ORIGINAL ARTICLE

Surgical Management of Persistent Intoeing Gait Due to

Increased Internal Tibial Torsion in Children
Jon R. Davids, MD,* Roy B. Davis, PhD,w Lisa C. Jameson, BS,w David E. Westberry, MD,w
and James W. Hardin, PhDz

Correction of the internal tibial torsion by rotation osteotomy

Background: Intoeing gait is frequently seen in developing chil-
dren, and in most cases it resolves with growth. However, per-
sistent, extreme intoeing gait, due to increased internal tibial
torsion, may disrupt gait function. At our institution, children
with symptomatic intoeing gait are evaluated per a standardized
protocol, which includes quantitative gait analysis. When the
primary cause is increased internal tibial torsion, surgical cor-
rection by supramalleolar tibial rotational osteotomy is recom-
mended.
Methods: The study design was a retrospective case series, with
normative controls (31 children), of typically developing chil-
dren with symptomatic intoeing gait who were treated by iso-
lated supramalleolar tibial rotation osteotomy (28 children, with
45 treated extremities). Preoperative and 1-year postoperative
physical examination, kinematic, kinetic, and pedobarographic
data were compared. Patient-reported and parent-reported
outcomes in functional and satisfaction domains were assessed
by items on a 7-point questionnaire.
Results: Internal tibial torsion, foot progression angle, and knee
rotation were normalized following tibial rotation osteotomy.
Compensatory external hip rotation and external knee pro-
gression angle were significantly improved but not normalized
following tibial rotation osteotomy. An increased coronal plane
knee varus moment was significantly decreased following sur-
gery. Increased sagittal and transverse plane knee moments were
significantly decreased but not normalized following surgery.
Significant improvements were observed with respect to trip-
ping, falling, foot/ankle pain, and knee pain following surgery.
Conclusions: Children with symptomatic intoeing gait because of
increased internal tibial torsion have characteristic primary and
compensatory kinematic gait deviations that result in increased
loading about the knee during the stance phase of gait.
From the *Shriners Hospital for Children, Sacramento, CA; wShriners
Hospital for Children, Greenville; and zDepartment of Epidemiol-
ogy and Biostatistics, Institute for Families in Society, University of
South Carolina, Columbia, SC.
Investigation was performed at Shriners Hospital for Children, Green-
ville, SC; Shriners Hospital for Children, Northern California, and
Arnold School of Public Health, University of South Carolina,
Columbia, SC.
The authors did not receive any outside funding or grants in support of
their research for the preparation of this work.
The authors declare no conflicts of interest.
Reprints: Jon R. Davids, MD, Shriners Hospital for Children, 2425
Stockton Boulevard, Sacramento, CA 95817. E-mail: jdavids@
shrinenet.org.
Copyright r 2014 by Lippincott Williams & Wilkins
improves, but does not normalize, all the kinematic and kinetic
gait deviations associated with intoeing gait. The association
between increased internal tibial torsion and degenerative
arthritis of the knee in adults may be a consequence of long-
standing increased loading of the knee joint due to the kinematic
gait deviations seen with intoeing gait.
Level of Evidence: Therapeutic intervention, level III
Key Words: intoeing, internal tibial torsion, knee kinetics, tibial
osteotomy
(J Pediatr Orthop 2014;34:467–473)
I ntoeing gait is frequently seen in typically developing
children and is defined by the presence of an internal
foot progression angle.1,2 Intoeing gait may be the con-
sequence of static anatomic malalignments such as met-
atarsus adductus, internal tibial torsion, and increased
femoral anteversion; or dynamic transverse plane gait
deviations at the level of the foot, knee, hip, and pelvis.
Mild intoeing gait while running, because of increased
internal tibial torsion, is seen more frequently in children
who are sprinters on their school’s track team.3 It is
postulated that the biomechanics of sprinting favors a
slight internal foot progression angle, which may be easier
to achieve with low normal range internal tibial torsion.
More extreme intoeing gait, due to increased in-
ternal tibial torsion, may disrupt gait function, by com-
promising clearance in swing phase (eg, catching of the
swing phase forefoot against the stance phase lower tibia)
and foot/ankle loading in stance phase (eg, loss of heel
strike and first rocker in loading response and lever arm
deficiency during forefoot or third rocker).4–6 Increased
internal tibial torsion has been associated with medial
compartment and panarticular osteoarthritis of the knee
in adults.7–11 Although the nature of this association is
not clear, quantitative gait analysis studies of subjects
with intoeing gait due to increased internal tibial torsion
have revealed abnormal loading of the knee in the coronal
plane.7,12 Intoeing gait may also compromise gait cosm-
esis. This is a great concern to parents and children,
particularly during the middle school years.13
At our institution, children with symptomatic in-
toeing gait (ie, functional complaints related to intoeing
gait) are evaluated per a standardized protocol with

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Davids et al
quantitative gait analysis to establish the magnitude and
cause(s) of the gait pattern. When the symptomatic in-
toeing gait is the consequence of increased internal tibial
torsion (ie, bimalleolar axis with knee extended <20 de-
grees external, which is Z20 degrees internal relative to
normal of 40 external), surgical correction by distal tibial
rotational osteotomy is recommended.2,13 The goal of the
surgery was to normalize the relation between the knee
flexion-extension and ankle dorsi-plantarflexion axes, as
reflected by the thigh foot angle. Follow-up assessment
with quantitative gait analysis was performed approx-
imately 1 year after surgery, before implant removal.
Review of our experience with this treatment paradigm
was performed to determine outcome in several domains.
We hypothesize that (1) intoeing gait due to increased
internal tibial torsion results in primary and compensa-
tory gait deviations, which lead to abnormal loading of
the knee, and (2) surgical correction of the internal tibial
torsion results in correction of these gait deviations and
improvement of knee loading.
METHODS
Participants
The study design was a retrospective case series in-
vestigating a therapeutic intervention, with normative
controls, resulting in level III evidence. The study was
approved by our hospital’s Institutional Review Board.
The cases for study were identified by searching 2 com-
puterized databases of all children seen in the Motion
Analysis Laboratory and all surgical procedures per-
formed at our institution between 2002 and 2010. In-
clusion criteria consisted of a presurgical gait analysis,
unilateral or bilateral distal tibial rotational osteotomy,
and a postsurgical gait analysis. Subjects with any asso-
ciated diagnosis of a neuromuscular disease were ex-
cluded. Subjects who underwent multilevel surgical
correction of transverse plane malalignments (such as
increased femoral anteversion and metatarsus adductus)
were also excluded. The final study group consisted of 28
typically developing children, with symptomatic intoeing
gait, who were treated by isolated tibial rotation osteo-
tomy.
Surgery
In all cases, surgical correction of excessive internal
tibial torsion was performed at the supramalleolar level,
without concomitant fibular osteotomy.14–16 A smooth
Steinmann pin was placed into the tibia, just proximal to
the plate, aligned with the flexion-extension axis of the
knee. A second pin was placed into the tibia distal to the
plate, aligned with the long axis of the foot. A gonio-
metric triangle was used to determine the angle created by
the proximal and distal pins. The osteotomy was per-
formed at a level between the pins, and the distal tibial
fragment was rotated externally until the pins were par-
allel, aligning the knee and ankle axes (thigh foot angle
approximately 5 degrees external). Fixation of the tibial
osteotomy was performed with a compression plate for all
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J Pediatr Orthop  Volume 34, Number 4, June 2014
case. The osteotomies were performed by 2 surgeons
(J.R.D. and D.E.W.) who utilized the same surgical
techniques and postoperative management.
Data Collection
Evaluation in the Motion Analysis Laboratory in-
cluded a physical examination performed by a physical
therapist or a kinesiologist. Goniometric assessment of
alignment and range of motion were performed in a
standardized manner. Femoral version was measured
with the child in the prone position, with the hip ex-
tended, and the knee flexed.2 Ranges of internal (normal
50 degrees) and external rotation (normal 40 degrees)
were measured. Tibial torsion was measured by the bi-
malleolar axis, with the knee extended (child supine, with
the hip and knee fully extended, normal 40 degrees ex-
ternal) and flexed to 90 degrees (child prone, with the hip
extended and the knee flexed, normal 20 degrees ex-
ternal).2,17,18 Bilateral 3-dimensional kinematic and ki-
netic data were collected by using a 12-camera motion
measurement system (Vicon 512; Oxford Metrics Group,
Oxford, UK) and 2 force platforms (Advanced Mech-
anical Technology Inc., Watertown, MA). Subjects were
instrumented with passive reflective markers consistent
with the Newington protocol for gait analysis.19
Variables
The preoperative and postoperative gait analyses
were reviewed and relevant data from the physical ex-
amination, kinematic analysis, kinetic analysis, and dy-
namic pedobarography were extracted. Demographic
data collected included age, sex, site(s) of surgery, and
time to follow-up. Data from physical examination in-
cluded weight, height, hip rotation, and tibial torsion.
Data from the kinematics include static, marker-based
tibial torsion, pelvic rotation, hip rotation, knee rotation,
knee progression angle, ankle rotation, and foot pro-
gression angle. Kinematic data were reported as mean
values during the single-support subphase of stance. Ki-
netic data analyzed included coronal, sagittal, and
transverse plane knee moments at opposite initial contact
and opposite toe off (which correspond to vertical force
peaks during terminal stance and loading response, re-
spectively) and during single support. Data from the pe-
dobarograph included foot progression angle, which was
calculated as described previously.20
Normative values for kinematic and kinetic data
were determined from a group of 31 typically developing
children evaluated in the Motion Analysis Laboratory at
Shriners Hospitals for Children, Salt Lake City, also us-
ing the Newington protocol and same measurement
technology as our Motion Analysis Laboratory. There
were 15 girls and 16 boys, with a mean age of 10.2 years
(SD 3.8 y) and a mean body mass index of 17.1 kg/m2.
Patient-reported and parent-reported outcomes in
functional and satisfaction domains were assessed by re-
view of the Motion Analysis Laboratory patient history
and follow-up clinic or telephone interviews. In the
absence of a validated outcome instrument specific to
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J Pediatr Orthop  Volume 34, Number 4, June 2014
torsional gait issues, a 7-point questionnaire was devel-
oped, based upon the expert opinion of 3 clinicians. The
questionnaire, which considered problems with walking,
running, and falling and pain in the feet/ankles, knees,
and hips, was applied retrospectively.
Statistical Analysis
Continuous data were analyzed with paired t tests
(preoperative vs. postoperative for the study group) or
independent sample t tests adjusted for multiple ob-
servations per subject (preoperative vs. normative con-
trols). The independent sample t tests for surgical
outcome variables were based on data for which the study
subjects could provide 1 or 2 measurements. Two meas-
urements from the same subject are assumed to be cor-
related, whereas 2 measurements from different persons
are assumed to be independent. Our inference was based
on statistics that were adjusted for within-person corre-
lation. Adjusted inferences are the result of interpreting
P-values of statistics based on the modified sandwich
variance estimator (which is different from the usual
variance estimator that assumes all observations are in-
dependent). Thus, the inference provided for results based
on the modified sandwich variance estimator are robust
to the presence of repeated observations per patient.
Categorical data were analyzed with w2 tests. Statistical
significance for both continuous and categorical data
analyses was inferred for P-values r0.05.
Source of Funding
The authors did not receive any outside funding or
grants in support of their research for the preparation of
this work.
RESULTS
Demographics and Complications
There were 28 children, with 45 treated extremities,
included in the study group. Seventeen were boys and 11
were girls. Mean age at the time of surgery was 10.4 years
(SD 2.0 y; range, 7 to 14.5 y). Time from surgery to fol-
low-up gait analysis study was 1.2 years (SD 0.5 y; range,
0.9 to 2.3 y). The mean body mass index at the time of the
initial gait analysis study was 19.3 kg/m2. There were 4
extremities, in 3 patients, with early postoperative com-
plications. All were partial, superficial wound dehiscence
appreciated at the 4- to 6-week postoperative cast re-
moval. No specific treatment was performed, and all in-
cisions healed by secondary intention at the sites of
dehiscence. There were no late postoperative surgical
complications appreciated at the follow-up gait analysis
study.
Physical Examination
Changes in the torsional profile portion of the
physical examination between preoperative and post-
operative evaluations are summarized in Table 1. Hip
rotation revealed a minimal internal bias on the pre-
operative evaluation and was not significantly different
following surgery. The bimalleolar axis, measured with
r 2014 Lippincott Williams & Wilkins
Management of Persistent Intoeing Gait
the knee extended, improved significantly from 6 degrees
external to 31 degrees external following surgery
(P < 0.001). The bimalleolar axis, measured with the knee
flexed, improved significantly from 2 degrees external to
20 degrees external following surgery (P < 0.001).
Kinematics
Changes in the kinematic data between preoperative
and postoperative evaluations, and their relation to nor-
mative values, are summarized in Table 2. Tibial torsion,
as measured by the static calibration trials, was sig-
nificantly internal relative to normal in the preoperative
assessment (7 degrees external, P < 0.001) and improved
significantly (14 degrees external, P < 0.001) following
surgery. On average, the postsurgical tibial torsion was
comparable to that of the normative children (15 degrees
external, P = 0.851). The mean foot progression angle in
single support was significantly internal relative to the
normative children in the preoperative assessment (7 de-
grees internal, P < 0.001) and improved significantly (6
degrees external, P < 0.001) following surgery. The
postsurgical value for foot progression angle was com-
parable to that of the normative children (8 degrees ex-
ternal, P = 0.1234). Mean hip rotation in single support
was significantly external relative to the normative chil-
dren in the preoperative assessment (6 degrees external,
P < 0.001), improved significantly following surgery (2
degrees external, P = 0.003), but remained significantly
different that of the normative children (4 degrees in-
ternal, P = 0.003). Mean knee rotation in single support
was significantly internal relative to the normative chil-
dren in the preoperative assessment (13 degrees internal,
P < 0.001), improved significantly following surgery (5
degrees external, P < 0.001), and was comparable to
normal (9 degrees external, P = 0.111). No significant
changes between preoperative and postoperative values
were appreciated for mean pelvic or ankle rotation in
single support (P = 0.190 and 0.996, respectively).
Kinetics
Changes in the kinetic data between preoperative
and postoperative evaluations, and their relation to nor-
mative values, are summarized in Table 3. Coronal plane
kinetics showed a strong trend toward increased external
varus moment at the knee at opposite initial contact
(P = 0.054) preoperatively. This moment was sig-
nificantly decreased following surgery, with respect to
both preoperative and normal values (P < 0.001,
P = 0.013, respectively). Mean knee moment in single
support was significantly reduced, with respect to both
preoperative and normal values (P < 0.001, P = 0.007,
respectively) following surgery. No significant changes
were observed in the knee moment at opposite toe off
following surgery.
Sagittal plane kinetics showed significantly in-
creased knee moment at opposite toe off, opposite initial
contact, in single support, and in loading response
preoperatively (P < 0.001, P = 0.032, P = 0.004, and
P = 0.006, respectively). The postoperative knee moment
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TABLE 1. Physical Examination Data

Preoperative vs. Postoperative
Parameters Preoperative (deg.)* Postoperative (deg.)* (Paired t Test)
Hip
Internal rotation 61 ± 11 (35-90) 62 ± 11 (40-90) 0.779
External rotation 44 ± 12 (20-65) 45 ± 11 (20-65) 0.289
Tibia
Bimalleolar axis-knee extendedw 6 ± 7 ( 5 to 20) 31 ± 8 (15-40) < 0.001
Bimalleolar axis-knee flexedw 2 ± 7 ( 10 to 20) 20 ± 6 (0-35) < 0.001
*The values are given as the mean and the SD, with the range in parentheses.
wPositive values are external, negative values are internal.

at opposite toe off was reduced with respect to the pre-
operative value (P = 0.073) but was still significantly
greater than normal (P = 0.024). No significant changes
were observed in the knee moments at opposite initial
contact, in single support, or in loading response fol-
lowing surgery.
Transverse plane kinetics showed increased knee
moment (mean and peak-to-peak amplitude) in single
support preoperatively. These moments were significantly
decreased following surgery, with respect to both pre-
operative and normal values (mean moment, P = 0.04
and P < 0.001, respectively; amplitude, P = 0.002 and
0.018, respectively).
Pedobarography
The preoperative foot progression angle in stance
phase calculated from the pedobarograph was internal 7
degrees, which improved significantly to external 4 de-
grees following surgery (P < 0.001).
Patient-reported/Parent-reported Outcomes
Patient-reported and parent-reported outcomes in
functional and satisfaction domains are summarized
in Table 4. Tripping (18 of 28, 64%), falling (11 of 28,
39%,), foot/ankle pain (11 of 28, 39%), and knee pain (9
of 28, 32%) were the most common problems associated
with intoeing before surgery. Significant improvement in
each of these parameters was noted at the time of follow-
up (tripping in 1 of 28, 4%, P < 0.0000; falling in 0 of 28,
P = 0.0000; foot/ankle pain in 2 of 28, 7%, P = 0.0013;
and knee pain in 1 of 28, 4%, P = 0.0187). Problems with
running due to intoeing were present in 7 of 28 subjects
(25%) before surgery and remained a problem in 5 of 28
(18%) following surgery. This difference was not
significant (P = 0.480). In all cases the subjects were

TABLE 2. Kinematic Data

Preoperative Postoperative Preoperative
vs. Normal vs. Normal vs.
Preoperative Postoperative Normal (Independent (Independent Postoperative
Parameter (deg.)* (deg.)* (deg.)* Sample t Test) Sample t Test) (Paired t Test)
Tibial torsion: static 7 ± 5 (1-16) 14 ± 8 (3-33) 15 ± 9 (1-37) < 0.001 0.851 < 0.001
calibrationw
Mean foot 9 ± 7 ( 6 to 24)  6 ± 7 ( 20 to 7) 8 ± 7 (24 to 8) 0.001 0.124 < 0.001
progression angle
in SSz
Mean pelvic 1 ± 4 ( 11 to 9)  2 ± 4 ( 11 to 7) 0 ± 4 (8 to 9) 0.242 0.023 0.190
rotation in SSz
Mean hip rotation 6 ± 9 ( 27 to 11)  2 ± 9 ( 22 to 12) 4 ± 9 (18 to 22) < 0.001 0.0033 0.0033
in SSz
Mean knee rotation 13 ± 10 (6 to 39)  5 ± 11 ( 29 to 22) 9 ± 11 (29 to 11) < 0.001 0.111 < 0.001
in SSz
Mean knee 6 ± 9 ( 28 to 12)  3 ± 9 ( 21 to 15) 4 ± 9 (16 to 23) < 0.001 0.001 0.038
progression angle
in SSz
Mean ankle rotation 3 ± 6 ( 8 to 17) 3 ± 5 ( 10 to 16) 3 ± 6 (15 to 9) < 0.001 0.000 0.996
in SSz
*The values are given as the mean and the SD, with the range in parentheses.
wPositive values are external.
zPositive values are internal, negative values are external.
SS indicates single support.

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J Pediatr Orthop  Volume 34, Number 4, June 2014 Management of Persistent Intoeing Gait

TABLE 3. Knee Kinetics

Preoperative vs. Postoperative vs. Preoperative vs.
Preoperative Postoperative Normal Normal (Independent Normal (Independent Postoperative
Parameters (N m/kg)* (N m/kg)* (N m/kg)* Sample t test) Sample t test) (Paired t test)
Coronal
Knee moment at 0.20 ± 0.15 0.20 ± 0.12 0.28 ± 0.05 0.048 0.032 0.926
OTO
Knee moment at 0.25 ± 0.11 0.14 ± 0.12 0.21 ± 0.11 0.054 0.013 < 0.001
OIC
Mean knee moment 0.23 ± 0.11 0.16 ± 0.09 0.21 ± 0.09 0.211 0.007 < 0.001
in SS
Sagittal
Knee moment at 0.57 ± 0.23 0.49 ± 0.21 0.39 ± 0.21 < 0.001 0.024 0.073
OTO
Knee moment at 0.15 ± 0.19 0.10 ± 0.20 0.07 ± 0.18 0.032 0.352 0.205
OIC
Mean knee moment 0.13 ± 0.14 0.10 ± 0.14 0.01 ± 0.14 < 0.001 0.004 0.178
in SS
Peak knee moment 0.60 ± 0.24 0.54 ± 0.22 0.45 ± 0.22 0.006 0.126 0.116
in LR
Transverse
Mean knee moment 0.06 ± 0.04 0.04 ± 0.03 0.05 ± 0.02 0.387 < 0.001 0.036
in SS
Amplitude knee 0.14 ± 0.06 0.11 ± 0.04 0.14 ± 0.05 0.792 0.018 0.002
moment in SS
*The values are given as the mean and the standard deviation.
LR indicates loading response; OIC, opposite initial contact; OTO, opposite toe off; SS, single support.

thought to be better off functionally following surgery,
and the parents were satisfied with the decision to per-
form surgery.
DISCUSSION
Intoeing gait is a common problem in childhood,
with an estimated prevalence of up to 30% in children
aged 6 years and younger, and up to 7% in children aged
9 years and older.21 Increased internal tibial torsion is the
most common cause of intoeing gait in children between 3
and 6 years of age.13,22,23 Increased femoral anteversion is
the most common cause of intoeing in children between 6
and 10 years of age.13,22,23 The most common cause of
torsional malalignment in adolescents is also increased
femoral anteversion, which may be accompanied by ex-
cessive internal or external tibial torsion.13,22,24,25
The natural history of unresolved intoeing gait be-
cause of persistent increased internal tibial torsion is not
well understood. Multiple investigators have found sig-
nificant internal tibial torsion in adults with 2 common
patterns of degenerative arthritis of the knee.7–11 Kine-
matic and kinetic studies of subjects with persistent,
symptomatic intoeing gait because of increased internal
tibial torsion have revealed increased varus loading of the
knee in the coronal plane during a subphase of stance.7,12
Intoeing gait due to increased internal tibial torsion
may be symptomatic in functional and cosmetic domains.
Although indications for surgical correction of internal
tibial torsion have been proposed, significant controversy
remain concerning the appropriateness of such inter-
ventions.13,22 Objective, multidomain outcome studies
following surgical correction of symptomatic intoeing
gait due to increased internal tibial torsion in typically
developing children has not, to our knowledge, been

TABLE 4. Patient-reported/Parent-reported Outcomes

Preoperative Postoperative Preoperative vs. Postoperative
Problems With Intoeing Yes No Yes No P
Tripping 18 10 1 27 0.000
Walking 6 22 0 28 0.007
Running 7 21 5 23 0.480
Falling 11 17 0 28 0.000
Foot/ankle pain 11 17 2 26 0.001
Knee pain 9 19 1 27 0.002
Hip pain 5 23 0 28 0.019
Better/pleased NA NA 28 0 NA
NA indicates not applicable.

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Davids et al
reported. Clinical decision making for the surgical man-
agement of intoeing gait at our center was based upon a
diagnostic matrix, which incorporated data from multiple
domains (eg, the clinical history, physical examination,
and occasionally diagnostic imaging), utilizing quantita-
tive gait analysis to confirm the magnitude and cause(s)
of this gait pattern and assess the outcomes following
surgery.
Technical and Functional Domain Outcomes
The objective assessment of tibial transverse plane
alignment is complex and controversial.26 Subjects in the
study had significantly increased internal tibial torsion, as
measured by goniometric-based physical examination and
kinematic marker static calculations. Both parameters
were normalized following distal tibial rotation osteot-
omy. The complication rate following this procedure
in the current study compared favorably with the
literature.14–16
Significant primary kinematic gait deviations in this
group of subjects with intoeing gait because of increased
internal tibial torsion included internal foot progression
angle (as measured by kinematics and dynamic pedobar-
ography) and increased internal knee rotation (ie, tibia
relative to femur). A significant compensatory kinematic
deviation, external hip rotation (presumably representing
an effort to correct the internal foot progression angle), was
appreciated. This resulted in a significant external knee
progression angle (knee relative to line of progression) in
stance phase. Foot progression angle (kinematic and pe-
dobarographic) and knee rotation were normalized fol-
lowing surgery to correct internal tibial torsion. Hip
rotation and knee progression angle were significantly im-
proved but not normalized following tibial rotation os-
teotomy.
Measurable kinetic deviations at the knee in the
coronal, sagittal, and transverse planes were identified in
this group of subjects with intoeing gait because of in-
creased internal tibial torsion. The coronal plane devia-
tions, indicating significantly increased varus or medial
loading of the knee, were comparable with those pre-
viously reported in the literature.7,12 The sagittal plane
deviations indicated significantly increased external flexor
loading of the knee throughout stance phase. The trans-
verse plane deviations indicated increased rotational
loading in the single-support subphase of stance. Five of
the 9 kinetic measures at the knee were significantly in-
creased preoperatively, 4 of the 9 measures were sig-
nificantly decreased (relative to preoperative values) after
surgery, and 7 of the 9 measures were comparable to, or
significantly less than, normal values following surgery.
Of the 5 kinetic measures that were significantly increased
before surgery, 3 were comparable to, or significantly less
than, normal values following surgery.
Patient-reported/Parent-reported Outcomes
Tripping falling, foot/ankle pain, and knee pain
were the most common problems associated with intoeing
before surgery, and significant improvement was noted
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J Pediatr Orthop  Volume 34, Number 4, June 2014
for each of these parameters following surgery. Problems
with running were not a common complaint associated
with intoeing gait (present in only 25% of subjects).
However, there were fewer complaints of problems with
running following tibial rotation osteotomy, but this
difference was not statistically significant. Problems with
running and improvement following surgery might be
more easily appreciated in a larger study group. Overall
parental satisfaction with the outcomes following surgery
was high.
Hypotheses
The first study hypothesis, that intoeing gait due to
increased internal tibial torsion results in primary and
compensatory gait deviations which lead to abnormal
loading of the knee, was supported by the results of the
study. Significant transverse plane kinematic deviations
were identified. Kinetic deviations about the knee were
appreciated in all 3 planes. The second hypothesis, that
surgical correction of the internal tibial torsion results in
correction of these gait deviations and improvement of
knee loading, was only partially supported by the results
of the study. Although significant kinematic and kinetic
improvements were appreciated following tibial rotation
osteotomy, a number of important parameters remained
increased (eg, hip rotation, knee progression angle, sag-
ittal knee moment at opposite toe off, and mean sagittal
knee moment in single support) relative to normal fol-
lowing surgery. Failure to normalize loading after pre-
sumed normalization of anatomic alignment suggests the
presence of other coexisting malalignments not captured
by gait analysis, persistent habitual dynamic gait devia-
tions, or both. Longitudinal study, and more sophisti-
cated analysis of kinematic and kinetic data, will be
required to better understand the etiology, natural his-
tory, indications for correction of transverse plane ma-
lalignments, and optimal surgical strategies for the
management of intoeing gait.
The results of this study shed some light on the re-
lationship between tibial torsion and degenerative ar-
thritis of the knee. The study shows that subjects with
symptomatic intoeing gait due to internal tibial torsion
have primary and compensatory gait deviations that re-
sult in abnormal loading about the knee in the stance
phase of gait. Longstanding static skeletal deformity, re-
lated dynamic gait deviations, and associated abnormal
loading may contribute to accelerated degenerative
changes at the knee over time. It is intuitive, and ap-
pealing, to believe that early surgical correction of the
increased internal tibial torsion will correct the gait kin-
ematics and kinetics to a degree that will improve the
loading about the knee and decrease the risk of sub-
sequent osteoarthritis. Unfortunately, this concept cannot
be supported (or refuted) by the current retrospective
study. Definitive assessment will require prospective study
utilizing a societal cradle-to-grave musculoskeletal data-
base and validated outcomes assessment tools. In the
absence of such natural history and long-term outcomes
data, we believe that surgical correction of persistent
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J Pediatr Orthop  Volume 34, Number 4, June 2014
internal tibial torsion should only be offered to subjects
with significant functional complaints related to the as-
sociated intoeing gait pattern.
SUMMARY
Children with symptomatic intoeing gait due to in-
creased internal tibial torsion have characteristic primary
and compensatory kinematic gait deviations that result in
increased loading about the knee during the stance phase
of gait. Correction of the internal tibial torsion by rota-
tion osteotomy improves but does not normalize all kin-
ematic and kinetic gait deviations associated with intoeing
gait. The association between increased internal tibial
torsion and degenerative arthritis of the knee in adults
may be a consequence of longstanding increased loading
of the knee joint due to the kinematic gait deviations seen
with intoeing gait.
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1. Staheli LT. Rotational problems in children. Instr Course Lect.
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