Internal tibial torsion + femoral retrotorsion + twisting = low back pain

note the internal tibial torsion and lack of internal rotation of the right hip secondary to femoral retroversion

internal rotation of less than 0 on the left hip

Here’s one that we’ve talked about before. Think about internal tibial torsion for a moment. You remember when the tibial tuberosity points straightahead and the foot points inward? 

Now combine that with femoral retro torsion. Remember that that’s when the angle of the femoral neck with the shaft is less than 8° which results in a loss of internal rotation of the hip. 

Put those two together and you have a foot that points inward and limited internal rotation of the hip on that same side. 

Stand on your right leg with your foot turned in. Twist your body to the right. Can you see how this is internal rotation of the right hip?

If people have to create internal rotation of the hip, then the motion has to occur somewhere. If it is not available at the hip and the lower extremity is fully internally rotated it has to occur north of the hip which is usually in the lumbar spine. Now think about when people are lifting things. Often times they do not do a hip hinge and reverse or flatten their lumbar lordosis, opening up the facet joints which allows more rotation. Do you remember that rotation of the lumbar spine is limited to about 5° unilaterally? Where do you think that hip rotation is going to occur? Hmmmm... Probably north of the hip. 

Better teach them to spin that weight bearing leg and foot out into some external rotation to create that needed range of motion, increase the amount of internal rotation of that hip or have them keep their shoulders and hips in the same plane when rotating.

Dr Ivo Waerlop, one of The Gait Guys 

#backpain #hipinternalrotation #internaltibialtorsion #retrotorsion #femoralretrotorsion 

3 clues that someone has internal tibial torsion

Watch this video a few times through and see what you notice. There are three clues that this patient has internal tibial torsion, can you find them?

He presented with right sided knee pain, medial aspect of the patella and medial joint line as well as tenderness over the medial joint line and pes anserine. Lower extremity musculature test strong and 5/5 save for his semi tendinosis on the right which tested 4/5.He has diminished endurance bilaterally in the external obliques

1. Note how his knees, right greater than left, fall outside the sagittal plane

2. Note the decreased progression angle of both feet during forward motion

3. Note how he toes off in supination, right greater than left.

This patient’s knee pain is coming from irritation of the pes anserine, particularly semitendinosus and his inability to recruit his abdominals sufficiently so, instead of the usual pattern of recruiting iliopsoas or rectus femoris, he chooses his sartorius, gracious and semi tendinosis.

Pay attention to how the new tracks, the progression angle as well as if they tow off in pronation, neutral, or supination in that can offer subtle clues to internal tibial torsion.

Dr Ivo Waerlop, one of The Gait Guys

#internaltibialtorsion #gaitanalysis #thegaitguys

https://vimeo.com/365342814

A primer on tibal torsions and versions....

We get tired of reading posts on squats, lifting, lunges and the whole “have your toes in”, “Have your tires pointing out”, “keep your feet straight” sort of advice for best performance. The truth of the matter is, when the knee is in the saggital plane, you will have the best results and cause the least amount of damage to the knee and menisci. In our opinion, if you are not paying attention to femoral and tibial torsions and versions, you are missing the boat.

This is not a post for the faint of heart, but hopefully will help clear up some questions you may (or may not) have had. Grab a cup of your favorite beverage and enjoy...

The tibia and femur are more prone to torsional defects, as they are longer lamellar (layered) bones as opposed to the cancellous bone that makes up the talus. These often present as an “in toeing” or “out toeing” of the foot with respect to the leg; changing the progression angle of gait.

Tibial versions and torsions can be measured by the “thigh foot angle” (the angulation of the foot to the thigh with the leg bent 90 degrees: above right) or the “transmalleolar angle” (the angle that a line drawn between the medial and lateral malleoli of the ankle makes with the tibial plateau).

At a gestational age of 5 months, the fetus has approximately 20° of internal 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 1.5 degrees per year until adult values are reached between ages 8 and 10 years of 23° of external tibial torsion (range, 0° to 40°).

Sometimes the rotation at birth is excessive. This is called a torsion. Five in 10,000 children born will have rotational deformities of the legs. The most common cause is position and pressure (on the lower legs) in the uterus (an unstretched uterus in a first pregnancy causes greater pressuremaking the first-born child more prone to rotational deformities. Growth of the unborn child accelerates during the last 10 weeks and the compression from the uterus thus increases. As you would guess, premature infants have less rotational deformities than full-term infants. This is probably due to decreased pressure in the uterus. Twins take up more space in the uterus and are more likely to have rotational deformities.

Of interesting note, there is a 2:1 preponderance of left sided deformities believed to be due to most babies being carried on their backs on the left side of the mother in utero, causing the left leg to overlie the right in an externally rotated and abducted position.

Normal ranges of versions and torsions are highly variable. Ranges less than 2 standard deviations are considered internal tibial torsion and greater external tibial torsion.

Internal tibial torsion (ITT) usually corrects 1 to 2 years after physiological bowing of the tibia (ie tibial varum) resolves. External tibial torsion (TT) is less common in infancy than ITT but is more likely to persist in later childhood and NOT resolve with growth because the natural progression of development is toward increasing external torsion.

Males and females seem to be affected equally, with about two thirds of patients are affected bilaterally and the differences in normal tibial version values are often expected to be cultural, lifestyle and posture related.

The ability to compensate for a tibial torsion depends on the amount of inversion and eversion present in the foot and on the amount of rotation possible at the hip. Internal torsion causes the foot to adduct, and the patient tries to compensate by everting the foot and/or by externally rotating at the hip. Similarly, persons with external tibial torsion invert at the foot and internally rotate at the hip. Both can decrease walking agility and speed if severe. With an external tibial torsion deformity of 30 degrees , the capacities of soleus, posterior gluteus medius, and gluteus maximus to extend both the hip and knee were all reduced by over 10%.

So, there you have it. Ina nutshell, the basics that will take you far and wide on your journey to better performance and biomechanics for yourself and your patients/clients.

What do you know about Internal Tibial Torsion?

A great review on how ITT effects gait

How can feet relate to golf swing?

This 52 year old right handed gentleman presented with pain at the thoracolumbar junction after playing golf. He noticed he had a limited amount of “back swing” and pain at the end of his “follow through”.

Take a look a these pix and think about why.

Full internal rotation

full external rotation

full internal rotation

full external rotation

neutral

neutral

Hopefully, in addition to he having hairy and scarred legs (he is a contractor by trade), you noted the following

• Top: note the normal internal rotation of the right hip; You need 4 degrees to walk normally and most folks have close to 40 degrees. He also has internal tibial torsion.
• second picture: loss of external rotation of the right hip. Again, you need 4 degrees (from neutral) of external rotation of the hip to supinate and walk normally.
• third picture: normal internal rotation of the left hip; internal tibial torsion
• 4th picture: limited external rotation of the left hip, especially with respect ti the amount of internal rotation present; this is to a greater degree than the right
• last 2 pictures: note the amount of tibial varum and tibial torsion. Yes, with this much varum, he has a forefoot varus.

The brain is wired so that it will (generally) not allow you to walk with your toes pointing in (pigeon toed), so you rotate them out to somewhat of a normal progression angle. If you have internal tibial torsion, this places the knees outside the saggital plane. (For more on tibial torsion, click here.) If you rotate your extremity outward, and already have a limited amount of range of motion available, you will take up some of that range of motion, making less available for normal physiological function. If the motion cannot occur at the knee or hip, it will usually occur at the next available joint cephalad, in this case the spine.

The lumbar spine has a limited amount of rotation available, ranging from 1.2-1.7 degrees per segment in a normal spine (1). This is generally less in degenerative conditions (2).

Place your feet on the ground with your feet pointing straight ahead. Now simulate a right handed golf swing, bending slightly at the waist androtating your body backward to the right. Now slowly swing and follow through from right to left. Note what happens to your hips: as you wind back to the right, the left hip is externally rotating and the right hip is internally rotating. As you follow through to the left, your right, your hip must externally rotate and your left hip must externally rotate. Can you see how his left hip is inhibiting his back swing and his right hip is limitinghis follow through? Can you see that because of his internal tibial torsion, he has already “used up” some of his external rotation range of motion?

If he does not have enough range of motion in the hip, where will it come from?

he will “borrow it” from a joint more north of the hip, in this case, his spine. More motion will occur at the thoracolumbar junction, since most likely (because of degenerative change) the most is available there; but you can only “borrow” so much before you need to “Pay it back”. In this case, he over rotated and injured the joint.

What did we do?

• we treated the injured joint locally, with manipulation of the pathomechanical segments
• we reduced inflammation and muscle spasm with acupuncture
• we gave him some lumbar and throacolumbar stabilization exercises: founders exercise, extension holds, non tripod, cross crawl, pull ups
• we gave him foot exercises to reduce his forefoot varus: tripod standing, EHB, lift-spread-reach
• we had him externally rotate both feet (duck) when playing golf

The Gait Guys. Helping you to store up lots “in your bank” of foot and gait literacy, so you can help people when they need to “pay it back”, one case at a time.

(1) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223353/

(2) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705911/

Subtle clues. Helping someone around their anatomy

This patient comes in with low back pain of years duration, helped temporarily with manipulation and activity. Her exam is relatively benign, save for increased lumbar discomfort with axial compression in extension and extension combined with lateral bending. Believe it or not, her abdominal and gluteal muscles (yes, all of them) test strong (no, we couldn’t believe it either; she is extremely regular with her exercises). She has bilateral internal tibial torsion (ITT) and bilateral femoral retro torsion (FRT). She has a decreased progression angle of the feet during walking and the knees do not progress past midlilne. There is a loss of active ankle rocker with gait, but not on the exam table; same with hip extension. 

We know she has a sweater on which obscures things a bit, but this is what you have to work with. Look carefully at her posture from the side. The gravitational line should pass from the earlobe, through the shoulder, greater trochanter and through or just anterior to the lateral malleolus.

In the top picture, can you see how her pelvis is anterior to this line? Do you see how it gets worse when she lifts her hands over her head (yes, they are directly over head)? This can signify many things, but often indicates a lack of flexibility in the lumbar lordosis; in this case, she cannot extend her lumbar spine further so she translates her pelvis forward. Most folks should have enough range of motion from a neutral pelvis and enough stability to allow the movement to occur without a significant change. Go ahead, we know you are curious, go watch yourself do this in a mirror and see if YOU change.

Looking at the this picture, can you pick out that she has a genu valgus? Look at the hips and look at the tibial angle.

Did you note the progression angle (or lack of) in her feet? This is a common finding (but NOT pathognomonic) in patients with internal tibial torsion. Notice the forefoot adductus on the right foot?

So what do we think is going on?

• ITT and FRT both limit the amount of internal rotation of the thigh and lower leg. Remember you NEED 4 degrees of each to walk normally. Most folks have significantly more
• if you don’t have enough internal rotation of the lower extremity, you will need to “create” it. You can do this by extending the lumbar spine (bottom picture, right) or externally rotating the lower extremity
• Since her ITT and FRT are bilateral, she flexes the pelvis and nutates the pelvis anteriorly.
• the lumbar facet joints should only carry 20% of load
• she is increasing the load and causing facet imbercation resulting in LBP.

What did we do?

• taught her about neutral pelvic positioning, creating more ROM in the lumbar spine
• had her consciously alter her progression angle of her foot on strike, to create more available ROM in internal rotation
• encouraged her to wear neutral shoes
• worked on helping her to create more ankle rocker and hip extension with active drills and exercise (ie gait rehabilitation); shuffle walks, Texas walk, toes up walking, etc

why didn’t we put her in an orthotic to externally rotate her lower extremity? Because with internal tibial torsion, this would move her knee outside the saggital plane and create a biomechanical conflict at the knee and possibly compromising her meniscus.

Cool case, eh? We thought so. Keep on learning so your brain keeps expanding. If you are not growing your brain, you are shrinking it!

The Gait Guys

Some Basic Tenets of Gait

Initial contact? Loading response? Mid stance? Terminal Stance? pre swing? Are these terms that are familiar to you? Hmmm. How about the wrong orthotic for someone with internal tibial torsion? Join us in this excerpt from a recent Gait and Needling seminar

https://vimeo.com/226733697

Tibial Torsion and Genu Valgum

Join us in this brief video about tibial torsion and genu valgum in a 6-year-old

Mooney JF 3rd Lower extremity rotational and angular issues in children. Pediatr Clin North Am. 2014 Dec;61(6):1175-83. doi: 10.1016/j.pcl.2014.08.006. Epub 2014 Sep 18.

Killam PE. Orthopedic assessment of young children: developmental variations. Nurse Pract. 1989 Jul;14(7):27-30, 32-4, 36.

Kling TF Jr, Hensinger RN. Angular and torsional deformities of the lower limbs in children. Clin Orthop Relat Res. 1983 Jun;(176):136-47.

When the wrong shoe, meets the right foot

Is it any wonder that this gentleman has pain on the dorsum of this his feet?

1st of all, how about his internal tibial torsion? It is bilateral, L > R. This places the majority of his weight on the outside of his feet, keeping him somewhat supinated most of the time.

2nd: he has an anatomical leg length discrepancy on the right which is tibial (see pictures 2 and 3). This will place EVEN MORE weight on the outside of the right foot, as it will often remain in supination in an attempt to "lengthen" itself.

3rd, take a look at his shoes. Is this particular model supposed to be rear foot posted in varus? Talk about adding insult to injury! This will place this guys feet into EVEN MORE supination and EVEN MORE on the outside of his feet. maybe the right shoe is worn into more supination because of his right sided LLD?

And if that wasn't enough, this particular shoe has increased torsional rigidity through the midfoot, slowing or arresting any hope of shock absorption that he may have. 

Yikes! We sure wish more folks knew more about feet and shoes! Maybe they should think about taking the National Shoe Fit Program? Email us for more info.

Got Motion Control? Sometimes too much of a good thing is a bad thing!

Welcome to Monday and News You can Use, Folks.

Today we look at short video showing what someone with internal tibial torsion looks like in a medially posted (ie motion control) running shoe. Note how the amount of internal rotation of the lower leg decreases when the shoe is removed and when he runs. Be careful what shoes you recommend, as a shoe like this is likely to cause damage down the road.

You can follow along listening to Dr Ivo’s commentary. This was filmed at a recent seminar he was teaching.