Tibial Torsion Clinical Presentation

Updated: Apr 09, 2021
  • Author: Minoo Patel, MBBS, PhD, MS, FRACS; Chief Editor: Thomas M DeBerardino, MD  more...
  • Print


The patient's history should consist of details of the age at onset, severity, disability, milestones, and family history. In children younger than 18 months, metatarsus adductus is the most common condition that causes in-toeing. Between the ages of 18 months and 3 years, tibial torsion is the most common condition. In children older than 3 years, femoral torsion is the most common diagnosis.


Physical Examination

The diagnosis is based on clinical findings, and other investigations generally are not required. Examination must include tests to exclude hip dysplasia, hip and ankle ranges of motion, and knee varus or valgus, which can cause apparent errors in examination. Imaging studies may be helpful. However, not every child who undergoes an evaluation because of torsional issues requires any or all imaging tests.

Parents are generally more concerned about in-toeing than the children are. Severe in-toeing can cause the child to trip or run awkwardly, and it can interfere with participation in sports and give rise to pain. [18] Excessive wear is seen along the lateral border of the shoe, mainly in the front half, because the child uses this as the presenting border of the foot on the heel- or foot-strike.

A rotational profile consists of the following [19, 20, 21, 6, 9, 10] :

  • Foot progression angle (FPA) [22]
  • Tibial version or torsion - Thigh-foot angle (TFA), transmalleolar angle (TMA)
  • Femoral anteversion (hip rotation)
  • Shape of the foot

The FPA is the angular difference between the axis of the foot and the line of progression. Normal FPA is 10-15° of external rotation. By convention, external rotation values are positive, and internal rotation values are negative. Degrees of in-toeing are as follows:

  • Mild is –5 to –10°
  • Moderate is –10 to –15°
  • Severe is more than –15°

Tibial version or torsion is the degree of rotation of the tibia along its long axis from the knee to the ankle. It is measured with the patient prone with his or her knees flexed to 90°. It is assessed by using two measures, the TFA and the TMA.

The TFA is measured with the patient prone and the knees flexed to 90°, with the examiner looking at the feet from above. It is the angle between the line of axis of the thigh and the line along axis of foot. A normal TFA is 10-15° of external rotation. By convention, external rotation values are positive, and internal rotation values are negative.

The transmalleolar axis is the axis of the line joining the two malleoli. Because the lateral malleolus is normally posterior to the medial malleolus, the transmalleolar axis is externally rotated by 15-20°, as measured with reference to the coronal plane axis. A transmalleolar axis that is externally rotated more than 20° signifies external tibial torsion, and a transmalleolar axis externally rotated less than 10° signifies internal tibial torsion.

Femoral anteversion is the axial angle between the plane of the neck of the femur and the femoral condyles. It can be clinically deduced by measuring hip rotation. Normal range of external rotation is 45-70°, and internal rotation is 10-45°. As femoral anteversion increases, internal rotation increases and external rotation decreases. These children can have as much as 90° of internal rotation and 0° of external rotation. They sit in the W position with their legs turned out (a position not attainable by normal adults), but they cannot sit cross-legged.

The shape of the foot is best assessed with the patient standing and examined from the back, or else the patient can be prone and the feet assessed by looking at the soles. Metatarsus adductus (or, uncommonly, abductus) can be seen.