Serial casting for internal tibial torsion

Kate Roberts · Nov 12, 2004

Members do not see these Ads. Sign Up.
Advice is needed here. I have been doing some reading on paediatric lower limb rotational problems. With respect to internal tibial position, this appears to be a condition only recognised by podiatry and even within podiatry, recognition and treatment via serial casting appears to be out of fashion.

Does anyone have any opinion, suggestions and/or knowledge of this subject?

Kate

admin · Nov 18, 2004

This message was cross posted on JSIC Podiatry Mal list. Here are 3 responses:

Try your paediatric physiotherapy department as they are the ones
who normally do this type of work along with clubfoot casting/taping.

Regards
John Bickerstaffe
Click to expand...

I would be interested in knowing how a serial cast can be applied to the
lower limb to provide a derotational force directly to the bone.
As far as I am aware an Ilizarov frame can do this, but in my experience
of serial casting, a full length leg castwith a bisection to allow the
external rotation of the tibia is fraught with problems.
Again I would ask the question why attempt to treat a condition in
patients without neurological involvement, where the condition resolves
without intervention and little evidence in the efficacy of intervention
Tony Achilles
Click to expand...

I certainly agree that applying a torque directly to the bone is
impossible. The question is where is the force applied when you have an
above the knee cast with the foot abducted. Certainly there will be an
abduction moment of the forefoot on the rearfoot. An abduction moment on
the forefoot will also apply an abduction moment on the rearfoot. It would
be hard to apply the moment to just the rearfoot. A moment on the rearfoot
would cause external rotation moment on the talus relative to the
tibia. This would be transmitted proximally as well to the structures
that resist rotation at the knee. Now the question is which structures
will change in response to these stresses. I don't know.

Cheers,
Eric Fuller
Click to expand...

admin · Nov 18, 2004

Another reply:

Dear Kate,

As you probably know, if two podiatrists from different schools look at a patient they may see 2 totally different things. If a podiatrist was trained at the Philadelphia College with Dr. Ganley, part of the pediatric in toe evaluation was to check for rotation of the tibia with the knee bent to 90 degrees. If there was an excessive amount of internal rotation relative to external rotation, it was called pseudomalleolar torsion. This term was used because they realized that the in toe was coming from the knee.
At the New York college with Dr. Tax, this was not done. Instead the malleolar position was noted, and if it was too internally rotated, treatment was instituted to decrease this "tibial torsion" with a Denis-Browne bar. One of the tricks with this device is to bend the bar, so the foot cannot pronate. This way the force is directed past the foot.
The concept that this internal rotation below the knee would out grow was started by Le Damany in his book Le Torsion de la Tibia in the early 1900's. He examined 6 adults and found none had internal rotation below the knee, therefore all people out grew it. I have seen this in some adults, so I have to disagree with him.
What is going on is that the knee has two basic movements. One is flexion-extension, and the other is internal rotation of the tibia with varus-external rotation of the tibia with valgus.
Babies are born with an internal rotated tibia that is in varus, and they are supposed to externally rotate and go into a more valgus attitude. If at 18 months this has not occurred, then it is not unreasonable to use the Denis-Browne bar. The bending of the bar also negates the valgus forces on the knee, so clinically we find more torsional correction.
The Denis-Browne bar can be used up until about 3 years of age, at which time the child learns to untie double knots and takes it off.

Stanley
Click to expand...

admin · Nov 18, 2004

Another response:

Kate and Colleagues:

Kate wrote:
<<"Advice is needed here. I have been doing some reading on paediatric lower
limb rotational problems. With respect to internal tibial position, this
appears to be a condition only recognised by podiatry and even within
podiatry, recognition and treatment via serial casting appears to be out of
fashion.
Does anyone have any opinion, suggestions and/or knowledge of this
subject?">>

A comment needs to be made regarding podiatry only recognizing internal tibial position. Does any other specialty recognize a plantarflexed first ray? Does any other specialty recognize a medially deviated subtalar joint axis? Does any other specialty recognize functional hallux limitus?

This brings to mind one of my favorite sayings in this regard that has been passed on to me from one of my old podiatry students that, in turn, heard a similar type of comment from a wise old orthopedic surgeon friend of his:

"Don't worry, even though you may not have ever seen internal tibial position before, it has seen you many times."

Cheers,

Kevin
****************************************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA

Voice: (916) 925-8111 Fax: (916) 925-8136
****************************************************************************
Click to expand...

Kate Roberts · Nov 18, 2004

internal tibial position

I will have mislead people by mentioning both internal tibial torsion and position. Orthopaedics and Physio do recognise the torsion but not the position. I have discussed it with my local orthopaedic paediatric consultant who is interested in the concept of internal tibial position but is not aware of it as a condition that may need serial casting. The physio who works with him only does serial casting for talipes conditions. It has become an issue for my dept because the role of serial casting for internal tibial position has been taken away from Podiatry based on a lack of evidence. There is now a drive by this consultant to include podiatrists in his paediatric orthopaedic clinic re serial casting for metatarsus adductus and if the evidence supports it, perhaps internal tibial position. I have tried to find evidence re this but it is quite old. If anyone out there is doing such work I would appreciate the cahnce of discussing it with you.

admin · Nov 19, 2004

Another response from JISC Podiatry:

Dear Stanley,

In regard to the statement ,< The concept that this internal rotation below the knee would out grow was started by Le Damany in his book Le Torsion de la Tibia in the early 1900's>

There have been several studies indicating the normal process of external rotation in correcting tibial torsion,which it has to be remembered is not a pathological process, but a normal variant of intra-uterine development. In the presence of delayed external rotation there is no evidence to demonstrate splinting makes a difference, in fact quite the opposite (Orthopedics. 1991 Jun;14(6):655-9. Lower extremity torsional deformities in children: a prospective comparison of two treatment modalities)

In regard to the Denis Browne, again I have a problem in determining how by applying the bar, inverting the feet to prevent pronation, externally rotating the leg, i.e. at the hip, applies an external torque to the tibia?

Tony Achilles
Click to expand...

Tony,

I haven't read the article that you quoted, so I am at a loss to answer this part of your query about the efficacy of this treatment. I would appreciate it if you could post the abstract of the article.

Regarding the question of the external torque on the tibial, I stated that this is probably done at the level of the knee. The shoes on the bar are eventually placed in an abducted postilion. This has to be absorbed somewhere in the leg. The subtalar joint is one place that it can be absorbed, but by inverting the feet, we supinate the subtalar joint and prevent the abduction associated with pronation. Next up the chain is the tibial, and I am sure this is not where the force is absorbed. Next is the knee, and it has a large enough range of motion with the knee flexed to absorb this positional change. After this, there is not anything left to rotate the hip, so this is not the indicated treatment in internal femoral position.

Stanley
Click to expand...

Thanks to the authors for permission to copy these messages.

admin · Nov 19, 2004

Another post:

Stanley,

As requested:

(Orthopedics. 1991 Jun;14(6):655-9. Lower extremity torsional deformities in children: a prospective comparison of two treatment modalities)

“A prospective randomized analysis was conducted on children with lower extremity torsional deformities. Its purpose was to define the natural history of these anomalies and to determine the efficacy of treatment with a Denis-Browne splint. The natural history of pediatric lower extremity torsional deformities is to correct toward the mean of the population. The Denis-Browne splint did not alter the natural history of lower extremity torsional deformities as defined by the foot progression angle.”

In relation to the application of the external torque applied by the bar, the degree of external rotation available at the knee is extremely limited in relation to the hip, therefore assuming the torque applied will occur at the point of least resistance, i.e. if you externally rotate your feet, the rotation occurs at the hip.

Allowing even for the fact that if the external torque occurs at the knee, the deformation due to stress applied to the ligaments seems a high price to pay, particularly when the underlying tibial torsion has not been affected

regards
Tony Achilles
Click to expand...

admin · Nov 20, 2004

Another reply:

Tony,

Thanks for the abstract.
So the way you see it is:
There is no reason to use a DB bar, because the legs correct and all we can do is cause damage to the knee. Furthermore the hips absorb all the motion.

I have used Denis-Browne bars for 26 years and found it to be a useful therapy.

The pediatric orthopedist at the Cleveland Clinic has lectured to the podiatry students at the Ohio College and has said that the tibial torsion will correct by themselves, and if not he has a simple procedure that he has used several times to correct it. He used a drill and makes several holes in the tibia percutaneously. When he has enough holes, he twists the leg, and he hears a crack and he positions the leg and places a cast on it.

Regarding the damage at the knee, I have never seen it D-B bars do not put an extreme force on the leg, on the contrary it is never placed at more than 45 degrees out on each foot and it takes a few months to increase the position to this point. It is a way to change the bad sleeping position that some children assume. I have seen a device that has caused damage to the subtalar, ankle and knee joint, and this is a twister cable.

The article states "the motion is absorbed by the hip". This is not correct, because anyone that has used a DB bar knows that it does not correct internal femoral position. Furthermore, the child sleeps with the knee bent, so there is an adequate range of motion in the knee to absorb this motion. It makes no sense that an external rotatory force on the foot will skip over the knee and go to the hip.

I haven't read the entire article, so I would be curious as to how the study was performed. How was the D-B bar applied and for how long? Does it explain where the change in the malleolar position occurs? Does it take into account the changes in the hip which are going in the opposite direction?

Respectfully,

Stanley
Click to expand...

admin · Nov 20, 2004

More replies:

Dear Dr. Stanley

You astound me. You state that you do not use the DB bar because it hurt
the knee and in the same breath you say the hip absorb the motion.

I read this as the hips absorb the motion.

I cannot understand how a solid object absorbs any energy without coming
second eventually.

Could you please explain to me what you mean by this?

Thank you.

PAul Conneely
Click to expand...

Dear Paul,

Thank you for your astute observations. That is exactly my point, but I didn't write it as clearly and to the point. You have made only one error. I didn't write that.I am the one who uses the DB bar. Please see below:

Stanley,
As requested:
(Orthopedics. 1991 Jun;14(6):655-9. Lower extremity torsional deformities in children: a prospective comparison of two treatment modalities)
A prospective randomized analysis was conducted on children with lower extremity torsional deformities. Its purpose was to define the natural history of these anomalies and to determine the efficacy of treatment with a Denis-Browne splint. The natural history of pediatric lower extremity torsional deformities is to correct toward the mean of the population. The Denis-Browne splint did not alter the natural history of lower extremity torsional deformities as defined by the foot progression angle.
In relation to the application of the external torque applied by the bar, the degree of external rotation available at the knee is extremely limited in relation to the hip, therefore assuming the torque applied will occur at the point of least resistance, i.e. if you externally rotate your feet, the rotation occurs at the hip.
Allowing even for the fact that if the external torque occurs at the knee, the deformation due to stress applied to the ligaments seems a high price to pay, particularly when the underlying tibial torsion has not been affected

regards

Tony Achilles
Click to expand...

Tony, Stanley, Kate and Colleagues:

Tony wrote:

<<There have been several studies indicating the normal process of external rotation in correcting tibial torsion,which it has to be remembered is not a pathological process, but a normal variant of intra-uterine development. In the presence of delayed external rotation there is no evidence to demonstrate splinting makes a difference, in fact quite the opposite (Orthopedics. 1991 Jun;14(6):655-9. Lower extremity torsional deformities in children: a prospective comparison of two treatment modalities).

In regard to the Denis Browne, again I have a problem in determining how by applying the bar, inverting the feet to prevent pronation, externally rotating the leg, i.e. at the hip, applies an external torque to the tibia.>>

Fortunately, during my podiatry school and Biomechanics Fellowship training, I got to spend a lot of time working closely with Ron Valmassy, DPM, who is a big advocate of using the Dennis Brown Bar (DBB). We saw many pediatric patients together during my Fellowship that had internal torsional problems of the lower extremity and we used the DBB quite regularly. The DBB, when properly used, will basically prevent the child from holding their feet in an abnormal internal position during their resting hours. This prevents an abnormal internal rotation moment from being applied to the segments of the lower extremity when the child sleeps that will tend to reinforce the internal rotation deformity of the foot and/or lower extremity during their waking hours. I am still not sure if the DBB truly accelerates any change in the malleolar torsion or tibial torsion in a child, but I still use it for a child when their parents are concerned about the intoed position of their child. I don't think it causes any harm to the child, as long as it is properly applied.

However, Tony, one thing that I am certain of is that it the DBB will apply an external rotation moment on the tibia and/or decrease the internal rotation moment on the tibia, compared to non-use of the DBB. Modeling this mechanical interaction within the lower extremity will show that when the DBB is applying an external rotation moment on the foot relative to the hip, that the tibia, and other segments of the lower extremity will also have an external rotation moment placed on them. The question becomes, however, is this external rotation moment of sufficient magnitude to accelerate the external rotation torsion within the shaft of the tibia in a child. My guess is that, in some children, yes, the DBB can externally rotate the tibia to some extent if correctly used. However, like all other mechanical therapies, incorrect use of the DBB probably causes more harm than good.

Cheers,

Kevin

****************************************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA

Voice: (916) 925-8111 Fax: (916) 925-8136
****************************************************************************
Click to expand...

admin · Nov 22, 2004

More responses:

Stanley, Kevin et al
I can accept that if you apply an external torque to the lower limb, once the hip has reached it's end ROM and the knee has been externally rotated as far as it's soft tissue structure and bony architecture will allow it, you will eventually apply an external torque to the proximal end of the tibia, but where does your 'correction' take place?

Stanley, you feel that the external rotation occurs at the knee, could you further explain this?

My concern is that in applying an external torque in the lower limb, where in a young child the acetabulum in relation to the head and neck of femur is in an externally rotated position, which subsequently reduces form 60 degrees to approx 10 degrees ext. rotated, what effect this external torque will have on the natural ontogenic development? The knees being in a flexed position will allow further external rotation at the knee, but surely the force will be applied along the path of least resistance i.e. the hip!

I find it very diffficult to comprehend the use of a "splint" in which there is no evidence to support it's use, and I do not doubt that lower limb external rotation occurs, but I find it unlikely to have occured within the tibia. For example a gait plate can alter an intoeing gait pattern by altering the line of progression, but it does not solve the underlying pathology.

respectfully

Tony Achilles
Click to expand...

Dear Paul,

Your sentiment regarding that if a compromise is made at one joint another suffers, is exactly what I am saying by the application of a splint that creates compensations elsewhere, but does little to correct the primary problem.

regards

Tony Achilles
Click to expand...

First of all, proper use of night splints (Denis Browne, Fillauer, Uni-bar, Ganley, etc) dictates that these devices **should not be applied** at the end of the external range of motion of the hip, since, indeed, this will likely result in some of the pathologies that you describe above. The idea is to hold the foot and lower extremity **in a less internally rotated position than the normal relaxed hip position but not at or beyond its external range of motion limit**. Ron Valmassy was very clear on this procedure when he taught it to us at CCPM. Ron's chapter on proper use of night splints goes into great detail as to the procedure that he recommends in regard to amount of correction that one should initially place into the night splint and how one should progress with the correction as time progresses (Valmassy RL: "Lower Extremity Treatment Modalities for the Pediatric Patient" in Valmassy RL (ed): Clinical Biomechanics of the Lower Extremities. Mosby, St. Louis, 1996, pp. 425-452).

Second, one does not need to be at the external range of motion limit of the foot and lower external extremity in order to achieve an external rotation moment on the tibia with a night splint. As long as the night splint is resisting an internal rotation moment of the foot and lower extremity, then, the tibia will have an external rotation moment being placed on it by the night splint. Those of you who saw my lecture on abductory twist at the PFOLA meeting in Boston may remember the video I showed demonstrating the elastic strain energy in the hip joint soft tissue elements that caused rapid external rotation of the whole lower extremity when released from an internally rotated position. Understanding these forces and moments allows one to better understand the mechanical effect of night splints when treating internal torsional problems in the pediatric patient. Biomechanical modeling of the mechanical effects of the night splints will clearly show that it places an external rotation moment on the tibia, if properly used.

Third, I don't have any problem comprehending the use of night splint in a growing child. Do orthodontists expect to achieve correction of bony structures of the jaw that surrounding the roots of the teeth by applying forces to the teeth over long periods of time in children? Doesn't the scientific literature support the fact that bones remodel (especially the bones of young children) depending on how stresses and where stresses are placed on them? Is this too much of a "leap of faith" to then hypothesize that a properly applied night splint might indeed change the tibial/malleolar torsion over time when it is worn for half of the hours of a day, months in a row?

I am wondering what is the podiatric clinician to do when a concerned parent brings their child in for help with significant torsional problems of the lower extremity? Do you just tell the parent that there is nothing you can do for their child since there is no evidence for its use, and then tell them that you will have to wait to see if they grow out of it and then perform surgery on them or live with the deformity it if they don't grow out of it? Or do you tell the parent that you will try this therapy that has been used for generations by many respected pediatric authorities with some success and that if this treatment doesn't work then we will know that we have at least tried our best to treat their child's condition without surgery?

And, please, don't get me started on discontinuing treatments that don't have sufficient evidence to support their use since this would effectively eliminate about 75% of the treatments that podiatrists use on a daily basis to help literally millions of patients with painful deformities and pathologies of the foot and/or lower extremities.

Cheers,

Kevin
Click to expand...

Tony,

Sorry I didn't make my self clear. What I originally wrote was "
.....the knee has two basic movements. One is flexion-extension, and the other is internal rotation of the tibia with varus-external rotation of the tibia with valgus.
Babies are born with an internal rotated tibia that is in varus, and they are supposed to externally rotate and go into a more valgus attitude. If at 18 months this has not occurred, then it is not unreasonable to use the Denis-Browne bar".

I hoped to show that this motion does occur at the knee. I also wrote that:
"...at the Philadelphia College with Dr. Ganley, part of the pediatric in toe evaluation was to check for rotation of the tibia with the knee bent to 90 degrees. If there was an excessive amount of internal rotation relative to external rotation, it was called pseudomalleolar torsion.

At the New York College we didn't learn this, but I think this is a very important part of the evaluation. This reinforces that the in toe is coming from the knee.

I agree that the tendency is to out grow the in toe from the knee, and when it is not, the prudent thing to do is to assist this. In my practice I look for the tibial varum with the lack of external malleolar position. If I see this then I realize the patient is just lagging behind. If I see the varus corrected and the lack of external malleolar position, then I think that there is something stopping the normal external out growing of this position. We typically help patients in this regard. If a patent has a tight gastrocnemius, we use night splints. If a patient has a tight external range of the knee, then we should use DB bars. One of the theories as to why the DB bar works is that it changes the sleeping position which prevents the normal derotation of the lower leg.

Respectfully,

Stanley
Click to expand...

admin · Nov 22, 2004

Stanley,In respect of pseudomalleolar torsion, isn't this a tibio-fibular rotation and doesn't the malleolar position continues to externally rotate for several years. A delay in ontogenic development does not necessarily mean that in the long term the rotation will not be achieved. In regard to the presence of tibial varum, this is primarily due to fat distribution, an X ray would show that the varus component is in fact much less than than is visually present.

In regard to your statement, that DB bars alter sleep position and therefore enable normal derotation, this I can see as a possibility,however, using a splint to change sleeping position and using it to apply external torque to the tibia are two completely different concepts respectfully Tony
Click to expand...

Kevin,
As I stated previously, it is possible to apply an external torque to the tibia, but this of course is going to be secondary to the torque being applied to the foot for example. Can you be sure that your correction is occuring in the right place?

I understand your stance in regard to treatment without the evidence, however, my concern here is that the possibility for complications outweighs the perceived improvements.

If you are using the DB bar to alter sleep position, and therefore enabling normal derotation to occur I can think of other ways that are less intrusive, e.g. place a pillow between the child's legs, not withstanding the fact that these days most infants are placed on their backs to reduce the incidence of SIDS.

Really enjoying the debate

Cheers

Tony
Click to expand...

Tony, Stanley and Colleagues:

Tony wrote: Kevin replies:

<<As I stated previously, it is possible to apply an external torque to the tibia, but this of course is going to be secondary to the torque being applied to the foot for example. Can you be sure that your correction is occuring in the right place?

No, I don't think anyone can be sure that the correction is occurring in the "right place" since the rotational force exerted by a night splint is applied through the foot to the pelvis, through all osseous and soft tissue structures that would tend to resist external rotation of the foot relative to the pelvis.

I understand your stance in regard to treatment without the evidence, however, my concern here is that the possibility for complications outweighs the perceived improvements.

Knowing Ron Valmassy very well as a friend and colleague, he would never perform a treatment that he thought would harm a child. He has treated far more children with night splints than I ever have or probably ever will. My personal experience with night splints is such that I am not convinced it is effective for all children but is at least worth a try if the parent is concerned or the deformity is very significant, to avoid a possible surgery and/or permanent gait pathology for their child. My belief, which I believe is shared by Dr. Valmassy, is that the potential for physical and psychological harm to the child with significant internal tibial/malleolar torsion is far greater with nontreatment than with treatment with night splints.

If you are using the DB bar to alter sleep position, and therefore enabling normal derotation to occur I can think of other ways that are less intrusive, e.g. place a pillow between the child's legs, not withstanding the fact that these days most infants are placed on their backs to reduce the incidence of SIDS.>>

Placing a pillow between the child's legs seems rather like a useless therapeutic measure, in my opinion. This therapy seems somewhat like treating a significant flatfoot deformity in a child with generic, over-the-counter arch supports. How does placing a pillow between a child's legs mechanically exert an external rotation moment on the tibia?

Always good to have a discussion with you, Tony. I respect your opinions in regards to pediatric foot and lower extremity pathologies and am also greatly enjoying the dialogue. By the way, Tony.....it was a pig. ;-)

Cheers,

Kevin

****************************************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA

Voice: (916) 925-8111 Fax: (916) 925-8136
****************************************************************************
Click to expand...

Tony,
This is an excellent question, and as a result of this discussion, I am going to look at something that which haven't but should have. I will check the malleolar position with relative to the knee joint axis, the malleolar position relative to tibial tuberosity, and the range of rotation with the knee flexed of the tibia. This will take me several years, as I don't have a very large pediatric practice.

All this aside, I tend to think it is occurring at the knee. When the concept of pseudomalleolar torsion came out, this was from the Philadelphia college and Dr. Ganley. They performed knee range of motion and if it was greater in internal rotation they called in pseudomalleolar torsion and casted it. They also stopped talking about internal tibial torsion (lack of external tibial torsion). What is interesting is that it was standard in the podiatric colleges to teach that there was a 5 degree difference between malleolar position and tibial position.

Regarding how the DB bars work, I think we are putting a mild torque on the leg. I start out with the feet pointed straight ahead and have the child wear it at night. This way the mother knows that if the child cries it is because of something foreign being applied. After the first week we increase the setting by about 10-15 degrees a week. Once in a while this adjustment will cause pain in the child, and the child will not sleep until the bar is taken off. Reapplication has the same result. So we decrease the correction for a few weeks and then we can reapply with the increased correction.

I am not sure the exact time that this process stops, but clinically I find that at about 4 years, we have reached the maximum. I know this is not the exact time and one of the more astute academicians will set me straight.

Regarding the tibia varum, it is present as a result of the intrauterine position. The fat may make it seem less, but it is present nonetheless.

Respectfully,

Stanley[/quote]

Tony and colleagues,

I just want to add a few things to what I wrote first of all I appreciate the fine line of questioning. This really helps to refine our thoughts in this area. Secondly, I am still bothered by the article you quoted. I would like to see it in its entirety, as I feel there is something that is important in it even though I cannot agree with its conclusions. I will go to the library tomorrow and get a copy to read. Finally, I have used the DB bar since I was a student at NYCPM in 1974. When I was a clinician at the Podopediatrics clinic at OCPM in 1978-1981, there were approximately 40 patient visits daily, mostly for "slewfootedness" and "flatfeet" and subsequently in practice. I haven't seen the joint laxity that you are rightfully concerned about. On the other hand, in a few severe cases, another podiatrist (who will remain nameless) used twister cables. I had the opportunity to evaluate these children, and it was enough to disgust me. The subtalar/ankle joint had horizontal movement that I still remember to this day. There was also transverse plane movement in the knee. Enough to concern me about a lifetime of arthritis. So I am painfully aware of your concerns.

By the way, while we are on the topic of in toe, I think I found that the reason for internal femoral position. During my fellowship, I read Fitzhugh's article on sitting position (I think here first name was

Margaret) written in the early 1900's. the question was why do these kids sit in the "W" position? I noticed that most of these kids were also clumsy, and when they started to walk (prior to developing the in toe), they would fall forwards and hit their knees and then their head, or they would fall backwards and hit their heads. It seems that they did not spend the normal 2 weeks in the sitting position at 6 months prior to crawling (the majority of these kids), or they took an exceptionally long time to walk, so they spent an exceptionally long time in the kneeling position. It seemed that the kids that sat but took a long time to walk did not have the clumsiness. My hypothesis is that the sitting position wires the balance and reflexes around the hips, so the child when he starts to walk can stick out his butt and land there. The child that misses sitting and therefore ends up kneeling gets wired around the knee, so when he loses his balance, he flexes his knee, which results in the falling. The rest of the hypothesis agrees with Fitzhugh. The treatment to get rid of the clumsiness, in addition to treating the internal femoral position, is to develop balance around the hips. I have the mother sit with the child and roll a ball back and forth to the child while the child is in the sitting position.

Respectfully,

Stanley
Click to expand...

THANKS to the authors for permission to cross post these messages.
Click to expand...

admin · Nov 23, 2004

More replies:

Kevin, Stanley and all,
In regard to my concerns as to where external torques are applied, this may help.

Moreland MS. Morphological effects of torsion applied to
growing bone: an in-vivo study in rabbits. J Bone Joint Surg
1980;62B:230-7.

For internal tibial torsion, some
clinicians claim success in using the Dennis-Brown
splint but there has been no scientific proof of its
usefulness. In the rabbit tibial model, lateral rotation
forces have been shown to lead to angulation of the
cells within the zone of hypertrophy of the physis, but
no cortical remodelling occurs.In a similar rabbit
model, lateral rotation splinting changes the static
foot angle but does not change bone rotation, which
indicates that the 'correction' achieved occurs primarily
through the ankle joint, thus potentially damaging
the ankle joint.

Now I realise it's rabbits!!, but does not the same principle apply?

Tony Achilles
Click to expand...

Tony,

I can see that you are very well read. I have a hard time seeing how a DB
bar will make a change within the tibia. I think it is the knee for the
reasons I previously stated. As far as the ankle, I think this is also
possible. I have noticed sometimes that the adductus of the foot is within
the ankle. On x-ray you can see the talar head is more adducted than it
should be in relation to the malleoli. I just let the patients out grow
this. When I tell the patient's parents this, I tend to lose the follow up,
so I don't know if it really outgrows. I will make sure I follow up from
now on.
Thanks for making me think.

Respectfully,

Stanley
Click to expand...

After careful review of the abstract of the article you provided, Tony, it seems that if an external rotation moment can be applied to the tibia of a rabbit and show a histological change within 24 hours within the epiphyseal plate in response to this external rotation moment, then this would certainly tend to support my hypothesis that an external rotation moment placed on the tibia in a human child could also cause a rotation in the epiphyseal plate to effect a correction in abnormal tibial torsion. In fact, Ron Valmassy was teaching this same fact to us at CCPM over 20 years ago that he thought the changes he saw in the malleolar torsion with the use of a night splint was occurring at the epiphyseal plate. The epiphyseal plate is part of the tibia and will ossify as the child matures into adulthood. Therefore, these facts make it imperative that we offer our best treatments to these young children that may help them avoid embarrassment, physical disability, or abnormal pathological function of the foot from the abnormal torsional problems in their lower extremities.

Every day of delay in treating the pediatric deformity is a golden opportunity lost forever (Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992).

Cheers,

Kevin
Click to expand...

admin · Dec 1, 2004

Another post:

Tony,

I just got the paper faxed to me, and there are some things I would like to
draw your attention to.
1. The study checked for foot progression angle, and not the structural
changes.
2. There were 7 limbs in the natural history group and 7 limbs in the
treated group with a diagnosis of tibial torsion. .
3. The range of change in the tibial torsion group was 44 degrees (from one
getting worse by 10 degrees to one improving by 34 degrees.
4. The range of change in the treatment group was 15 degrees (from one
improving by 5 degrees to one improving by 20 degrees.
5. In the editorial section at the end, the examiners state that if the
sample is divided according to the diagnosis of internal tibial torsion,
the sample size is too small to have significance.
6. The DB bars were place at 40 degrees out for 6 months.
7. The initial foot progression angle in the natural history group was 21.7
degrees and the treatment group was 18.4 degrees.
8. The progression angle was measured by six chalk foot prints (three from
each side) No other description of this test is mentioned. Not speed, how
many steps prior, or base of gait.
9. No description of the measuring device is given. It could have been done
by eye.
10. No data is given as to the structural changes in the two groups.

Tony, this study is not what I would base my treatment on. They say it was
not significant for tibial torsion, (how could it be with 7 limbs). Look
at the ranges and you have to question the testing method. The application
of the DB bar is 20 degrees out per leg, which is 25 degrees less than what
I end up using on my patients, so it is almost meaningless. The accuracy
of the data is suspect. Gait angle is the least reliable indicator of
changes in the lower extremity for torsion, especially since we don't know
how it was performed. If you treat children, they can toe in of they have
to go to the potty. The age group was 14 to 27 months prior to treatment in
the natural history group. At three years, not all kids are potty trained,
so were some wearing diapers?

If a senior student came before the research committee in your podiatry
college and wanted to do this paper, it would not be a pretty scene.

Thanks for bringing the article to my attention. When you decide to do your
article, I am convinced, that you will do a much better job.

Respectfully,

Stanley
Click to expand...

Jbwheele · Jun 19, 2005

Gait Plates

Hi Kate,

I took part in a great Biomech short course run by ICB (icbmedical.com)and the speaker was quite confident about using gait plates to help create external / internal torsion to the lower leg.

Just a thought.

Cheers JOE

Craig Payne · Jun 19, 2005

I took part in a great Biomech short course run by ICB and the speaker was quite confident about using gait plates to help create external / internal torsion to the lower leg.
Click to expand...

They need to go and read the evidence... but then what would you expect from a company that used to claim on their website that they are endorsed by the Australian Biomechanics Associaton (....which does not exist! :cool: ) .. ...

Kate Roberts · Jun 20, 2005

Kate

Thanks for all these comments. Why is it that, if the use of splinting has been used for so long, there is very little evidence to support it? Comments have been made that suggest the splinting can be effective for both pseudo-malleolar torsion ( a condition I know as Internal Tibial Position and Medial Genicular Rotation ) and the bony Internal Tibial Torsion. No one has mentioned the use of serial casting for the soft tissue internal rotation. In the mid 80's this treatment was being recommended by eminent Podiatrists. What am I missing? Are there any recommendations for gold standard papers on the subject of tibial spinting? Kate

Kate Roberts Welcome New Poster

admin Administrator Staff Member

admin Administrator Staff Member

admin Administrator Staff Member

Kate Roberts Welcome New Poster

admin Administrator Staff Member

admin Administrator Staff Member

admin Administrator Staff Member

admin Administrator Staff Member

admin Administrator Staff Member

admin Administrator Staff Member

admin Administrator Staff Member

admin Administrator Staff Member

Jbwheele Active Member

Craig Payne Moderator

Kate Roberts Welcome New Poster

Metatarsus Adductus Serial Casting

Foot position during serial casting

Serial anaesthetic for sinus tarsi syndrome?

Sand box, wax sheet casting method

Sound casting and modifying cast after pouring

Total Contact Casting Kit 1/2 Case (5 boxes) - No Longer Available

Research Backs Weight-bearing Casting Methods

Share This Page