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Internal Tibial Torsion

- Discussion:
    - medial rotation of the tibia at the knee causes an intoeing gait;
    - it is measured by the angular difference between transmalleolar axis & bicondylar axis of knee;
    - may result in part to excessive medial ligamentous tightness;
    - it is associated with metatarsus adductus in about one-third;
    - infant exhibits in-toeing and may trip and appear clumsy;
    - usually improves with growth;
    - incidence:
           - it is the most common cause of intoeing;
           - usually seen during the second year of life;
           - medial tibial torsion is most apparent when infants first begin to walk,
           - it affects both sexes equally
           - condition is bilateral in about two-thirds of affected infants (left side affected more than the right);
    - differential diagnosis of intoeing:
           - metatarsus adductus
           - tibial torsion
           - femoral anteversion
           - cerebral palsy can be an early cause of tibial intoeing;

- Exam:
    - foot progression angle:
           - a rough measurement which is obtained during gait by observing the angle of the foot off of the line of progression;
           - note that severe foot deformities (club foot) which interfere with the usual measurement;
           - normal values: range from about 6-10 deg of external rotation;
    - thigh foot angle:
           - measured with the child in the prone position and knee flexed 90 deg, by observing the angle of the foot and the thigh;
           - thigh foot angle can upto - 5 deg (internal) in infants, but in young children the normal values is about 15 deg;
           - besides internal tibial torsion, metatarsus adductus will decrease FPA;
    - unilateral medial tibial torsion is seen twice as often on left side as on the right side;
    - feet are medially rotated, while patella remains in neutral position;

- Non Op Treatment:
    - Denis Brown splint can be used if symptoms persist, but its efficacy is questionable;

- Operative Treatment:
    - correction is seldom necessary except in severe cases, which are adressed with a supramalleolar osteotomy;
    - references:
          - Medial femoral torsion: experience with operative treatment
          - Tibial rotational osteotomy for idiopathic torsion. A comparison of the proximal and distal osteotomy levels.

Tibial torsion in patients with medial-type osteoarthrotic knees.

Lower-extremity rotational problems in children. Normal values to guide management.

Tibial torsion: a method of assessment and a survey of normal children.  

Distal Tibial Rotation Osteotomies Normalize Frontal Plane Knee Moments

- Misc:
    - lateral tibial torsion is usually initially seen during late childhood or adolescence; sometimes it is first detected when adolescent is evaluated for patellofemoral pain;
         - it is often unilateral, and it is more common on the right side