suggest to everyone, when it counts and when your reputation is on the line, plead the 5th, until you have completed your hands on clinical examination.  ”Seeing may be believing” but that still doesn’t always make it so.

Want to learn more about these kinds of things, foot beds, foot types, shoe anatomy and shoe function, proper shoe prescription etc ?  Our National Shoe Fit program will help you get smarter about this stuff. email us at : 

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*Photo courtesy of BIG EAST Conference

Podcast #25: Bionics, Arm Swing & Footwear

Great podcast today, #25. Wide range of topics today: the first truly bionic body part, technical shoe issues, GTO’s and more. 

podcast link:

iTunes link:

Gait Guys online /download store:

Today’s show notes:


1. The First Truly Bionic Hand

“The first bionic hand that allows an amputee to feel what they are touching will be transplanted later this year in a pioneering operation that could introduce a new generation of artificial limbs with sensory perception.

2. Effects of toning shoes on lower extremity gait biomechanics

Clinical Biomechanics, Jan 2013

3. Beware of trendy barefoot running shoes – you could end up with broken bones in your foot—end-broken-bones-foot.html?ito=feeds-newsxml

  • Advocates of barefoot running claim it can reduce injuries and back pain
  • ‘Minimalist’ shoes such as these now account for 15% of sales
  • But experts say many people suffer injuries by overdoing it early on
  • Runners should make transition from regular trainers more slowly, they say

4. Foot strike and injury rates in endurance runners: a retrospective study.

Daoud AI, Geissler GJ, Wang F, Saretsky J, Daoud YA, Lieberman DE.
Med Sci Sports Exerc. 2012 Jul;44(7):1325-34. doi: 10.1249/MSS.0b013e3182465115.

Department of Human Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA.

5. Effects of foot strike on low back posture, shock attenuation, and comfort in running.
Med Sci Sports Exerc. 2013 Mar;45(3):490-6

CONCLUSION: Change in foot strike from RFS to FFS decreased overall ROM in the lumbar spine but did not make a difference in flexion or extension in which the lumbar spine is positioned. Shock attenuation was greater in RFS. RFS was perceived a more comfortable running pattern.

*it seems to becoming a question as to what you are doing with the body parts at impact……..where it be you are RFS or FFS.  Do you have the ability to protect the parts in varying mechanical stressful positions.

6. Hey guys, Dr. Ryan:

I just listened to Pod 23 and Ivo you mentioned sagittal curves not developing until after birth..  There is evidence they begin to develop in-utero.  Here is an article excerpt and link to it.
“In many anatomy texts, it is often claimed and/or assumed that the cervical lordosis is a secondary curve and is not present during intra-uterine life. However, as early as 1977, Bagnall et al3 demonstrated that the cervical lordotic curve is formed in intrauterine life (9.5 weeks). In 195 fetuses, Bagnall et al3 found that by 9.5 weeks, 83% of fetuses have a cervical lordosis, 11% have a military configuration, and only 6% of fetuses are in the typically described kyphotic position of the cervical spine. This means that by 9.5 weeks, 94% of the fetuses are starting to use their posterior cervical muscles to pull the cervical curve away from the fetal “C”-shape. Fetuses have a cervical lordosis before birth, however, the lordosis increases during post-natal life at ages 3 months-9 months as the infant raises his/her head and begins to sit up.4”


  1. Harrison DD, et al. Spine 1996; 21: 667-675.
  2. Harrison DD, et al. Spine 2004; 29:2485-2492.
  3. Bagnall KM, et al. J Anat 1977;124:791-802.
  4. Kure S. J Tokyo Med Collage 1972;30;453-470.
  5. Kasai T, et al. Growth. Spine 1996;21:2067-2073.
  6. Harrison DE, Harrson DD, Haas JW. Evanston, WY: Harrison CBP Seminars, Inc., 2002, ISBN 0-9721314-0-X.
  7. Shatz A, et al. Acta Anat 1994;149:141-145.
  8. McAviney J, et al. J Manipulative Physiol Ther 2005;28:187-193.
  9. Bastecki A, et al. ADHD: A CBP Case Study. J Manipulative Physiol Ther 2004; 27(8):e14.

7. “Dynamic Arm Swing in Human Walking, ( where it was determined that normal arm swinging required minimal shoulder torque, while volitionally holding the arms still required 12% more metabolic energy. Among measures of gait mechanics, vertical ground reaction moment was most affected by arm swinging and increased by 63% without it.
* brings up issues of shoulder pathology……rot cuff, frozen shoulder, carrying a purse, water bottle etc

8. Winter foot wear:
We like Steger Mukluks…….youtube video   “gait guys mukluks”

9. Versions: one of the more difficult concepts to grasp………… is a Q from a FB reader

  • Does retroversion mean this child will automatically grow up with abnormal mechanics – leading to possible knee foot hip back issue etc? Is there a fix to prevent such without an ortho’s bone saw?
    10. The role of GTO’s in plyometric exercises.