Intoeing–Tibial Torsion
Intoeing–Tibial Torsion: Excerpt from The 5-Minute Pediatric Consult
John P. Dormans, MD
Intoeing–Tibial Torsion - BASICS
Intoeing–Tibial Torsion - description
- Tibial torsion: Twisting (internal or external) of the tibia (may be associated with femoral torsion)
- Medial or internal tibial torsion associated with intoeing (most common)
- Lateral or external tibial torsion associated with outtoeing
- Normal defined as within 2 standard deviations of mean
Intoeing–Tibial Torsion - epidemiology
Common and usually normal (i.e., within 2 standard deviations of the mean)
Intoeing–Tibial Torsion - risk factors
Intoeing–Tibial Torsion - genetics
No strong evidence to suggest that this is an inherited condition (heredity-familial tendency)
Intoeing–Tibial Torsion - pathophysiology
- Tibial torsion: Twisting the tibia; usually medial or internal; associated with intoeing
- If associated with increased femoral anteversion, may be associated with patellofemoral malalignment (kneecap subluxation)
Intoeing–Tibial Torsion - etiology
- Normal fetal development
- Intrauterine position
- Heredity-familial tendency
- Posturing (sitting position): Cause or effect?
- Associated pathology (e.g., spasticity, fracture malunion, or developmental dislocation of the hip (DDH)
Intoeing–Tibial Torsion - DIAGNOSIS
Intoeing–Tibial Torsion - signs & symptoms
Intoeing–Tibial Torsion - history
- Birth history: Common in 1st-borns
- Pain or limping may indicate other diagnosis.
- Metatarsus adductus, torticollis, DDH may be associated with other conditions that result from immobility in uterus
- Functional limitations (i.e., child trips and falls frequently) may suggest other diagnosis, such as mild cerebral palsy, especially if abnormal birth history, abnormalities in developmental milestones, and physical findings consistent with cerebral palsy
Intoeing–Tibial Torsion - physical exam
- If child is ambulatory, watch gait and assess for foot progression angle: The angle formed between the axis of the foot and the axis of forward progression of gait.
- Also assess other aspects of gait: Stride, heel-toe gait, cadence, limping, other abnormalities. Unilateral or bilateral torsion
- Leg length discrepancy, hip abnormalities, contractures, spasticity, thigh-foot axis (TFA)
- With the child prone, the knee flexed to 90°, and the ankle at neutral, measure the difference between the axis of the foot and the axis of the femur.
- If the TFA is internal, this suggests internal tibial torsion; if external, external tibial torsion.
- Transmalleolar axis: With the child seated and the knee flexed to 90°, assess the malleolar axis in reference to the coronal plane (less reliable than TFA).
- Look for abnormalities of the feet: Metatarsus adductus or clubfoot may be a primary cause of intoeing. Significant calcaneovalgus may be a component of outtoeing.
- Careful neurologic examination: To see if intoeing is related to a mild neurologic abnormality, such as mild spastic diplegic cerebral palsy
- Physical examination tricks:
- “Torsional profile” consists of foot-progression angle, medial hip rotation in extension (to assess femoral torsion), lateral hip rotation in extension (to assess femoral torsion), thigh-foot angle (to assess tibial torsion), transmalleolar axis (to assess tibial torsion), configuration of the foot
- “Kissing patellae”: Occurs when bilateral increased femoral anteversion causes the patellae to face one another, giving the appearance of kissing patellae
Intoeing–Tibial Torsion - tests
Intoeing–Tibial Torsion - lab
Usually not helpful (i.e., normal with tibial torsion)
Intoeing–Tibial Torsion - imaging
- Usually not needed; physical examination gives information needed
- Hip x-ray: May be indicated if hip pathology (i.e., DDH) is suspected
- CT: An accurate way to measure tibial and femoral torsion, but there is radiation exposure. An occasional indication may be a patient who is being evaluated for surgery.
- MRI and ultrasound: Have been described to quantify torsion, but generally are less accurate than CT
Intoeing–Tibial Torsion - differencial diagnosis
Look for DDH, spasticity (e.g., mild cerebral palsy)
Intoeing–Tibial Torsion - TREATMENT
Intoeing–Tibial Torsion - initial stabilization
- Observation and familial and patient reassurance (almost always the treatment of choice)
- Devices such as casts, shoe wedges, twister cables, splints, and Denis-Brown bars have no proven benefit (i.e., they will not change the natural history). Some of these may in fact cause problems such as ligamentous damage to hip, knee, ankle, and foot.
- Reassurance is usually enough. The condition improves spontaneously. Usually corrects enough by 8 years of age.
- Surgery seldom needed
- Tibial osteotomy: When done, is usually a distal supramalleolar osteotomy
Intoeing–Tibial Torsion - general measures
- Observation
- Physical therapy: Will not change natural history (it may help with associated patellofemoral malalignment pain)
- Devices (casts, shoe wedges, twister cables, splints, Denis-Brown bars): No proven benefit
- Tibial osteotomy is seldom, if ever, needed.
Intoeing–Tibial Torsion - activity
No restrictions
Intoeing–Tibial Torsion - surgery
Rarely needed
Intoeing–Tibial Torsion - FOLLOW UP
Intoeing–Tibial Torsion - prognosis
- Good; usually not painful, cosmetically unattractive, or dysfunctional
- Usually corrects enough by 8 years of age
- Should improve with growth and development. There is no substantial evidence that increased femoral anteversion will cause arthritis of the hip or knee.
- Overall, good prognosis for the majority of patients
Intoeing–Tibial Torsion - complications
Functional if severe; no long-term complications (osteoarthritis) proven
Intoeing–Tibial Torsion - bibliography
- Craig CL, Goldberg MJ. Foot and leg problems. Pediatr Rev. 1993;14:395–400.
Schoenecker PL, Rich MM. The lower extremity. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s Pediatric Orthopaedics. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2001:1059–1104.
- Staheli LT. Lower positional deformity in infants and children: A review. J Pediatr Orthop. 1990;10:559–563.
- Staheli LT. Torsional deformities. Pediatr Clin North Amer. 1977;24:799–811.
Intoeing–Tibial Torsion - CODES
Intoeing–Tibial Torsion - icd9
754.43 Congenital bowing of tibia and fibula
Intoeing–Tibial Torsion - FAQ
- Q: When are special shoes or braces indicated for tibial torsion?
- A: Almost never. The situation will improve without treatment in most patients. There is no convincing evidence that any of these treatments truly alter the natural history of the condition.
- Q: Why do patients with torsional pathology occasionally have knee pain?
- A: Children may have increased femoral anteversion with associated external tibial torsion (i.e., an external rotation of the tibia that matches and, in effect, balances the internal rotation of the femur). This can be diagnosed by observing the above rotational profile and by noting increased Q-angle. This situation is sometimes a “setup” for patellofemoral pain.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
More About Torsion
More Medical Textbooks Online about Torsion
Review other book chapters online related to Torsion:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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