#tibial

https://vimeo.com/365342814

So, Which is it? When his knees are Straightahead, his feet point out; when his feet are straightahead, his knees point inward. A plumbline from the tibial tuberosity passes medial to the second metatarsal. Looking at the pictures, you can see that he is external tibial torsion along with a sandal thong deformity that we talked about last week. Dr Ivo Waerlop, one of The Gait Guys. #externaltibialtorsion #outturnedfoot #increasedprogressionangle #kneepain #thegaitguys

Here’s one that we’ve talked about before. Think about internal tibial torsion for a moment. You remember when the tibial tuberosity points straightahead and the foot points inward?  Now combine that with femoral retro torsion. Remember that that’s when the angle of the femoral neck with the shaft is less than 8° which results in a loss of internal rotation of the hip.  Put those two together and you have a foot that points inward and limited internal rotation of the hip on that same side.  Stand on your right leg with your foot turned in. Twist your body to the right. Can you see how this is internal rotation of the right hip? If people have to create internal rotation of the hip, then the motion has to occur somewhere. If it is not available at the hip and the lower extremity is fully internally rotated it has to occur north of the hip which is usually in the lumbar spine. Now think about when people are lifting things. Often times they do not do a hip hinge and reverse or flatten their lumbar lordosis, opening up the facet joints which allows more rotation. Do you remember that rotation of the lumbar spine is limited to about 5° unilaterally? Where do you think that hip rotation is going to occur? Hmmmm... Probably north of the hip.  Better teach them to spin that weight bearing leg and foot out into some external rotation to create that needed range of motion, increase the amount of internal rotation of that hip or have them keep their shoulders and hips in the same plane when rotating. Dr Ivo Waerlop, one of The Gait Guys  #backpain #hipinternalrotation #internaltibialtorsion #retrotorsion #femoralretrotorsion 

We talked about this woman in yesterday‘s post and, when viewing from the front, we wanted to bring out a few salient points Notice how her foot progression angle is diminished bilaterally. Normally the foot will “toe out“ somewhere between 12 and 20° when the foot hits the ground and hers are nearly straightahead. This can be due to numerous things such as femoral retro torsion, internal tibial torsion, or subtalar version. All of these things will often have the foot point medially when examining a patient on the table and placing the knee in the sagittal plane. In this particular case, she has internal tibial torsion. The next thing we would like you to look at is noting how her knee falls “outside“ the sagittal plane. In other words, instead of the knees pointing straight ahead, the point slightly out laterally. This is a cardinal sign of internal tibial torsion, especially in a gait analysis. So what’s a clinician to do? In this particular case, there’s nothing really to “fix“ as these are hard deformities that are often congenital. Our job is to help the patient to compensate and the best way possible so that they can remain pain and as injury free as possible. We discussed remediation in the post yesterday, So please refer back to that for what we did Dr Ivo Waerlop, one of The Gait Guys #invertedforefoot #forefootsupinatus #forefootvarus #pronation #forefoot #gaitanalysis #decreasedprogressionangle #toeingin

Take a look at these pictures. This is also a good reason to always look at the insoles. Take a good look. Can you see the increase printing on the lateral aspect of the right foot? You’ll note that he has internal tibial torsion on the side. This often presents with a forefoot supinatus and results in pressuring of the lateral column of the foot and an inability to descend the first ray. Note that the footbed on the right shows increased pressure of the lateral column and a lack of pressure under the head of the first. Stand up and put the weight on the outside of your right foot. Can you feel how the toes on right side pressing more in an attempt to shift the center of gravity medially while it offloading the toes on the left foot? This is also represented in the foot beds. Yet another great reason to not only look at the wear on the outside, but also on the inside of your clients/patients shoes. Dr Ivo Waerlop, one of The Gait Guys #footbeds #internaltibialtorsion #lateralfootpressure #insoles

Take a look at this gent in the picture. Do you notice anything peculiar? Pick a point and start either moving from above down or from the ground up. From the ground up, the first thing you may notice is that he has a hallux abducto valgus on the right side. This could be for any number of reasons and what it actually tells you is that he is unable to anchor his first ray to the ground and have appropriate function of the adductor hallucis. Your job, during the examination process, is to sort that out. The second thing you may notice is that he has more midfoot collapse on this same side. You would think that with that much midfoot collapse he would get his first ray to the ground but that’s obviously not the case. Moving up from there, you may have noticed that he has significantly more tibial varum on the left-hand side. Tibial varum should be about 4-6 degrees and is largely a function of in utero positioning although diseases like osteomalacia and rickets can increase it though this is often more bilaterally symmetrical. You need to be aware increased tibial varum means that the foot, particularly the forefoot, needs to pronate a greater degree to create a stable foot tripod on the ground. You need to ensure during the examination process that adequate range of motion in the forefoot and 1st ray are available. You may have noticed that there is prominence of the left medial head of the gastroc which is most likely a combination of positioning as well as increased mechanical advantage secondary to the varum. Hopefully you noticed that the knees are (relatively) in the sagittal plane and that there’s an increase progression angle on the left-hand side. If you drop a plumbline from the tibial tuberosity you’ll see the falls medial to the second metatarsal shaft indicating external tibial torsion in the lower extremity. The unilateral increased tibial varum on the left-hand side is secondary to an anatomical leg length discrepancy where the right tibia is shorter. This has been long-standing and in compensation, the left tibia has “bowed“ to compensate for the difference, In an attempt to shorten the left leg. Dr Ivo Waerlop, one of The Gait Guys Like this stuff? Come and drink from the fire hydrant. Consider joining us this Wednesday evening on online CE.com for bio mechanics 326, 6 PM Mountain standard time. Likewise, you can become a Patreon supporter and get this kind of information every week. #tibialvarum #leglengthdiscrepancy #lld #bowedlegs #pronation

Dr Ivo Waerlop, one of The Gait Guys