Gait Patterns: Foot Angle and Tibial Torsion

Foot Progression Angle

• This is an angle formed between the bisection of the foot and the line of progression.
• A positive value means out toe (greater than 20 degrees).
• A negative value means in toe (greater than -20 degrees).

Knee Position in Newborns

• The head and neck of the femur is laterally angled at 60 degrees from the frontal plane.
• The twist of the femur is 30 degrees medially.
• The knee position is 30 degrees from the frontal plane.
• The inward twist is often masked because of outward rotation at the hip. The outward influence is greater than the inward influence.

Tibial Torsion at Different Ages

• At birth, it is 0 degrees.
• At 6 years old, the adult value is 18-23 degrees.

Intoe Gait Pattern

• Characterized by the internal rotation of the foot's long axis in relation to the line of progression.
• Many cases resolve without intervention.
• Genetic in-toeing does not resolve spontaneously. Cerebral palsy can be a cause of in-toeing.

Common Causes of Intoeing

• Infancy: Metatarsus adductus and clubfoot (TEV).
• 1-2 years old: Internal tibial torsion.
• Over 3 years old: Femoral anteversion.
• Spasticity of medial hip rotators and adductors (cerebral palsy patients, often with toe walking).
• Metatarsus adductus is the most common cause in infants, internal tibial torsion at 1-2 years, and increased femoral anteversion over 3 years. Severe cases are due to a combination of factors.

Pediatric Orthopedic Society of North America (POSNA) Recommendations

• Simple in-toeing: no radiographs, bracing, or surgery for children under 8 years old.
• Most of the femur untwists before age 9.

Key Components to Evaluate Intoeing

• Hip rotations
• Femoral torsion
• Tibial torsion
• Foot deformity
• Foot progression angle

Symptoms of Intoe

• Tripping
• Clumsiness
• Fatigue-like pains. Tripping and falling in 3-year-old males.

Sequelae of Retained Intoe Gait in Adults

• Patellofemoral pathology
• Abnormal pronation of the foot
• Patellar instability
• Lever arm dysfunction

Tibia in Newborns

• Straight in the transverse plane without twisting.
• Unlike the femur, the tibia starts straight and then twists.

Internal Tibial Torsion (ITT)

• The most common cause of in-toe gait in the first 3 years of life with intrauterine positioning.
• Distal leg rotation on the thigh at the knee joint, along with fibula tilting.
• Kid's feet point inward while sitting.
• Often noticed by parents between 6-18 years old with a complaint of bowed leg or pigeon-toed gait.
• May be compensated by increased lateral femoral rotation and foot pronation.
• Laterally faced hips mask ITT and are more rare to see ITT or medial femoral torsion in infants.

Diagnosing Tibial vs. Femoral/Hip Deformity

• Tibial deformity results in straight or outward knees.
• Femoral or hip deformity results in inward knees.

Pseudobowing

• ITT can give the appearance of bowing.
• It is not true bowing; X-rays will show normal tibia appearance.
• An illusion due to the bulky calf on the lateral leg aspect.
• Bowing seems to disappear when the leg is turned outward.

Malleolar Position

• At birth, it is -5 degrees.
• At 6 years old (adult value), it is 13-18 degrees.
• There are 5 degrees less than tibial torsion.
• In normal children, the medial malleolus is anterior to the lateral malleolus. ITT is present if it is even or posterior.

Qualitative Tibial Torsion Evaluation

• Patient lies on their stomach with knees flexed to compare foot's long axis to the thigh.
• Normal: STJ in neutral, the foot should be lateral to the thigh.
• ITT: the foot is medial to the thigh.

ITT Treatment

• Above-knee casting for preambulatory children.
• Night splinting for 12-15 months with high likelihood of self-correction before age 1 and unlikely to work approaching age 2.
• Initial night splint setting is 20-25° out-toe, adding 5° monthly to 45°. Unilateral ITT keeps unaffected side at 20°.
• Wheaton bracing for unilateral internal tibial torsion. It includes a pelvic band and derotation straps. Usually used after toilet training (5-6 y.o). Used for severe intoeing cases with tripping and falling.
• Dobbs brace is a preferred treatment for ITT because it is flexible with shoulder-width.

Femur Version

• Twisting of long bone around its longitudinal axis.
• Femoral version is the angular difference between the transcondylar axis of the knee and the head-neck axis of the femur.
• A higher femoral version angle leads to intoeing.
• Normal femoral version: newborns = 30-50°, adults = 10-15°.

Abnormal Femoral Version

• Greater than 2 standard deviations from the norm.
• Also termed medial femoral torsion or increased femoral anteversion.
• Squinting patella and "W" sitting signs.

Medial Femoral Torsion

• 80° medial, 20° lateral.
• If it is a true bone problem, the angle remains the same whether flexed or extended.
• Look at leg appearance when asking to lay on stomach and let legs go. They flop outward.
• Infants under 3 years with a high medial femoral torsion, may not show in-toeing from the hip due to lateral soft tissue contractures masking the internal twist.
• High medial twist of the femur in newborns masked due to lateral rotation contracture of the intrauterine position.
• Reduced through growth, hip flexor tightness reduction and lateral hip rotation.

Femoral Torsion Treatments

• Activities like ballet, martial arts, biking & less flexible shoes.
• Gait plates improve the angle of gait, requiring > 25° lateral hip rotation, and work at the push-off phase 3.5-4.5 years old.
• Denis Browne bars are not for femoral torsion treatment, as it will create problems. It can treat tibial torsion.
• Femoral torsion is pathology, & femoral version is normal.

Femoral Anteversion

• The angle between the femoral head and neck axis and the frontal plane of the body. Anteverted in the head & neck from the frontal plane.
• Results in in-toeing.
• Best evaluated via CT scan. The most accurate form, however it does not account for dynamic motion.
• Medial hip rotation degree is greater than 70°.
• Angles: at birth = 37°, 14-15 years old = 12°.
• Greatest change in angle between 1 & 2 years of age.
• The most improvement occurs at 9 years old, guiding osteotomy timing.

Netters method

• Prone with knee flexed 90°, palpate greater trochanter with one hand while other hand internally rotates the hip to greatest trochanter prominence. Place the neck parallel to the table.
• Find the angle of the tibi and true vertical.
• Femoral anteversion averages 3-4 years old and peaks at 5-6 years. More common in females, often symmetric.

Femoral Antetorsion

• Measures osseous twist between the femur's upper and lower ends.

Lateral & Medial Femoral Rotations

• In infants, it is 60° lateral, 0-30° medial.
• 1-4 years old, it is 40-45° lateral, 35-45° medial.
• Medial should never be larger than lateral.
• If lateral/medial femoral rotation is affected differently in different positions, indicates tight hamstrings.
• Hip & knees extended: 40° medial rotation & 45° lateral rotation vs hip & knees flexed at 55° medial rotation & 10° lateral rotation which indicates a tight medial hamstring.
• Medial femoral rotation (anteversion): with child prone, legs flop to the chair sides rotating the thighs & femurs inward.
• Lateral femoral rotation: with child prone, cross tibia over the midline.
• The knee points straight by age 4 with a twist in femur decreases (derotates) to a -15° from inward 30°.
• The angle of the head & neck to the frontal plane decreases to +15° (from forward 60°).
• If 15 opposed is by-15, equals 0° in the frontal plane.
• The medially twisted bone derotates through a reduction of lateral soft tissue contracture.
• Measure Hamstring flexibility with 70° hip angle should be obtained.
• Popliteal angle assesses hamstring tightness where superior method is to flex hip at 90° then extend knee until resistance. This shows the acute angle. Normal popliteal angle is
• Birth-2 y.o = 0-6°

• 5 y.o = 0-25°

Torsional Profile

• Intoed child with normal torsional profile possibly has ligamentous laxity.
• A 6-year-old female presents w/ the following torsional profile: 75° medial & 5° lateral femoral rotation w/ hip flexed & extended. Femoral torsion is 25° internal. Tibial torsion is 22°. Bleck's test 2nd digit. In this case, the cause is femoral anteversion/torsion. This can bedetermined by measuring the difference in medial & lateral torsion.
• A 2.5-year-old female presents w/ the following torsional profile: lateral > medial femoral rotation w/ hip flexed & extended. Bleck's test 3rd digit. Tibial torsion is -5° bilateral. The cuase is met adductus and ITT.

Out-Toe

• Foot progression angle is greater than 20°.
• Early walkers with out-toe should not be sent for surgery as it is normal for them.
• An obese, 12-year-old male w/ a limp or waddle along with out-toe and groin pain for 6 months indicates Slipped Capital Femoral Epiphysis (SCFE).

Risks for causing Out-Toeing Gait

• Infancy: Calcaneovalgus or convex pes valgus.
• Childhood: Contracture of triceps surae (pes valgus) or tarsal coalition with peroneal spasm.
• All age groups: Neuromuscular equinovalgus (Cerebral Palsy).

Hip Deformities Causing Out-Toeing

• Tightness of lateral hip rotators (infancy)
• Developmental dysplasia (when a child begins to walk)
• Lateral femoral torsion (retrotorsion) in pre-adolescence and adolescence.
• Neuromuscular disorders (spina bifida) at all ages.

Convex Pes Valgus

• Though less common, makes a much more difficult congenital flatfoot deformity.
• It creates a rocker-bottom foot.
• Primarily is caused by dislocation of the TN joint that requires surgery.

Calcaneovalgus

• A congenital deformity where the foot is stuck in dorsiflexion and abduction creating the "up and out foot".
• Clinical signs include calcaneus posture (fixed DF), valgus heel (limited inversion), tight anterior and lateral structures, and low arch with prominent medial talus.
• Etiology: uterine wall pressure during pregnancy and is common in primigravida with a tight uterus.

Slipped Capital Femoral Epiphysis (SCFE)

• Lateral femoral torsion aka retrotorsion.
• 12-year-old presents as a male with a rightsided limp.
• Limited internal rotation, abduction, and flexion of the right hip.
• Common during adolescence, especially boys between 13-16 and girls between 11-14.
• Pain referred to groin or medial knee.
• Limits internal rotation, abduction & flexion.
• Surgical treatment

Femoral Retroversion

• Head and neck of the femur directed posteriorly from transcondylar axis along the frontal plane. Head and neck are retroverted (directed backward.
• It causes out-toe with less than 10° of torsion. It is essential to have enough medial twist in in the bone.
• Saying "femoral retroversion" means "OUT TOE". It may present as 90° lateral & 10° medial femoral rotation no matter ifhip is flexed or extended, indicating Femoral retroversion over soft tissue influence.
• Indicates femoral retroversion if lateral rotation decreases with hip extension, suggesting tight hip ligaments. 35° medial rotation & 45° lateral rotation hip & knee extended vs. 10° medial rotation & 45° lateral rotation hip flexed & knee extended leads to out-toe due to tight lateral hamstrings.

Knock Knees

• Progression of genu varum and valgum in childhood: Birth to 1.5 years is genu varum which is staight from 1.5 - 3 then goes to genu valgum from 3-6 and stragith from 6-12 years
• Asymmetry Genu Varum (bowed legged) is concerning but symmetric is normal.
• Associated with Blount’s disease, rickets, achondroplasia
• Blount’s disease (tibia vara): Growth disturbances of the proximal tibia that form a distal with a "beaking” appearance.

Classic Blount’s Disease Patient

• Early walker, short-statured, overweight, black female with associated ITT where curve bows from proximal 1/3 of the tibia.
• Infantile: Typically bilateral between 1-3 years old; seen in obese kids/early walkers
• Juvenile: Typically bilateral between 4-10 years old and unilateral.
• Adolescent: typically unilateral 11 years old and older.
• Radiographic staging is the Langenskiöld classification to describe progression of tibial vara progression. Treat child less than 4 years old withlangenskiold classification of I or II with brace.
• Treat child greater than 5 years old w/ langenskiold of III or VI with surgical osteotomy.
• The cover-up test places the child on back, covering middle 1/3 of tibia evaluate valgus/varus relationship between tibia and thigh. This differentaites between physiologic genu varum vs Blounts disease. Adolescent Blount's disease is unilateral Valgus relationship (negative) which means physiologic or pseudobowing Varus relationship (positive): means Bount’s disease that is Vitamin D deficiency with weak bones and the possibility of tibial varum.

Congenital Tibial Angulation

• Group 1
  • Angulation: anterolateral bowing of tibia
  • Associated disease: neurofibromatosis
• Group 2
  • Angulation = anterior bowing of tibia
  • Fibular deficiency association with short leg
• Group 3
  • Angulation = posteromedial bowing of tibia -Associated disease: calcaneovalgus
• Refer a bowlegged child to a pediatric orthopedist for consult if greater than 3 y.o

Genu Valgum (knock knees)

• Refer genu valgum if older than 7.
• Unilateral when greater than 3.5 inches intermalleolar distance.
• Causes physiological, congenital where congenital is a short fibula, trauma and infection, Bone dysplasia with multiple enchondromatosis. The ollie's disease is unilateral with skin bumps or lumps all over the body, Renal osteodystrophy
• Ligamentous laxity with down Syndrome .
• Symptoms is pain and lipping. Associated diseases including multiple endochondral disease Ollier's Disease which can present with benign bone tumore and all over. There is real osteodystrophy, like minute is laxity and down syndrome.

Child Abuse

• Abuse indicates physical/sexual harm risk
• Neglect leads to child’s condition impaired or an imminent danger . There may be failure to provide/meet basic things including failure for the minimum degree of care. Report in state wide central register. If a written report is not provided within for any hours or any.
• There needs to be a reasonable cause if you suspect abuse and report to mandated reporter who must report when reasonable cause exists
• The police are involved when there is an emergency or immediate danger regarding a child’s health or well-being

Pediatric Pharmacology

• Make sure there's an actual infection present before administering antibiotics to children. Overprescribing antibiotics can cause antibiotic resistance.
• Use narrow-spectrum penicillins or amoxicillin for most common pediatric cases.
• Cephalexin (Keflex) would be the 1st generation to treat a mix of gram positive and negative infections. Do not use sulfonamides and Macrobid
• Dicloxacillin Or oral penicillin is indicated by the Staph aureus that is pennacilnase resistant. That's his penicillin of choice for stat that is not M RSA
• Amoxicillin is indicated for group a beta hemolytic Strep that is not Penicillinase resistant
• If Amoxillin, you'd use Penicillin for strep, ear symptoms in sinus infections.
• If it was strep these would not work,
• Typically would use Augmentin for ingrown toenail and cannot prescribe if there's allergies or diarrhea
• Broad spectrum and you give erythromycin to a patient with a penicillin allergy can be useful for macro lights for Staffen strep. Some benefit from taking it for five, three or one days. Less GI upset comparing into erythromycin

Drugs for MRSA

• Bactrim: Is a combination drug that can be given to individuals with penicill allergic or individuals allergic to sulfa that can lead to can give a point with penicillin allergy contraindicated for sulfur allergy patients
• Clindamycin: Good choice when the patient has MRSA indications are solve tissue infections but has a side effects of diarrhea
• Tetracycline is contraindicated and pediatric patients that are or under the is you because it can come and leave stains on teeth
• flouroquinolones are contraindicated in Children 2 concerns of increased pneumococcal resistance and adult joint and cartilage toxicity.
• The first step is to always see to our seven, i and deed for a foot abscess with no systemic signs.
• Mupirocin the Bactroban the most common topical treatment topical treatment for simple bacterial skin infection and pet ego Staff were marisa can occur on the face both with face can occur anywhere there's are not and soul slaves
• Silvadene treat's burns
• Acetaminophen but it's not anti-inflammatory.
• Aspirin is contraindicated and children with like systems like it can lead to Reyes symptoms
• If a patient has a penicillin allergy, you can't say piperacillin/tazobactam & can also not give cephalosporins

Soft Tissue Infection Treatment

• The majority of all solf tissue infections occur 70 % d/t S. Areus and treatment is penicillinase resistant penicillins like Cephalexin and is a risk of developing resistance to multiple families of antibacterials
• Benadryl diphenhydramine used to give the pediatric and is used for milk sedation and kids
• Promethazine is Contra indicated is over 2y.o can lead to 25 Max Doses of 25 mg.
• For Drylesions of ointment
• Where Lesions means use powder topical medication which is
• Powders or absorbent solution. Soloutions are drying, gels like drying
• Lotions of small oil but needs more water Creams like more oil. Topical steoreoids and overuse side effects of add Atrophy of striate with del Telang act is that are a. Its Poten in your children. For Low mode it's hydro cortisone 1. I am usel most for topical antifungal as top gel. The anti fungal that is given if it is from in com function with oral anti fungal Penlac is most effective. Do not giveketoconizal to children who have Hepatotoxic side effets

Dosing

• Best to dose according to body surface area (West nomogram) Conversions:
• 2.2 lbs= 1 kg
• 5 mL= tsp
• 15 ml = tablespoon

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Practice Questions

• Oral suspension:
• DTD: 100 mLS
• Sig: 1 tsp every 12 hours for 10 days

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