Tibial Torsion

Introduction

Torsion refers to a twist in the bone. Tibial torsion occurs when there is a twist in the lower leg bone (tibia). The tibia can either twist inward, called internal tibial torsion, or outward, called external tibial torsion. Males and females are affected equally.

Cause

Internal tibial torsion can occur before birth when the legs internally rotate to fit in the womb, as early as 7 weeks into fetal development. It can be associated with tibia vara or a severe bowleg condition called Blount’s disease.

External tibial torsion can occur on its own or be associated with other medical conditions including cerebral palsy. It commonly occurs with bowlegs and with femoral torsion (anteversion).

Torsion in both directions can be associated with a number of other conditions or limb deformities, such as cerebral palsy, hip dysplasia and neuromuscular disorders. Most torsion is idiopathic (unknown cause).

Symptoms

Tibial torsion can cause a patient to walk with their toes pointing inward (called in-toeing) or outward (called out-toeing) instead of pointing straight ahead.

In-toeing is often noticed by parents when children first begin walking. It is usually painless. Children may appear clumsy, trip often, and run awkwardly.

Out-toeing is also often noticed by parents. Out-toeing can be associated with other conditions. When it is associated with femoral anteversion (inward twist of the femur), there can be knee problems such as patellar (knee cap) instability and pain. External tibial torsion may be seen with symptomatic flat feet and tarsal coalitions.

In adults, tibial torsion can lead to difficulty running and may be a risk factor for ankle and knee injuries in sports. Patients can complain of the inability to align their feet and knees in yoga and difficulty riding a bicycle.

Doctor Examination (physical exam, imaging studies, tests)

Your doctor will obtain your family history, as rotational deformity often runs in families. Your doctor will also exam your gait or how you walk.  They will also examine the lower extremities for range of motion, pain and assess the rotation of the femur and tibia, oftentimes with the child face down on the exam table.

Imaging studies are usually not necessary, but occasionally an MRI or CT scan may be obtained to further evaluate the rotation of the femurs and tibias, generally in preparation for surgery.

Non-surgical Treatment

Internal tibial torsion in young children usually improves on its own with growth. Special shoes, braces, orthotics or exercises have not been shown to help.  Most of the internal torsion improvement occurs before school age. It is generally not associated with any significant problems.

External tibial torsion generally does not improve with growth and development but also does not cause symptoms in most children.

In both cases pain is generally not noted until the child is older, and physical therapy is commonly used and oftentimes will resolve the pain.

Physical therapy can also be used in adulthood but there are not effective bracing options. Many adults simply reduce their activity level to work around their torsional deformity.

Surgical Treatment

In children, there are uncommon cases where internal tibial torsion does not correct on its own and causes persistent symptoms such as tripping. External tibial torsion that causes significant functional problems or pain can be improved with surgery. Surgery involves cutting the tibia (an osteotomy) and turning it so the toes point forward. The bone can be held in position while it heals with wires, plates, screws, an internal nail, or an external fixator (halo) depending on patient age. A cast may be required as well to help the bone heal correctly. Surgery is usually reserved for older children and adult patients.

Patients can have more trouble with tibial torsion when they reach adulthood. Surgical correction can get people active again and alleviate joint pain. It is thought that realignment surgery in patients with significant symptoms might decrease their risk of future arthritis. Although osteotomy surgery sounds daunting it has become routine and acceptably safe with good results.

Tibial torsion in association with other limb deformities is more commonly symptomatic. In these cases the torsion is generally corrected along with the remainder of the deformity. For example, tibial torsion and bowlegs can be corrected through the same osteotomy, and tibial torsion and femoral anteversion are corrected through a tibial and femoral osteotomy.