Peds

Internal Tibial Torsion

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Internal Tibial Torsion, Medial Tibial Torsion

  • See Also
  1. In-Toeing
  2. Femoral Anteversion
  3. Metatarsus Adductus
  4. Pediatric Leg Disorder
  5. Pediatric Limp
  6. Gait Evaluation in Children
  • Definitions
  1. Internal Tibial Torsion
    1. Tibia internally rotated with toe pointing inward
  • Epidemiology
  1. Common pediatric leg rotation variant
  2. Most common cause of In-Toeing in age 1-3 years (typically presenting in toddlers)
    1. Newborns have mean tibial internal rotation of 5 degrees
  • Pathophysiology
  1. Internal Tibial Torsion may be related to in utero positioning
  • Signs
  1. Bilateral in two thirds of cases
  2. Observation of child walking
    1. Knee caps point forward
      1. Femur external
      2. Tibial internal rotation cancels femur rotation
    2. Foot points inward (due to tibial rotation)
      1. Internally rotated thigh foot angle
      2. Negative Foot Progression Angle
  3. Assess Thigh-Foot Angle
    1. See Tibial Rotation in Children
    2. Abnormal if tibial internal rotation >10 degrees (referral indication at age >8 years)
  • Course
  1. Spontaneous resolution in 95% of children by age 5-8 years old
  • Management
  1. Avoid braces, night splints, shoe modifications, Orthotics, serial Casting
  2. Treat any associated Metatarsus Varus (other cause of In-Toeing)
  3. Surgical indications (rare)
    1. Children >8 years with Thigh-Foot Angle >15 degrees (>3 SD above mean) AND
    2. Severe functional or cosmetic abnormality not expected to improve
  • Prognosis
  1. Persistent Internal Tibial Torsion is not associated with significant morbidity, Disability or joint degeneration
  • References
  1. Baird (2025) Am Fam Physician 111(2): 125-39 [PubMed]
  2. Rerucha (2017) Am Fam Physician 96(4): 226-33 [PubMed]