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Working with Tibial Torsion

I just returned from teaching an intensive course at TCU after a 2-year hiatus, due to the pandemic. It was WONDERFUL to be back teaching in person… even with a mask. This course starts with individual assessments before delving into essential anatomy. Love love love teaching it!

Anyways, there were quite a few students with tibial torsion who didn’t know they had tibial torsion… but were aware of always being told to get their knees over their feet! They were aware that parallel was challenging because during demi pliés, their knees felt like they were going to knock into each other. In first position, they had to pull their knees out over their feet, and were often also lifting up their arches as they were doing so.

The students began to understand that they needed to focus in 2 places, their feet and their hips, to work with their tibial torsion.

They began to monitor the weight on the feet, noticing whether or not it was even between the 3 points of the feet. (The heel, pad of the big toe, pad of the little toe) When the knees are being pulled out over the feet you will notice the weight shifting to the outside of the foot.

They need to temporarily reduce their external rotation at the hip while they work to turn on the turnout muscles appropriately. It is a common pattern to underutilize the rotators on the side with more tibial torsion.

Some of them found that they caught themselves pronating the foot on the side with less tibial torsion. (Monitoring the weight on the feet is always a good idea!)

As they got better with monitoring their hips and feet, their pelvis was better aligned. Why? Because an anteriorly tipped pelvis often goes hand in hand with underutilizing the rotators (and hip extensors) If the pelvis is slightly tipped forward it is easier to turn out the feet without straining the knees.

IT’S ALL CONNECTED!

Tibial torsion doesn’t have to get in the way of being an exquisite technician as long as students are smart about how they work with it. In fact – having the extra external rotation makes their first position look extra sweet, and won’t get in the way, as long as they work the rotators appropriately.

Tibial torsion often is created during growth spurts when the student is turning their feet out more than what they can accurately and efficiently create at the hips. The tibia responds to the force by rotating. It is SO common to see one leg with more tibial torsion and it almost always connects with less access to proper turnout at that same hip. While the student can’t un-rotate that bone, they can correct the way they are using their turnout.

It’s so rewarding to teach students about how their body works. I watched the lightbulbs go off – as they connected their patterns with their technique and their teachers’ corrections. When they shared their insights I clapped my hands in delight and had a huge grin on my face. It’s the best feeling – as I’m sure my fellow teachers would agree!

Below is a clip talking about tibial torsion from some years ago (I miss my dark dark hair:)

Enjoy!

External Tibial Torsion

Adult tibial torsion?

I recently viewed your video “tibial torsion audio” on youtube and was directed to your website thebodyseries.com; I was amazed to realize that the dancer in the video seemed to have the same problem as me, where she did not stand evenly on her legs, and in a demi pliet the knee turned inward in relation to the foot. I believe that my right leg has tibial torsion which is negatively impacting my ability to dance or workout. I was wondering if you knew of any doctor who specializes in diagnosing or treating adult tibial torsion, or could provide exercises to help correct this condition. I am a bit clueless, because this is the first time I have heard of someone with knowledge of the asymetry which affects others and me. Any help or direction you could provide would be invaluable and greatly appreciated.

Sincerely,
Josh

Unfortunately, Josh, you can’t undue the tibial torsion once you have it – but it doesn’t have to stop you from dancing. You do, however, need to focus first and foremost on keeping the weight even between the 3 points of the foot, the pads of the big toe, little toe, and heel. The knees will not be over the middle of the foot as we so often hear in dance class. For the dancer with tibial torsion if they pull the knees out to get them over the middle of the foot they are doing it by supinating the foot or overly using the sartorious muscle to pull the knees out to the side. Then you’ll have more problems than just pulling the knees out to the side!

The treatment? To simply balance out any muscular imbalances and keep the weight on the feet properly placed while working the turnout as well as you can from the hip – not the knees and feet.

Looking at a demi plié

click here to view a quick clip on demi pliés. Start to train your eye to see assymetries! I’ve got a few spaces left for the workshop in June – only 20 total participants. Come join me!

Toeing – In

Happy Labor Day weekend! Many of you have already started back into the fall semester and others will start on Tuesday. I hope your fall is getting off to a splendid start!

Onto the question of the week….

I had the great fortune of attending your classes at the DTSC again this year. I was returning after having taken your class 5 years ago – after which I ran right out and purchased some pinky balls. Since that time, my father has taken up working out and has had many successes with that. He has had the occasional ache and pain however, to which I have recommended some of your ball-work. Although he listened, it wasn’t until the PT suggested something similar that he gave my suggestions some validity! I’m trying to get him to borrow my ballwork video that I purchased. 🙂

My question today is in regards to my daughter’s feet. At an early age, watching her on the sidelines and even in her own early dance classes – I took notice of something funky going on with her feet. Now, age 6, I have concern still. As she has taken some ballet technique and gymnastics classes – it has become more apparent that her feet appear to turn in while in action. She can stand in first, draw her leg up to passé and keep the knee back, heel forward as long as I remind her. When her movement is stationary or sustained she understands and tries to make corrections… yet when she is dancing her feet turn in..quite a bit. A simple leap – toes turn in, a small arabesque – turned in, on the uneven bars her teacher called me over before coming to the conference because when she circles the barre – her foot turns in. I’m beginning to notice it might be in her right foot more then the left. The pediatrician looked at her feet at the 5 yr. and 6 yr. visit and has determined she is turned in slightly – but it is mild. Although she may never be a professional dancer – it is difficult for me as a dance teacher to see her little feet so turned in when she dances. Should I be concerned or not? Is there anything I can have her do at home to help? What type of orthopedist should I be looking for to look at her feet? If her feet are mildly turned in – is there any concern I should have other then dance related?

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Lovely question! Turning in of the feet or pigeon-toed can come from three different areas – at the feet, the shin bone, or the hips. Let’s take a look at each one individually.

9052When the feet turn in at the feet it is called metatarsus adductus . This is where the bones of the feet turn in. Typically, this is caught before the child even begins walking and the doctor would have suggested massaging and stretching the feet as she grew. Since it was not caught when she was really young, I would rule out this cause for your daughter’s turning in of her feet.

We have talked about tibial torsion in other newsletters, more often we talk about external tibial torsion – but there is internal tibial torsion. In dancers I see more external tibial torsion which describes an outward rotation of the shin bone. I often find this in dancers who aren’t using their turnout from the hips, but rather are turning out from the knee down. Over time, that stress from standing in too much turnout creates a rotation at the bone that one might think is a good thing – but actually, it means that your knees and the feet won’t be lined up and leaves the dancer vulnerable to knee and ankle injuries.

202b.Par.0001.ImageInternal tibial torsion, which your daughter might have is where the shinbone rotates in making for a pigeon-toed walk. This isn’t unusual in toddlers and preschoolers, and often corrects itself as they become more active in running and walking – the 5-6 year old stage. Sometimes toeing in lasts into the school years, but usually isn’t a problem. In fact there are some sports that favor internal rotation, such as martial arts, soccer, and sometimes basketball.

If the toeing in was happening just from the shin you could sit your daughter on the edge of a table with her knees facing forward and you would see a clear inward rotation of the shin bone – as in the picture to the right.

When the turning in is coming from the hip it is called anteversion. The normal range of turnout and turn in at the hip is 45 degrees for both. When you have more turnout it is called retroversion, when you have more turn in it is called anteversion. This is a structural situation where it describes the angle of the neck of the femur to the shaft or long body of the femur or thigh bone. If you test your daughter’s range of motion at the hip by lying her on her stomach that might give you an idea if she has some natural anteversion.

W Sitting1A child with anteversion easily W sits – as shown in this picture. It will be interesting to find out what the relationship is between the two hips – are they even as far as their range, or is one more turned out or more turned in. This is very common, and while it isn’t a significant issue, you would want a young dancer to create her first position based on the lesser turned out leg, rather than the more turned out leg.

Watching the recent Olympics and especially the gymnastics competition, I was struck by how many of the gymnasts had a slight tendency to turn in their feet on the balance beam as well as on the floor routines. No one would ever say that their line wasn’t beautiful and elongated – even if it wasn’t as turned out as what the dance world would like.

All in all, I think I would take a look at these 3 areas on your daughter, see if you can get a better idea where her toeing in is coming from – and then encourage her to be as well-rounded and active in all ways as possible. At 5-6 years of age, I’m prone to suggest going light on the amount of turnout emphasis and focus on the alignment of the hip, knee and foot – which is what you are already doing. Since she can do that when she thinks about it – my intuition says she will improve her ability to automatically line her legs up as she gets older and better able to maintain that specific focus during class. Now you have a way to periodically assess her range of motion and know better where to focus her attention.

Below are pictures of what normal turnout would look like, a retroverted hip (excessive turnout) and an anteverted hip (more turn in than turnout)

Normal ext RotNormal amt. of turnout – 45 degrees

 

 

 

Retroversion t-oRetroversion – more than normal turnout (leg is resting on other thigh)
Anteversion: more than normal amt. of turn inOLYMPUS DIGITAL CAMERA

Until next time,

Be well,

Deborah

“Education is the key to injury prevention”