Paediatric Lower Extremity Torsional Conditions: Difference between revisions

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== Introduction ==
== Introduction ==
Paediatric lower extremity and gait concerns are common reasons for visits to the paediatrician and therapy services<ref name=":2">Kahf H, Kesbeh Y, van Baarsel E, Patel V, Alonzo N. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6769356/ Approach to pediatric rotational limb deformities]. Orthopedic Reviews. 2019 Sep 9;11(3).</ref><ref name=":0">BMJ Best Practice. Torsion of the Lower Limb in Children. Available from: https://bestpractice.bmj.com/topics/en-us/748 (accessed 14/October/2023).</ref><ref name=":1">Eskay, K. Paediatric Physiotherapy Programme. Paediatric Lower Extremity Torsional Conditions. Physioplus. 2023.</ref><ref name=":7">Cao LA, Wimberly L. When to Be Concerned About Abnormal Gait: Toe Walking, In-Toeing, Out-Toeing, Bowlegs, and Knock-Knees. Pediatric Annals. 2022 Sep 1;51(9):e340-5.</ref><ref name=":8">Kainz H, Mindler GT, Kranzl A. [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0291458 Influence of femoral anteversion angle and neck-shaft angle on muscle forces and joint loading during walking]. Plos one. 2023 Oct 12;18(10):e0291458.</ref>, and can account for up to 16% of all new paediatric orthopaedic surgeonn referrals.<ref name=":3">Chandrananth J, Hannan R, Bouton D, Raney E, Sienko S, Do P, Bauer JP. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9351693/ The Effects of Lower Extremity Rotational Malalignment on Pediatric Patient-reported Outcomes Measurement and Information System (PROMIS) Scores]. Journal of Pediatric Orthopedics. 2022 Sep;42(8):e889.</ref> The most common concern for parents is in-toeing and fear of delayed meeting of developmental milestones.<ref name=":2" /> <ref name=":0" /><ref name=":7" /> Typically in-toeing improves and resolves itself with skeletal maturity, however out-toeing can be a more persistent condition.<ref name=":3" />An understanding of typical and atypical lower extremity development, and when to initiate a pediatrician or orthopaedic referral is an important skill for paediatric rehabiliation professionals.<blockquote>Torsion of the lower extremity can be the "summation of anatomic axial (transverse) plane tilt or twist between the ends of the bones, capsular laxity or tightness, and muscular control during growth."<ref name=":0" /></blockquote>This article will summarise the pathophysiology, clinical presentation, assessment and basic treatment interventions of lower extremity torsional conditions commonly referred to therapy services.
Paediatric lower extremity and gait concerns are common reasons for visits to paediatricians and therapy services.<ref name=":2">Kahf H, Kesbeh Y, van Baarsel E, Patel V, Alonzo N. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6769356/ Approach to pediatric rotational limb deformities]. Orthopedic Reviews. 2019 Sep 9;11(3).</ref><ref name=":0">BMJ Best Practice. Torsion of the Lower Limb in Children. Available from: https://bestpractice.bmj.com/topics/en-us/748 (accessed 14/October/2023).</ref><ref name=":1">Eskay K. Paediatric Physiotherapy Programme. Paediatric Lower Extremity Torsional Conditions Course. Plus, 2023.</ref><ref name=":7">Cao LA, Wimberly L. When to Be Concerned About Abnormal Gait: Toe Walking, In-Toeing, Out-Toeing, Bowlegs, and Knock-Knees. Pediatric Annals. 2022 Sep 1;51(9):e340-5.</ref><ref name=":8">Kainz H, Mindler GT, Kranzl A. [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0291458 Influence of femoral anteversion angle and neck-shaft angle on muscle forces and joint loading during walking]. Plos one. 2023 Oct 12;18(10):e0291458.</ref> They can account for up to 16% of all new paediatric orthopaedic surgeon referrals.<ref name=":3">Chandrananth J, Hannan R, Bouton D, Raney E, Sienko S, Do P, Bauer JP. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9351693/ The Effects of Lower Extremity Rotational Malalignment on Pediatric Patient-reported Outcomes Measurement and Information System (PROMIS) Scores]. Journal of Pediatric Orthopedics. 2022 Sep;42(8):e889.</ref> Parents commonly worry about in-toeing or that their child might be delayed in meeting developmental milestones because of lower extremity or gait conditions.<ref name=":2" /> <ref name=":0" /><ref name=":7" /> In-toeing typically resolves with skeletal maturity. However, out-toeing can be a more persistent condition.<ref name=":3" /> It is, therefore, important that rehabilitation professionals understand typical and atypical lower extremity development, and when to initiate a referral to a paediatrician or orthopaedic surgeon. <blockquote>Torsion of the lower extremity can be the "summation of anatomic axial (transverse) plane tilt or twist between the ends of the bones, capsular laxity or tightness, and muscular control during growth."<ref name=":0" /></blockquote>This article summarises the pathophysiology, clinical presentation and assessment of lower extremity torsional conditions and basic rehabilitation interventions.


== Torsional Conditions ==
== Torsional Conditions ==


=== Femoral Torsion ===
=== Femoral Torsion ===
 
In newborns, internal femoral torsion of up to 40° can be considered typical. External femoral torsion can also be prominent and considered typical at birth.<ref>Merck Manual. Femoral Torsion (Twisting). Available from: https://www.merckmanuals.com/professional/pediatrics/congenital-craniofacial-and-musculoskeletal-abnormalities/femoral-torsion-twisting (accessed 24 October 2023).</ref><blockquote>
* In newborns, internal femoral torsion up to 40° can be considered typical, and external femoral torsion can also be prominent and considered typical at birth.<ref>Merck Manual. Femoral Torsion (Twisting). Available from: https://www.merckmanuals.com/professional/pediatrics/congenital-craniofacial-and-musculoskeletal-abnormalities/femoral-torsion-twisting (accessed 24 October 2023).</ref>
 
<blockquote>
==== Special Topic: what is the Difference between femoral torsion and femoral version? ====
==== Special Topic: what is the Difference between femoral torsion and femoral version? ====
Version and torsion are not identical conditions, however they may both occur at the same time.<ref name=":1" /><ref name=":4">Cusick BD, Stuberg WA. Assessment of lower-extremity alignment in the transverse plane: implications for management of children with neuromotor dysfunction. Physical therapy. 1992 Jan 1;72(1):3-15.</ref>
Version and torsion are not identical conditions, but they may both occur at the same time.<ref name=":1" /><ref name=":4">Cusick BD, Stuberg WA. Assessment of lower-extremity alignment in the transverse plane: implications for management of children with neuromotor dysfunction. Physical therapy. 1992 Jan 1;72(1):3-15.</ref>


'''Torsion''' is a "structural, osseous state of twist in a bone along its longitudinal axis." <ref name=":4" />
'''Torsion''' is a "structural, osseous state of twist in a bone along its longitudinal axis."<ref name=":4" />


* '''Femoral antetorsion''' (medial femoral torsion) is when the femur demonstrates a medial twist of the distal-on-proximal ends.
* '''Femoral antetorsion''' (medial femoral torsion): when the femur has a medial twist of the distal-on-proximal ends.
* '''Femoral retrotorsion''' (lateral femoral torsion) describes a deformity ranging from a lack of typical femoral medial torsion to a true lateral twist of the distal-on-proximal ends of the femur.
* '''Femoral retrotorsion''' (lateral femoral torsion): a deformity that ranges from a lack of typical femoral medial torsion to a true lateral twist of the distal-on-proximal ends of the femur.


'''Version''' describes "a position in space relative to a plane"<ref name=":4" /> of motion and refers to the rotation of the neck of the femur in relation to the femoral condyles at the level of the knee.<ref name=":1" />
'''Version''' describes "a position in space relative to a plane"<ref name=":4" /> of motion and refers to the rotation of the neck of the femur in relation to the femoral condyles at the level of the knee.<ref name=":1" />


* '''Femoral anteversion''' – Decreased angle between the neck of the femur and femoral condyles. Normal anteversion of the femoral neck is approximately 15°. Femoral anteversion is more common than femoral retroversion.<ref name=":1" />
* '''Femoral anteversion''': decreased angle between the neck of the femur and the femoral condyles. Normal anteversion of the femoral neck is approximately 15°. Femoral anteversion is more common than femoral retroversion.<ref name=":1" />
* '''Femoral retroversion''' -Increased angle between the neck of the femur and femoral condyles<ref name=":1" />
* '''Femoral retroversion''': increased angle between the neck of the femur and the femoral condyles.<ref name=":1" />
</blockquote>
</blockquote>


=== Tibial Torsion ===
=== Tibial Torsion ===
* Internal tibial torsion is common in children less than four years old, and it typically presents as internal rotation of the tibia and in-toeing gait
* Internal tibial torsion is common in children less than four years old, and it typically presents as internal rotation of the tibia and in-toeing gait.
* Often resolves spontaneously by four-years of age, less than 1% of torsional deformities fail to resolve in childhood
* Often resolves spontaneously by four-years of age; less than 1% of torsional deformities fail to resolve in childhood.
* Tibial torsions are often associated with (1) increased incidence of knee osteoarthritis later in life, (2) increased incidence of osteochondritis dissecans, and be a predisposing factor for (3) Osgood-Schlatter syndrome in male athletes<ref name=":1" />
* Tibial torsions are often associated with (1) increased incidence of knee osteoarthritis later in life and (2) increased incidence of osteochondritis dissecans. They can also be a predisposing factor for (3) Osgood-Schlatter syndrome in male athletes.<ref name=":1" />


=== What is the Source of the Rotation? ===
=== What is the Source of the Rotation? ===
There can be some mild in-toeing and out-toeing throughout typical development, therefore it is important to differentiate typical versus atypical as part of a lower extremity assessment. If it is determined to be atypical in or out-toeing, the next step is to determine which components of the lower extremity are the source of the torsional condition, and intervene at that level.<ref name=":1" />
Some mild in-toeing and out-toeing can occur in typically developing children. Therefore, it is important to differentiate between what is typical and what is atypical as part of the lower extremity assessment. If in- or out-toeing is found to be atypical, the next step is to determine which components of the lower extremity are the source of the torsional condition, and intervene at that level.<ref name=":1" />


'''Components that can contribute to in-toeing''':
'''Components that can contribute to in-toeing''':


* Femoral anteversion
* femoral anteversion
* Internal tibial rotation
* internal tibial rotation
* Metatarsus adductus
* metatarsus adductus




'''Components that can contribute to out-toeing''':
'''Components that can contribute to out-toeing''':


* External rotation contractures of the hip
* external rotation contractures of the hip
* Femoral retroversion (rare)
* femoral retroversion (rare)
* External tibial rotation
* external tibial rotation
* Calcaneovalgus
* calcaneovalgus
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=== Past Medial History ===
=== Past Medial History ===
The evaluation interveiw for torsion considerations is similar to those for most lower extremity orthopaedic concerns.<ref name=":1" />
The evaluation / subjective interview for torsion considerations is similar to those for most lower extremity orthopaedic concerns.<ref name=":1" /> It will cover the following areas:


* Child's birth history (premature versus full term)  
* child's birth history (premature versus full term)
* Orthopaedic or neurological concerns  
* orthopaedic or neurological concerns
* Developmental milestone history or concerns  
* developmental milestone history or concerns
* Child's age when in or out-toeing was first observed
* child's age when in or out-toeing was first observed
* Significant family history, especially sort of torsional or orthopaedic conditions
* significant family history, especially torsional or orthopaedic conditions
* Previous interventions
* previous interventions
* Child's common sleeping and sitting positions
* the child's common sleeping and sitting positions
* When the child started to walk independently and how long they have been walking
* when the child started to walk independently and how long they have been walking


<blockquote>
<blockquote>
=== Clinical Pearl: can sitting and sleeping position exacerbate torsional conditions? ===
=== Clinical pearl: can a child's sitting and sleeping positions exacerbate torsional conditions? ===
Literature reviews have identified certain "myths in pediatric orthopedics" surrounding topics such as in and out-toeing, W-sitting, and toe-walking. which are common and can be normal variants of growth and development in young children.<ref name=":6">Honig EL, Haeberle HS, Kehoe CM, Dodwell ER. Pediatric orthopedic mythbusters: the truth about flexible flatfeet, tibial and femoral torsion, W-sitting, and idiopathic toe-walking. Current Opinion in Pediatrics. 2021 Feb 1;33(1):105-13.</ref>
Literature reviews have identified certain "myths in pediatric orthopedics" surrounding topics such as in and out-toeing, W-sitting, and toe-walking. These are common positions/conditions and can be examples of normal variations in growth and development in young children.<ref name=":6">Honig EL, Haeberle HS, Kehoe CM, Dodwell ER. Pediatric orthopedic mythbusters: the truth about flexible flatfeet, tibial and femoral torsion, W-sitting, and idiopathic toe-walking. Current Opinion in Pediatrics. 2021 Feb 1;33(1):105-13.</ref>


* "Femoral and tibial torsion typically improve in the first 10–14 years of life. Bracing has shown no benefit over the natural course, and is not recommended."<ref name=":6" />
* "Femoral and tibial torsion typically improve in the first 10–14 years of life. Bracing has shown no benefit over the natural course, and is not recommended."<ref name=":6" />
* "W-sitting is a comfortable seating position for children with femoral anteversion<ref name=":1" /> <ref name=":6" /> and increased internal hip rotation. W-sitting does not cause hip dysplasia, nor is there evidence to support the concern that it may cause future functional deficits."<ref name=":6" />
* "W-sitting is a comfortable seating position for children with femoral anteversion<ref name=":1" /> <ref name=":6" /> and increased internal hip rotation. W-sitting does not cause hip dysplasia, nor is there evidence to support the concern that it may cause future functional deficits."<ref name=":6" />


However, for a small percentage of patients certain positions, such as W-sitting, can exacerbate torsion. This is due to the ground reaction forces in this position encouraging the limb into more external rotation if the patient is still in early bone modeling stages of development.<ref name=":1" />   
However, for a small percentage of patients, certain positions, such as W-sitting, can exacerbate torsion. This is due to the ground reaction forces in this position, which encourage the limb into more external rotation (when the patient is still in the early bone modelling stages of development).<ref name=":1" />   


A referral is warranted if the patient exhibits moderate to severe deformity, lack of resolution or worsening with time, pain, or functional impairments.<ref name=":6" /><ref name=":8" /> </blockquote>
A referral is warranted if the patient exhibits moderate to severe deformity, lack of resolution or worsening with time, pain, or functional impairments.<ref name=":6" /><ref name=":8" /> </blockquote>


=== Physical Assessment ===
=== Physical Assessment ===
General assessment should include:<ref name=":1" />
The general assessment should include:<ref name=":1" />
 
* range of motion (ROM) testing
* strength testing
* tone assessment
* balance testing
* gait analysis and functional movement assessment
* general appearance of the limb to rule out concerns beyond orthopaedic issues, such as muscle atrophy, oedema, erythema, or a difference in temperature between the lower limbs
 
 
 
When assessing for sources of torsional conditions, it is important to consider factors that could affect the alignment of the lower quarter. This could include the following.<ref name=":1" />[[File:Foot Progression Angle.png|thumb|316x316px|Foot Progression Angle]]'''Foot progression angle''' (FPA): the angular difference between the axis of the foot and the line of progression during gait (see image).<ref name=":1" />


* Range of Motion (ROM)
* In-toeing is expressed as a negative value
* Strength testing
* Out-toeing is expressed as a positive value
* Tone assessment
* FPA is variable during infancy
* Balance testing
* Mean value in children: +10° (range -3 to +2-)
* Gait analysis and functional movement assessment
* Severity of in-toeing in children:
* General appearance of the limb to rule out concerns beyond an orthopedic issues such as muscle atrophy, oedema, erythema, or difference in temperature between the lower limbs
** Mild  −5° to −10°
** Moderate −10° to −15°
** Severe more than −15°


'''Femoral version''': rotation of the neck of the femur in relation to the femoral condyles at the level of the knee. At times, femoral version is combined with femoral torsion (a physical torsion or twist in the shaft of the femur). Femoral torsion will also cause a change in the angle between the neck of the femur and the femoral condyles.<ref name=":1" />


When assessing for sources of torsional conditions, it is important to consider factors that could affect the alignment of the lower quarter, this can include:<ref name=":1" />
* '''[[Craig's Test|Craig's test]]''' (also known as the Trochanteric Prominence Angle Test) is a passive test that is used to measure femoral anteversion or forward torsion of the femoral neck.<ref>Scorcelletti M, Reeves ND, Rittweger J, Ireland A. [[/onlinelibrary.wiley.com/doi/full/10.1111/joa.13249|Femoral anteversion: significance and measurement.]]Journal of Anatomy. 2020 Nov;237(5):811-26.</ref>


# '''Foot progression angle''' (FPA) is the angular difference between the axis of the foot and the line of progression during gait.<ref name=":1" />
'''Hip rotation range of motion''' <ref name=":1" />
##* [[File:Foot Progression Angle.png|thumb|316x316px|Foot Progression Angle]]In-toeing is expressed as a negative value
 
##* Out-toeing is expressed as a positive value
* '''Lateral hip rotation''' (LHR) - also known as external rotation of the hip. Femoral retroverison is indicated by increased external rotation compared to internal rotation
##* FPA is variable during infancy
* '''Medial hip rotation''' (MHR) - also known as internal rotation of the hip. Femoral anteverison is indicated by increased internal rotation compared to external rotation
##* Mean value in children: +10° (range -3 to +2-)
 
##* Severity of in-toeing in children:
'''Thigh-foot angle''' (TFA): a means to measure tibial torsion.<ref name=":1" />
##** Mild  −5° to −10°
 
##** Moderate −10° to −15°
* To measure internal or external tibial torsion, the patient is positioned in prone lying with their knees flexed to 90°. The TFA is measured between the line bisecting the posterior thigh and another line bisecting the foot.<ref>Stuberg W, Temme J, Kaplan P, Clarke A, Fuchs R. Measurement of tibial torsion and thigh-foot angle using goniometry and computed tomography. Clinical orthopaedics and related research. 1991 Nov 1;272:208-12.</ref>
##** Severe more than −15°
** Normal TFA is between 0° to 30°
# '''Femoral version''' refers to the rotation of the neck of the femur in relation to the femoral condyles at the level of the knee.  Femoral version at times is combined with femoral torsion (a physical torsion or twist in the shaft of the femur).  Femoral torsion will also cause a change in the angle between the neck of the femur and the femoral condyles.<ref name=":1" />
** External tibial torsion is a TFA of more than 30°
#** '''[[Craig's Test|Craig's test]]''' (also known as Trochanteric Prominence Angle Test)is a passive test that is used to measure femoral anteversion or forward torsion of the femoral neck.<ref>Scorcelletti M, Reeves ND, Rittweger J, Ireland A. [[/onlinelibrary.wiley.com/doi/full/10.1111/joa.13249|Femoral anteversion: significance and measurement.]]Journal of Anatomy. 2020 Nov;237(5):811-26.</ref>   
** Internal tibial torsion is a TFA of less than 0°
# '''Hip rotation range of motion''' <ref name=":1" />
 
#** '''Lateral hip rotation''' (LHR) also known as external rotation of the hip. Femoral retroverison indicated by increased external rotation compared to internal rotation
'''Transmalleolar axis''' (TMA): another way to measure tibial torsion.<ref name=":1" />
#** '''Medial hip rotation''' (MHR) also known as internal rotation of the hip. Femoral anteverison indicated by increased internal rotation compared to external rotation
 
# '''Thigh-foot angle''' (TFA) is a means to measure tibial torsion.<ref name=":1" />  
* To measure internal or external tibial torsion, the patient is positioned in prone lying with their knees flexed to 90°. Their ankle is in neutral and the sole of their foot is parallel to the floor. The TMA is measured between the line bisecting the longitudinal axis of the thigh and the line perpendicular to the axis between the most prominent portions of the medial and lateral malleolus.<ref>Lee SH, Chung CY, Park MS, Choi IH, Cho TJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2706340/ Tibial torsion in cerebral palsy: validity and reliability of measurement]. Clinical Orthopaedics and Related Research®. 2009 Aug;467:2098-104.</ref>
#** To measure internal or external tibial torsion, the patient is positioned in prone lying with knees flexed to 90°. TFA is measured between the line bisecting the posterior thigh and another line bisecting the foot.<ref>Stuberg W, Temme J, Kaplan P, Clarke A, Fuchs R. Measurement of tibial torsion and thigh-foot angle using goniometry and computed tomography. Clinical orthopaedics and related research. 1991 Nov 1;272:208-12.</ref>
 
#*** Normal TFA is between 0° to 30°
'''Forefoot alignment'''<ref name=":1" />
#*** External tibial torsion is a TFA more than 30°
#*** Internal tibial torsion is a TFA less than 0°
# '''Transmalleolar axis''' (TMA) is another means to measure tibial torsion.<ref name=":1" />
##* To measure internal or external tibial torsion, the patient is positioned in prone lying with knees flexed to 90°, the ankle in the neutral position, and the sole of the foot parallel to the floor. TMA is measured between the line bisecting the longitudinal axis of the thigh and the line perpendicular to the axis between the most prominent portions of the medial and lateral malleolus.<ref>Lee SH, Chung CY, Park MS, Choi IH, Cho TJ. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2706340/ Tibial torsion in cerebral palsy: validity and reliability of measurement]. Clinical Orthopaedics and Related Research®. 2009 Aug;467:2098-104.</ref>
# '''Forefoot alignment''' <ref name=":1" />


=== Other Diagnostic Tests ===
=== Other Diagnostic Tests ===
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=== Femoral Torsion Treatment ===
=== Femoral Torsion Treatment ===
# '''Bracing with strapping and compression'''. 
'''Bracing with strapping and compression''':
#* [https://theratogs.com TheraTogs]
* [https://theratogs.com TheraTogs]
#* Can improve gait quality when wearing the device, however lacking evidence based support. Carryover and consistency with device outside of the clinic is vital for long-time positive outcomes.
* Can improve gait quality when wearing the device, but there is a lack of evidence-based support. Carryover and consistency with wearing the device outside of the clinic is vital for long-time positive outcomes.
# '''Encourage ring-sitting and avoid/discourge W-sitting'''
'''Encourage ring-sitting and avoid/discourge W-sitting'''
# '''Surgical correction'''
 
#* '''Femoral denotation osteotomy''' if significant femoral anteversion is still present at ages 10 to 14 years old. This is a highly invasive surgery and should only be considered if the child is having significant safety and fall issues, is unable to keep up with their peers, has severe hip and/or knee pain, or showing signs of a femoral acetabular impingement.  
'''Surgical correction: femoral denotation osteotomy''' considered if significant femoral anteversion is still present in children aged 10 to 14 years. This is a highly invasive surgery and should only be considered if the child is having significant safety and fall issues, is unable to keep up with their peers, has severe hip and/or knee pain, or is showing signs of a femoral acetabular impingement.


=== Tibial Torsion Treatment ===
=== Tibial Torsion Treatment ===
Tibial torsion occurs as part of typical development, however, because there is a small percentage of children who do not improve and can have resulting significant functional deficits.<ref name=":1" />
Tibial torsion can occur as part of typical development, but a small percentage of children do not improve and can have resulting significant functional deficits.<ref name=":1" />  
 
# '''Splinting and/or bracing''' <ref name=":1" />
#* '''Friedman counter splint''': a dynamic splint consisting of a belt around the posterior heels which allows for motion in all planes except internal rotation.<ref name=":5">Musculoskeletal Key. Pediatrics. Available from: https://musculoskeletalkey.com/pediatrics-8/ (accessed 25 October 2023).</ref>
#* '''Denis Browne bar''': a bar is attached to the soles of the child's shoes, it is used to treat metatarsus adductus, convex pes planovalgus, and positional abnormalities of the leg.<ref name=":5" />
#* '''Wheaton brace''':is similar in appearance to an ankle foot orthosis (AFO) but has a medial flare to abduct the forefoot.  can be used as an alternative to serial casting for the treatment of metatarsus adductus.<ref name=":5" />
# '''Surgical correction'''
#* '''External rotational osteotomy of the tibia and fibula.''' Surgical management can be indicated for children that are greater than six to eight years old who have functional problems and a thigh-foot angle of more than 15°.<ref name=":1" />


== Resources  ==
'''Splinting and/or bracing'''<ref name=":1" />
* '''Friedman counter splint''': a dynamic splint consisting of a belt around the posterior heels which allows for motion in all planes except internal rotation.<ref name=":5">Musculoskeletal Key. Pediatrics. Available from: https://musculoskeletalkey.com/pediatrics-8/ (accessed 25 October 2023).</ref>
* '''Denis Browne bar''': a bar is attached to the soles of the child's shoes. It is used to treat metatarsus adductus, convex pes planovalgus, and positional abnormalities of the leg.<ref name=":5" />
* '''Wheaton brace''': similar in appearance to an ankle foot orthosis (AFO), but it has a medial flare to abduct the forefoot. It can be used as an alternative to serial casting for the treatment of metatarsus adductus.<ref name=":5" />
'''Surgical correction: external rotational osteotomy of the tibia and fibula.''' Surgical management can be indicated for children who are aged more than six to eight years old and who have functional problems and a thigh-foot angle of more than 15°.<ref name=":1" />


==== Optional Physiopedia Page Reading: ====
== Optional Additional Resources  ==
*[[Biomechanical Assessment of Foot and Ankle]]
*[[Biomechanical Assessment of Foot and Ankle]]
*[[Craig's Test]]
*[[Craig's Test]]

Revision as of 03:08, 21 November 2023

Original Editor - Stacy Schiurring based on the course by Krista Eskay
Top Contributors - Stacy Schiurring, Jess Bell and Kim Jackson

Introduction[edit | edit source]

Paediatric lower extremity and gait concerns are common reasons for visits to paediatricians and therapy services.[1][2][3][4][5] They can account for up to 16% of all new paediatric orthopaedic surgeon referrals.[6] Parents commonly worry about in-toeing or that their child might be delayed in meeting developmental milestones because of lower extremity or gait conditions.[1] [2][4] In-toeing typically resolves with skeletal maturity. However, out-toeing can be a more persistent condition.[6] It is, therefore, important that rehabilitation professionals understand typical and atypical lower extremity development, and when to initiate a referral to a paediatrician or orthopaedic surgeon.

Torsion of the lower extremity can be the "summation of anatomic axial (transverse) plane tilt or twist between the ends of the bones, capsular laxity or tightness, and muscular control during growth."[2]

This article summarises the pathophysiology, clinical presentation and assessment of lower extremity torsional conditions and basic rehabilitation interventions.

Torsional Conditions[edit | edit source]

Femoral Torsion[edit | edit source]

In newborns, internal femoral torsion of up to 40° can be considered typical. External femoral torsion can also be prominent and considered typical at birth.[7]

Special Topic: what is the Difference between femoral torsion and femoral version?[edit | edit source]

Version and torsion are not identical conditions, but they may both occur at the same time.[3][8]

Torsion is a "structural, osseous state of twist in a bone along its longitudinal axis."[8]

  • Femoral antetorsion (medial femoral torsion): when the femur has a medial twist of the distal-on-proximal ends.
  • Femoral retrotorsion (lateral femoral torsion): a deformity that ranges from a lack of typical femoral medial torsion to a true lateral twist of the distal-on-proximal ends of the femur.

Version describes "a position in space relative to a plane"[8] of motion and refers to the rotation of the neck of the femur in relation to the femoral condyles at the level of the knee.[3]

  • Femoral anteversion: decreased angle between the neck of the femur and the femoral condyles. Normal anteversion of the femoral neck is approximately 15°. Femoral anteversion is more common than femoral retroversion.[3]
  • Femoral retroversion: increased angle between the neck of the femur and the femoral condyles.[3]

Tibial Torsion[edit | edit source]

  • Internal tibial torsion is common in children less than four years old, and it typically presents as internal rotation of the tibia and in-toeing gait.
  • Often resolves spontaneously by four-years of age; less than 1% of torsional deformities fail to resolve in childhood.
  • Tibial torsions are often associated with (1) increased incidence of knee osteoarthritis later in life and (2) increased incidence of osteochondritis dissecans. They can also be a predisposing factor for (3) Osgood-Schlatter syndrome in male athletes.[3]

What is the Source of the Rotation?[edit | edit source]

Some mild in-toeing and out-toeing can occur in typically developing children. Therefore, it is important to differentiate between what is typical and what is atypical as part of the lower extremity assessment. If in- or out-toeing is found to be atypical, the next step is to determine which components of the lower extremity are the source of the torsional condition, and intervene at that level.[3]

Components that can contribute to in-toeing:

  • femoral anteversion
  • internal tibial rotation
  • metatarsus adductus


Components that can contribute to out-toeing:

  • external rotation contractures of the hip
  • femoral retroversion (rare)
  • external tibial rotation
  • calcaneovalgus
  • Genu Valgum Varum - Shutterstock.jpg
  • Metatarsus adductus.jpeg
  • Tibial torsion.jpeg
  • In and out-toeing.jpeg

Rehabilitation Examination for Torsional Conditions[edit | edit source]

Past Medial History[edit | edit source]

The evaluation / subjective interview for torsion considerations is similar to those for most lower extremity orthopaedic concerns.[3] It will cover the following areas:

  • child's birth history (premature versus full term)
  • orthopaedic or neurological concerns
  • developmental milestone history or concerns
  • child's age when in or out-toeing was first observed
  • significant family history, especially torsional or orthopaedic conditions
  • previous interventions
  • the child's common sleeping and sitting positions
  • when the child started to walk independently and how long they have been walking

Clinical pearl: can a child's sitting and sleeping positions exacerbate torsional conditions?[edit | edit source]

Literature reviews have identified certain "myths in pediatric orthopedics" surrounding topics such as in and out-toeing, W-sitting, and toe-walking. These are common positions/conditions and can be examples of normal variations in growth and development in young children.[9]

  • "Femoral and tibial torsion typically improve in the first 10–14 years of life. Bracing has shown no benefit over the natural course, and is not recommended."[9]
  • "W-sitting is a comfortable seating position for children with femoral anteversion[3] [9] and increased internal hip rotation. W-sitting does not cause hip dysplasia, nor is there evidence to support the concern that it may cause future functional deficits."[9]

However, for a small percentage of patients, certain positions, such as W-sitting, can exacerbate torsion. This is due to the ground reaction forces in this position, which encourage the limb into more external rotation (when the patient is still in the early bone modelling stages of development).[3]

A referral is warranted if the patient exhibits moderate to severe deformity, lack of resolution or worsening with time, pain, or functional impairments.[9][5]

Physical Assessment[edit | edit source]

The general assessment should include:[3]

  • range of motion (ROM) testing
  • strength testing
  • tone assessment
  • balance testing
  • gait analysis and functional movement assessment
  • general appearance of the limb to rule out concerns beyond orthopaedic issues, such as muscle atrophy, oedema, erythema, or a difference in temperature between the lower limbs


When assessing for sources of torsional conditions, it is important to consider factors that could affect the alignment of the lower quarter. This could include the following.[3]

Foot Progression Angle

Foot progression angle (FPA): the angular difference between the axis of the foot and the line of progression during gait (see image).[3]

  • In-toeing is expressed as a negative value
  • Out-toeing is expressed as a positive value
  • FPA is variable during infancy
  • Mean value in children: +10° (range -3 to +2-)
  • Severity of in-toeing in children:
    • Mild  −5° to −10°
    • Moderate −10° to −15°
    • Severe more than −15°

Femoral version: rotation of the neck of the femur in relation to the femoral condyles at the level of the knee. At times, femoral version is combined with femoral torsion (a physical torsion or twist in the shaft of the femur). Femoral torsion will also cause a change in the angle between the neck of the femur and the femoral condyles.[3]

  • Craig's test (also known as the Trochanteric Prominence Angle Test) is a passive test that is used to measure femoral anteversion or forward torsion of the femoral neck.[10]

Hip rotation range of motion [3]

  • Lateral hip rotation (LHR) - also known as external rotation of the hip. Femoral retroverison is indicated by increased external rotation compared to internal rotation
  • Medial hip rotation (MHR) - also known as internal rotation of the hip. Femoral anteverison is indicated by increased internal rotation compared to external rotation

Thigh-foot angle (TFA): a means to measure tibial torsion.[3]

  • To measure internal or external tibial torsion, the patient is positioned in prone lying with their knees flexed to 90°. The TFA is measured between the line bisecting the posterior thigh and another line bisecting the foot.[11]
    • Normal TFA is between 0° to 30°
    • External tibial torsion is a TFA of more than 30°
    • Internal tibial torsion is a TFA of less than 0°

Transmalleolar axis (TMA): another way to measure tibial torsion.[3]

  • To measure internal or external tibial torsion, the patient is positioned in prone lying with their knees flexed to 90°. Their ankle is in neutral and the sole of their foot is parallel to the floor. The TMA is measured between the line bisecting the longitudinal axis of the thigh and the line perpendicular to the axis between the most prominent portions of the medial and lateral malleolus.[12]

Forefoot alignment[3]

Other Diagnostic Tests[edit | edit source]

  • X-ray imaging
  • Magnetic resonance imaging (MRI)
  • Computed tomography (CT) scan
  • Bone scans
  • Laboratory tests such as blood work[3]

Treatment Options for Torsional Conditions[edit | edit source]

Femoral Torsion Treatment[edit | edit source]

Bracing with strapping and compression:

  • TheraTogs
  • Can improve gait quality when wearing the device, but there is a lack of evidence-based support. Carryover and consistency with wearing the device outside of the clinic is vital for long-time positive outcomes.

Encourage ring-sitting and avoid/discourge W-sitting

Surgical correction: femoral denotation osteotomy considered if significant femoral anteversion is still present in children aged 10 to 14 years. This is a highly invasive surgery and should only be considered if the child is having significant safety and fall issues, is unable to keep up with their peers, has severe hip and/or knee pain, or is showing signs of a femoral acetabular impingement.

Tibial Torsion Treatment[edit | edit source]

Tibial torsion can occur as part of typical development, but a small percentage of children do not improve and can have resulting significant functional deficits.[3]

Splinting and/or bracing[3]

  • Friedman counter splint: a dynamic splint consisting of a belt around the posterior heels which allows for motion in all planes except internal rotation.[13]
  • Denis Browne bar: a bar is attached to the soles of the child's shoes. It is used to treat metatarsus adductus, convex pes planovalgus, and positional abnormalities of the leg.[13]
  • Wheaton brace: similar in appearance to an ankle foot orthosis (AFO), but it has a medial flare to abduct the forefoot. It can be used as an alternative to serial casting for the treatment of metatarsus adductus.[13]

Surgical correction: external rotational osteotomy of the tibia and fibula. Surgical management can be indicated for children who are aged more than six to eight years old and who have functional problems and a thigh-foot angle of more than 15°.[3]

Optional Additional Resources[edit | edit source]

References[edit | edit source]

  1. ↑ 1.0 1.1 Kahf H, Kesbeh Y, van Baarsel E, Patel V, Alonzo N. Approach to pediatric rotational limb deformities. Orthopedic Reviews. 2019 Sep 9;11(3).
  2. ↑ 2.0 2.1 2.2 BMJ Best Practice. Torsion of the Lower Limb in Children. Available from: https://bestpractice.bmj.com/topics/en-us/748 (accessed 14/October/2023).
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19 3.20 3.21 Eskay K. Paediatric Physiotherapy Programme. Paediatric Lower Extremity Torsional Conditions Course. Plus, 2023.
  4. ↑ 4.0 4.1 Cao LA, Wimberly L. When to Be Concerned About Abnormal Gait: Toe Walking, In-Toeing, Out-Toeing, Bowlegs, and Knock-Knees. Pediatric Annals. 2022 Sep 1;51(9):e340-5.
  5. ↑ 5.0 5.1 Kainz H, Mindler GT, Kranzl A. Influence of femoral anteversion angle and neck-shaft angle on muscle forces and joint loading during walking. Plos one. 2023 Oct 12;18(10):e0291458.
  6. ↑ 6.0 6.1 Chandrananth J, Hannan R, Bouton D, Raney E, Sienko S, Do P, Bauer JP. The Effects of Lower Extremity Rotational Malalignment on Pediatric Patient-reported Outcomes Measurement and Information System (PROMIS) Scores. Journal of Pediatric Orthopedics. 2022 Sep;42(8):e889.
  7. ↑ Merck Manual. Femoral Torsion (Twisting). Available from: https://www.merckmanuals.com/professional/pediatrics/congenital-craniofacial-and-musculoskeletal-abnormalities/femoral-torsion-twisting (accessed 24 October 2023).
  8. ↑ 8.0 8.1 8.2 Cusick BD, Stuberg WA. Assessment of lower-extremity alignment in the transverse plane: implications for management of children with neuromotor dysfunction. Physical therapy. 1992 Jan 1;72(1):3-15.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 Honig EL, Haeberle HS, Kehoe CM, Dodwell ER. Pediatric orthopedic mythbusters: the truth about flexible flatfeet, tibial and femoral torsion, W-sitting, and idiopathic toe-walking. Current Opinion in Pediatrics. 2021 Feb 1;33(1):105-13.
  10. ↑ Scorcelletti M, Reeves ND, Rittweger J, Ireland A. Femoral anteversion: significance and measurement.Journal of Anatomy. 2020 Nov;237(5):811-26.
  11. ↑ Stuberg W, Temme J, Kaplan P, Clarke A, Fuchs R. Measurement of tibial torsion and thigh-foot angle using goniometry and computed tomography. Clinical orthopaedics and related research. 1991 Nov 1;272:208-12.
  12. ↑ Lee SH, Chung CY, Park MS, Choi IH, Cho TJ. Tibial torsion in cerebral palsy: validity and reliability of measurement. Clinical Orthopaedics and Related Research®. 2009 Aug;467:2098-104.
  13. ↑ 13.0 13.1 13.2 Musculoskeletal Key. Pediatrics. Available from: https://musculoskeletalkey.com/pediatrics-8/ (accessed 25 October 2023).
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