Tibial Torsion and Patellofemoral Pain and Instability in the Adult Population: Current Concept Review

Abstract

Purpose of review: Tibial torsion is a recognized cause of patellofemoral pain and instability in the paediatric population; however, it is commonly overlooked in the adult population. The aim of this review article is to summarize the current best evidence on tibial torsion for the adult orthopaedic surgeon.

Recent findings: The true incidence of tibial torsion in the adult population is unknown, with significant geographical variations making assessment very difficult. CT currently remains the gold standard for quantitatively assessing the level of tibial torsion and allows assessment of any associated femoral and knee joint rotational anomalies. Surgical correction should only be considered after completion of a course of physiotherapy aimed at addressing the associated proximal and gluteal weakness. Tibial torsion greater than 30° is used as the main indicator for tibial de-rotation osteotomy by the majority of authors. In patients with associated abnormal femoral rotation, current evidence would suggest that a single-level correction of the tibia (if considered to be a dominant deformity) is sufficient in the majority of cases. Proximal de-rotational osteotomy has been more commonly reported in the adult population and confers the advantage of allowing simultaneous correction of patella alta or excessive tubercle lateralization. Previous surgery prior to de-rotational osteotomy is common; however, in patients with persistent symptoms surgical correction still provides significant benefit. Tibial torsion persists into adulthood and can play a significant role in patellofemoral pathology. A high index of suspicion is required in order to identify torsion clinically. Surgical correction is effective for both pain and instability, but results are inferior in patients with very high pain levels pre-surgery and multiple previous surgeries.

Keywords: Patella instability; Patellofemoral pain; Rotational osteotomy; Tibial torsion.

Conflict of interest statement

Martyn Snow declares that he has no conflict of interest.

Figures

Fig. 1

Clinical picture demonstrating the inward-pointing knee and the typical “knee in” gait of a patient with tibial torsion. Compensatory internal rotation of the hip results in a dynamic valgus and a resulting lateral vector on the patella. Typical gait pattern of increased FPA and the knee pointing inwards (as a result of compensatory hip internal rotation) during stance phase resulting in a dynamic valgus

Fig. 2

Measurement of the a TFA; the angle between the longitudinal axis of the thigh and the longitudinal axis through the 2nd metatarsal with the foot held in subtalar neutral b TMA; the angle between the longitudinal axis of the thigh and a line perpendicular to the axis connecting the most prominent portions of the medial and lateral malleolus. c Second toe test: the patient is prone with the knee extended; the hip is rotated until the 2nd toe points directly towards the floor; the knee is then flexed to 90° while preventing a change in thigh rotation; the angle between the vertical and the tibial longitudinal axes is the degree of tibial torsion

Fig. 3

a Proximal posterior axis—line the contour of the posterior condyles. b Transcondylar axis across the widest diameter of the tibial condyles. c Distal bimalleolar axis—drawn in a cut just below the tibial pilon’s articular surface, with the medial and lateral malleoli and talar dome evident between the centres of the dense surfaces of the malleoli. d Distal trans-tibial axis, a line on the distal articular surface of tibia connecting the tip of the medial malleolus to the mid-point of the lateral border (fibular sulcus)