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A 12-year-old boy presents to the clinic with complaints of right sided anterior knee pain and an outtoeing gait that has worsened over the past few years. Examination reveals an external foot-progression angle of 25 degrees, a thigh-foot axis of +30 degrees, and a positive apprehension test for lateral patellar subluxation on the right side. There is also noted symmetrical hip rotation on exam. What is the most likely cause of this patient's outtoeing and knee pain?
Bilateral developmentally dislocated hips
Excessive external tibial torsion
Excessive femoral anteversion
External rotation contracture of the hips
Excessive internal tibial torsion
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Out-toeing gait in late childhood and early adolescence is most commonly caused by excessive external tibial torsion. By late childhood and early adolescence the average thigh foot axis is 10 degrees external (range -5 to +30), and the average foot progression angle is approximately 5 degrees external for late childhood/early adolescence.
External rotation contracture of the hips is most common cause of out-toeing in infancy and early toddlers. Excessive external tibial torsion is mostly unilateral affecting the right side and patients will also present with complaints of patellofemoral pain and instability.
Lincoln et al summarizes the most common deformities of children with intoeing and outtoeing gaits both in infancy, toddlers and adolescence. While uncommon, surgical treatment of tibial torsion is reserved for symptomatic patients with measurements > 3 standard deviations from the normal via supramalleolar rotational osteotomies. The two most common causes of intoeing reviewed in this article are internal tibial torsion and femoral anteversion in early childhood.
Staheli further discusses lower extremity rotational deformities in pediatric patients and provides treatment guidelines.
Lincoln TL, Suen PW
J Am Acad Orthop Surg. 2003 Sep-Oct;11(5):312-20. PMID: 14565753 (Link to Abstract)
Instr Course Lect. 1994;43:199-209. PMID: 9097150 (Link to Abstract)
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This video demonstrates how to measure the thigh-foot axis. It is an effective w...