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Hey Everyone,

How are you all assessing tibial torsion discern if functional versus structural?

Regards,
Scott Gray

 

Is there such a thing as Functional Tibial torsion?

 

Thigh-foot angle

http://bestpractice.bmj.com/best-practice/monograph/748/diagnosis/step-by-step.html

 

Hi Mike,

I think you could have a functional torsion of the tibia if the femur falls into IR (not structural anteversion) due to a weak posterior hip. That said, as a compensation to keep the lower extremity going straight I believe the tibia could external rotate. What are your thoughts?

 

That a Tibial torsion is structural that can have functional changes

 

I have been dancing around my handbag, deciding whether to say anything here. Anyone that knows me and my work, knows that I am into error associated with measurement - and it is no different here than anywhere else. I am unfamiliar with any imaging techniques to assess this sort of thing - and if they are good - then I accept that. However, any skin line type measurements of tibial torsion are laughable. And the whole concept of a functional tibial torsion needs a very careful thinking through; does the knee joint work like that? As always, thinking aloud,, Rob

 

Rob,

I agree that there is definitely measurements errors when assessing for tibial torsion and imaging would be ideal; however, as a US physio we are not blessed with imaging as part of our practice act.

The reason I am asking others in regards to how they assess because I find it clinically relevant in regards to loss of ankle DF. Having already cleared the foot and soft tissues, it is plausible a torsion in the tibia may be impacting ankle mobility.

If anyone on this forum still looks and accounts for torsion of the tibia I would appreciate how you are evaluating and assessing.

 

I'm having a hard time understanding what a functional tibial torsion is. Tibial torsion would be a twist in the tibia. I was taught that this was a transverse plane measurement between the top of the tibia and the bottom of the tibia. So, you need to define a line that represents the top of the tibia and a line that represents the bottom of the tibia. You would then measure the angle between those two lines in the transverse plane to determine tibial torsion. I don't see how that would change with function.

What are you using the tibial torsion measurement for?

Eric

 

Eric,

I am assessing the tibial torsion to rule in if this is a structural issue and that this patient will not be able to get increased ankle mobility.

I think a functional tibial torsion could be present in a patient who presents with excessive TFL and ITB tightness which would externally rotate the tibia. Like wise the medial hamstrings could also pull the tibia internally. Also, we could also postulate the tibia is rotated externally relative to the femur in a patient that has anterversion or if their femur falls into IR through muscles weakness. At the end of the day it is just semantics in regards to how you are referencing. Sure, there maybe no actual "twist" in the patients tibia when the femur is rotated internally relative to the tibia; however, I do know the tibia articulates directly with the talus and that will impact joint kinematics.

Thanks for your repose, Eric. BTW, do you only check open chain or do you actually test in a closed chain with and without the talus in neutral?

 

I don't see how tibial torsion affects ankle joint range of motion. What do you mean by ankle mobility?

TFL = tib-fib Ligament? ITB = Illio tibial band? The IT band is not in a very good position to rotate the tibia relative to the femur in the transverse plane. It appears that you are talking about rotation of the tibia relative to the femur. I'm not sure that I would call this tibial torsion. The hamstrings also have a poor orientation to internally or externally rotate the tibia relative to the femur. Internal and external rotation is a transverse plane position and the hamstrings pull pretty much perpendicular to the transverse plane. If either the ITB or the hamstrings were tight I would expect you would see frontal or sagittal problems before you saw transverse plane problems.

I was wondering what treatments you would change based on this measurement. I use the malleolar position measurement to help explain angle of gait. Malleolar position is supposed be correlated with tibial torsion. When I do the malleolar torsion measurement I use the knee joint axis as the top reference line and a line connection the two malleoli as the bottom reference line.

The measurement is one factor that goes into the angle of gait. Angle of gait is angle between the long axis of the foot and the line of progression when walking. A high amount of malleolar position will tend to correlate with an out toed gait. Unless there is a lot of internal rotation of the femur relative to the hip.

An example of how this measurement changed my treatment was in a bicyclist who had high malleolar torsion. His problem was his medial malleolus hitting the pedal crank. Altererd his pedal so that he could put his foot further away from the crank.

Can anyone think of any other change in treatment they would make based on malleolar position?

Eric