Tibial Torsion
Dancing Smart Newsletter
May 13, 2005
Happy Friday the thirteenth! This has always been a favorite day. Growing up, I decidedthat because so many people had an adverse reaction to Friday the thirteenth, Iwould love it! (I admit to have asomewhat rebellious, although I liked to think of them as my independentthinking teenage years.)
Today's newsletter is a small section of Tune Up YourTurnout. There has been no extratime to answer questions this week, as it was the last week of the semester,and my children's end of season tennis tournaments, their new found love. I'll back to answering questions innext week's newsletter. Untilthen, have a wonderful week, I wish you much sunshine and warm temperatures!
PS: I wasunable to post the pictures that go along with this part of the book, and thereare a few punctuation marks that didn't come through.
Tibial Torsion
The tibia is the primary shinbone. You have another longbone in the lower leg called the fibula—it's lateral, or outside of thetibia. The term "tibial torsion"describes what happens when the tibia rotates during bone growth. It caninternally rotate (turn-in) or externally rotate (turnout).
Tibial torsion could be genetic or there could be physicalactivities in the child's life that have caused or contributed to the rotation.
When you see a young child with an internally rotated tibiatheir knees will face forward while they walk with a toeing-in gait. These same children are often quitecomfortable W-sitting and sleeping on their stomachs with their feet turned in,their big toes close together. While they may be comfortable W-sitting, it doescreate an undesirable torque on the knees, so should be avoided.
If their knees face inward and they walk toe-in, theyprobably have anteversion of the hip joint. They would test with more turn inthan turnout at the hip. With internal tibial torsion they may have a normalrange of turnout at the hip, but they will have trouble standing in turnoutbecause the knees and ankles do not line up. Often this internal tibial torsion self corrects by age 8through the child's normal activity.
The externally rotated tibial torsion is less common inchildren—with the exception of the dance community. I have found a fairamount of external tibial torsion in dancers who started ballet at a young ageand did not understand how to work with the turnout at the hip, and wereturning out the feet to create better turnout. It is the over-turning out oftheir feet that promotes the tibia to rotate outwardly in order to compensatefor the stress that is being placed on the tibia.
When you look at the dancer who has an externally rotatedtibia you will see that either their knees are facing forward and their feetare slightly turned out, or if they put their feet into a parallel position,then their knees face inward towards each other.
In the following pictures you will see this dancer has moretibial torsion on her right side. Notice that her knees are in parallel in bothpictures while the feet are turned out.
It is not unusual to find that a dancer has more tibialtorsion on one leg. A common pattern is for the side with tibial torsion to begenerally the side with less turnout at the hip. We are not symmetrical humanbeings, so unequal turnout is not an uncommon finding. Often I find dancerswith tibial torsion testing with a tighter iliopsoas on that same side. Thisfinding makes sense, as a tighter iliopsoas would affect their ability to usetheir turnout, so the dancer would turn out the foot on that side to make theirfeet look equal in first position. (We'll talk in more detail about themuscular influences of the iliopsoas in Chapter 5.)
It is SO important for the young dancer to line up theirfeet with their knees and learn where turnout is supposed to happen and preventtibial torsion from occurring. If the dancer is older and their bone structureis set, it is useful to know if there is any tibial torsion so they can learnhow to work with it, instead of against it.
For example, I had a nineteen-year-old dancer in class withpretty significant tibial torsion on both legs. She was taking a modern danceclass where we worked in parallel position as much as first position. She cameup to me one day after class because in demi plié when her feet wereinparallel her knees would hit each other. If she pulled her knees out to theside to keep them over her feet, she would have pain on the outside of theknee. She wanted to know why she was getting pain during this simple movement.
After a quick evaluation where I tested her turnout andlooked at her knee and ankle alignment, we confirmed that she had externaltibial torsion. She adapted her parallel position to allow the feet to turnoutever so slightly. This allowed her to access the correct turnout muscles at thehip more easily and took the strain off the knees. She was instructed tocontinue to think of lining up the three joints of the lower extremity and tomonitor the three points of her feet. These three points were the pad of thebig toe, the pad of the little toe and the heel. Her instructions were to haveequal weight on all three points of the foot—which are the samedirections that all dancers should follow.
When she worked in first position she easily turned out. Isuggested she not go to her full turnout at the feet in order to focus onworking her turnout more correctly at the hip. In time she may be able toturnout her full amount—but always she will be monitoring the weight onher feet.
The concern with young dancers and tibial torsion comes backto the importance of monitoring young dancers and how and where they arecreating their turnout. This is why it is so useful to know what their range of motion is at the hip and match that up with what you are seeing in their pliésand other dance movements.
Until next week,
Warmest regards,
Deborah