Internal Tibial Torsion

Topic updated on 09/25/15 11:32am
  • A condition that is characterized by internal rotation of tibia
    • most common cause of in-toeing
  • Epidemiology
    • demographics
      • usually seen in toddlers (1-3 years)
    • location
      • often bilateral
  • Pathophysiology
    • exact etiology unknown
    • believed to be caused by intra-uterine positioning
    • possibly due to excessive tightness of the medial ligamentous structures of the leg
  • Associated conditions
    • developmental dysplasia of the hip (DDH)
      • 15-20% of cases
    • metatarsus adductus
  • Prognosis
    • outcomes
      • usually resolves spontaneously by age 6
  • History
    • commonly noticed once child begins walking 
    • parents report that the legs are "turning in"
    • increased tripping and/or falling reported by parents/caregivers
  • Symptoms
    • usually asymptomatic
  • Physical exam 
    • assess tibial torsion in prone position
      • thigh-foot angle 
        • normal
          • average = 0 to -10 degrees internal rotation in childhood 
        • abnormal
          • thigh-foot angle greater than -15 degrees internal rotation, or greater than 3 standard deviations
      • technique  
        • measure the angle formed by a line bisecting the foot relative to a line bisecting the thigh 
    • assess tibial torsion at the ankle
      • transmalleolar angle
        • normal
          • average = 0 to -10 degrees internal rotation in childhood 
        • abnormal
          • transmalleolar angle greater than -15 degrees internal rotation, or greater than 3 standard deviations
      • technique
        • measure the angle formed by a line passing through the lateral and medial malleoli relative to a line perpendicular to the long axis of the thigh
    • assess tibial torsion during gait 
      • foot-progression angle
        • normal is -5 to +20 degrees
      • technique 
        • measure the angle of the foot relative the line of progression during gait
  • Radiographs
    • usually not indicated unless other conditions present (see above)
Causes of Intoeing
Condition Key findings
Tibial Torsion Thigh-foot angle < -10 degrees

Femoral Anteversion Internal rotation >70 degrees and < 20 degrees of external rotation (tested in prone position)
Metatarsus Adductus   Medial deviation of the forefoot with normal alignment of the hindfoot
  • In-toeing associated with the following necessitates further work-up
    • pain
    • limb length discrepancy
    • progressive deformity
    • family history positive for rickets/skeletal dysplasias/mucopolysaccharidoses
    • limb rotational profiles 2 standard deviations outside of normal 
  • Nonoperative
    • observation and parental education
      • indications
        • most cases 
      • outcomes
        • usually resolves spontaneously by age 6
        • bracing/orthotics do not change natural history of condition
  • Operative
    • derotational supramalleolar tibial osteotomy
      • indications
        • child > 8 years of age 
        • thigh-foot angle >15 degrees, or greater than 3 standard deviations
        • very rarely required


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Qbank (2 Questions)

(OBQ09.39) A 2-year-old boy is brought to your clinic by his mother for being "pigeon-toed". Each of the following measurements found on physical examination are a routine part of defining the child's lower extremity rotational profile EXCEPT. Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

(OBQ08.39) An 18-month-old girl is brought to clinic by her mother for in-toeing. All of the following features should prompt the physician to perform further evaluation (including radiographs) if found in conjunction with in-toeing EXCEPT: Topic Review Topic

1. limb length discrepancy
2. metatarsus adductus
3. pain
4. family history of skeletal dysplasias
5. limb rotational profiles 2 standard deviations outside of normal



Beautiful Presentation to understand In-toeing of gait
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