Torsional Problems

Key Points:

  • Torsional problems in children include in-toeing and out-toeing
  • In-toeing is commonly caused by internal tibial torsion, femoral anteversion, or metatarsus adductus
  • Out-toeing is most commonly caused by external tibial torsion 
  • Most cases of torsional problems resolve spontaneously with growth
  • Surgery may be indicated in cases of severe malalignment persisting after age 8 if causing a functional problem

Description:

Lower-extremity rotational variations are seen in many children. These can be categorized as in-toeing or out-toeing.  A large range of normal rotational variation can occur in children, and this range varies with age. It is important to understand this developmental process so that the provider can distinguish between normal anatomic variation and more serious structural problems to appropriately counsel families. 

In-toeing can be caused by internal tibial torsion, femoral anteversion, and/or metatarsus adductus (Mooney, 2014; Lincoln, 2003). Other more serious conditions resulting in in-toeing include clubfoot, skew foot, hip disorders, and neuromuscular disorders such as cerebral palsy (Lincoln, 2003). 

Out-toeing may be caused by femoral retroversion, external rotation contracture of the hip, external tibial torsion, or abduction of the forefoot associated with pes planovalgus. More serious conditions leading to out-toeing can include slipped capital femoral epiphysis, coxa vara, and hip dysplasia (Lincoln, 2003). 

Epidemiology:

Internal tibial torsion is the most common cause of in-toeing in children 1-3 years old. A majority of cases are bilateral (Lincoln, 2003).

Femoral anteversion is the most common overall cause of perceived in-toeing (Mooney, 2014). It is frequently found in elementary school age children, is typically bilateral, and is more frequent in females.  Patients with femoral anteversion may sit in a “W” position, or run with a circumduction or “egg beater” gait (Mooney, 2014; Lincoln, 2003).

Metatarsus adductus is a medial deviation of the forefoot relative to the hindfoot and is described in detail elsewhere in the study guide (link to Metatarsus Adductus topic). 

External tibial torsion commonly affects older children or adolescents. This tends to be more often unilateral, primarily affecting the right side (Lincoln, 2003).

Clinical Findings:

A thorough history should be obtained, outlining onset and duration of the problem as well as evaluating for changes over time. Physical exam concentrates on the rotational profile of the patient which includes documentation of the foot progression angle, hip rotation, the thigh-foot axis, transmalleolar axis, and the heel-bisector angle (Staheli 1993). 

The foot progression angle represents the sum of tibial torsion, femoral torsion, and foot contour. This is the angle of the foot relative to a straight line being walked, with out-toeing receiving a positive value (Lincoln, 2003). 

Hip rotation should be measured with the patient prone in order to help stabilize the pelvis during the examination. Infants have an average of 40° of internal rotation and 70° of external rotation (Staheli, 1993). At age 10, these measurements average 50° and 45° of internal and external rotation, respectively (Staheli, 1993). Mild, moderate, and severe increases in internal rotation are demonstrated at 70°, 80°, and 90° (Staheli, 1985).

The thigh-foot axis may also be measured while the patient is prone with 90° of knee flexion. This measurement represents the degree of tibial torsion by comparing the alignment of the longitudinal axis of the thigh to the tibia and hindfoot. In infants, this measurement is 5° of internal rotation on average compared to 10° of external rotation in 8-year olds (Staheli, 1993). 

The transmalleolar axis also is used to determine tibial torsion. This is formed by the angle between a line connecting the lateral and medial malleoli compared to a line connecting the lateral and medial femoral condyles. A fetus at five months of gestational age has about 20° of internal rotation, with newborns having around 4° of internal rotation. The tibia continues to externally rotate with growth to an average of 23° of external rotation in adults (Staheli, 1985).

The heel-bisector angle is useful for determining the relationship between the hindfoot and forefoot (Smith, 1991). In a neutral foot, the line will pass through the second web space.  An abnormal heel-bisector line should suggest that a potential cause of the child’s torsional alignment is due to the structure of the foot itself, such as metatarsus adductus.

Imaging Studies:

Often imaging studies are unnecessary unless the rotational profile is two standard deviations outside of the mean or if there is concern for a specific abnormality (Lincoln, 2003). CT scans with limited cuts are commonly used for further evaluation and operative planning to measure femoral anteversion (Hernandez, 1981; Weiner, 1978) and tibial torsion (Eckhoff, 1994; Jakob, 1980). 

Etiology:

The four limb buds begin to develop in the fifth week of gestation with all four having a parallel axis. The great toes initially develop in a preaxial position, and with medial rotation are seated at the midline by week seven. Intrauterine molding continues, with variable positioning of the feet, internal rotation of the tibia, and external rotation of the hip. This can lead newborns to have common deformities related to these positions. The lower extremities continue to externally rotate in the postnatal period until around age 8-10 years when adult values are typically reached. On average, femoral anteversion will decrease about 25 degrees to a value of 15 degrees, with the tibia externally rotating 15 degrees (Staheli, 1985).

Treatment:

Femoral anteversion typically resolves spontaneously without intervention (Mooney, 2014; Lincoln, 2003). Braces, special shoes, and bars between the shoes have not shown any benefit and may actually have a negative psychological impact later in life (Wenger, 1989; Driano, 1998). Surgery may be considered in children over the age of 8 years with a significant functional or cosmetic deformity, anteversion over 50°, and internal rotation over 80° (Lincoln, 2003). Surgical treatment typically consists of either a proximal or distal femoral derotation osteotomy.

Internal tibial torsion typically resolves spontaneously (Mooney, 2014; Lincoln, 2003). Shoes and braces have been utilized in the past, but they are no longer recommended as the rotation will generally improve with growth. Persistent rotation rarely causes significant issues. Similar to femoral anteversion, surgery may be considered in children with a significant functional or cosmetic deformity or in a child with a thigh-foot angle greater than three standard deviations beyond the mean (Mooney, 2014; Lincoln, 2003).   Options consist of supramalleolar tibial derotation osteotomy or less commonly proximal derotation osteotomy (Walton, 2012; Savva, 2006; Krengel, 1992). 

External tibial torsion increases with age. Significant external tibial torsion may result in lever arm dysfunction.  Surgery indications are the same as those for internal torsion with treatment consisting of a supramalleolar or proximal tibial osteotomy. 

In children with an underlying neuromuscular condition, such as cerebral palsy, there is evidence that excess changes in femoral version and/or tibial torsion can affect gait mechanics and contribute to pain (Stefko 1998).  These children do not have the same muscular strength and coordination as children who do not have underlying neuromuscular conditions and are more likely to require surgical intervention for significant torsional deformities that interfere with ambulation (Rethlefsen 2013, Er 2017, Thompson 2017). 

Complications:

Most causes of in-toeing and out-toeing are benign processes. 

Femoral anteversion has not been found to be associated with degenerative joint disease of the hip or knee (Wedge, 1989; Hubbard, 1988). It is, however, associated with knee pain, particularly when found in association with external tibial torsion (Delgado, 1996; Reikeras, 1992). 

Internal tibial torsion is also not a risk factor for degenerative joint disease and has been suggested to improve sprinting ability (Fuchs, 1996; Turner, 1994). 

External tibial torsion can be associated with miserable malalignment syndrome and may have an association with degenerative joint disease (Turner, 1994). 

References:

  1. Delgado ED, Schoenecker PL, Rich MM, Capelli AM. Treatment of severe torsional malalignment syndrome. J Ped Orthop. 1996; 16: 484-488.
  2. Driano A, Staheli L, Staheli LT. Psychosocial development and corrective shoewear use in childhood. J Ped Orthop. 1998; 18: 346-349. 
  3. Eckhoff DG, Johnson KK. Three-dimensional computed tomography reconstruction of tibial torsion. CORR. 1994; 302: 42-46.
  4. Er MS, et al. Long-term outcome of internal tibial derotation osteotomies in children with cerebral palsy. J Ped Orthop. 2017; 37(7): 454-459.
  5. Fuchs R, Staheli LT. Sprinting and in-toeing. J Ped Orthop. 1996; 16: 489-491. 
  6. Hernandez RJ, Tachdijian MO, Poznanski AK, Dias LS. CT determination of femoral torsion. Am J Roentgenol. 1981; 137: 97-101.
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  13. Rethlefsen SA, et al. Transverse plane gait problems in children with cerebral palsy. J PED ORTHOP. 2013; 33:422-430.
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  15. Smith JT, Bleck EE, Gamble JG, Rinsky LA, Pena T. Simple method of documenting metatarsus adductus. J Ped Orthop. 1991; 11: 679-680.
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  17. Staheli LT. Rotational problems in children. JBJS. 1993; 75: 939-949.
  18. Stefko RM, et al. Kinematic and kinetic data analysis of distal rotational osteotomy of the leg in children with cerebral palsy. J Ped Orthop. 1998; 18:81-87.
  19. Thompson RM, et al. Tibial derotational osteotomies in two neuromuscular populations: comparing cerebral palsy with myelomeningocele. J Child Orthop. 2017; 11(4):243-248.
  20. Turner MS. The association between tibial torsion and knee joint pathology. CORR. 1994; 302: 47-51.
  21. Walton DM, Liu RW, Farrow LD, Thompson GH. Proximal tibial derotation osteotomy for torsion of the tibia: a review of 43 cases. J Child Orthop. 2012; 6: 81-85.
  22. Wedge JH, Munkacsi I, Loback D. Anteversion of the femur and idiopathic osteoarthrosis of the hip. JBJS. 1989; 71: 1040-1043.
  23. Weiner DS, Cook AJ, Hoyt WA, Oravec CE. Computed tomography in the measurement of femoral anteversion. Orthopedics. 1978; 1: 299-306.
  24. Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. JBJS. 1989; 71: 800-810.

Top Contributors:

Eric Christianson, MD
Karen Bovid, MD
Western Michigan Homer Stryker School of Medicine