Clinical Measures Associated With Tibial Torsion in Ambulatory Children With Cerebral Palsy and Pes Valgus
Background: Transverse plane alignment deviations in individuals with cerebral palsy (CP) contribute to lever arm dysfunction. The cause of this is often multifactorial. External tibial torsion and pes valgus are both possible causes. Tibial torsion could be missed without detailed clinical exam. Th...
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2025-02-01
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| Series: | Journal of the Pediatric Orthopaedic Society of North America |
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| Online Access: | http://www.sciencedirect.com/science/article/pii/S2768276524009775 |
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| author | Eva Ciccodicola, PT, DPT, PCS Oussama Abousamra, MD Veronica Beltran, BS Susan A. Rethlefsen, PT, DPT Tishya A.L. Wren, PhD |
| author_facet | Eva Ciccodicola, PT, DPT, PCS Oussama Abousamra, MD Veronica Beltran, BS Susan A. Rethlefsen, PT, DPT Tishya A.L. Wren, PhD |
| author_sort | Eva Ciccodicola, PT, DPT, PCS |
| collection | DOAJ |
| description | Background: Transverse plane alignment deviations in individuals with cerebral palsy (CP) contribute to lever arm dysfunction. The cause of this is often multifactorial. External tibial torsion and pes valgus are both possible causes. Tibial torsion could be missed without detailed clinical exam. The purpose of this study was to examine factors associated with external tibial torsion in patients with CP and pes valgus. Methods: We retrospectively examined patients with CP who had pes valgus. Participants underwent clinical examination, including transmalleolar axis angle (TMA). TMA >20° external was considered clinically significant external tibial torsion. The association of TMA and external tibial torsion to demographic and clinical examination data were examined. Results: Two hundred forty-seven patients were included with 422 valgus feet (175 bilateral). External tibial torsion was observed in 11.6% of limbs. Tibial torsion became more external with age (β = 0.12, 95% CI = [0.02, 0.22], P = .02). TMA was correlated with dorsiflexion (β = −0.10, 95% CI = [-0.18, −0.02], P = .02) and hindfoot inversion range of motion (ROM) (β = 0.19, 95% CI = [0.06, 0.31], P = .005). Tibial torsion was not correlated with gender, Gross Motor Function Classification System (GMFCS) level, plantarflexor spasticity, or knee extension ROM. Conclusions: External tibial torsion as a possible contributor to transverse plane malalignment needs to be considered in older patients with CP who have pes valgus with limited hindfoot inversion ROM. Our results highlight that external tibial torsion increases with age, increased dorsiflexion, and limited hindfoot inversion ROM. Overlooking external tibial torsion when correcting pes valgus could result in under correction of malalignment and continued functional limitations related to lever arm dysfunction. Key Concepts: (1) The causes of external foot progression are often multifactorial, including both external tibial torsion and pes valgus. (2) External tibial torsion needs to be considered as a possible contributor to transverse plane malalignment in older patients with CP with pes valgus and limited hindfoot inversion ROM. (3) Failure to recognize external tibial torsion may lead to undercorrection of lever arm dysfunction for patients with CP. Level of Evidence: III |
| format | Article |
| id | doaj-art-601cb94a33b84ab5af61fd7aacfc2020 |
| institution | DOAJ |
| issn | 2768-2765 |
| language | English |
| publishDate | 2025-02-01 |
| publisher | Elsevier |
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| series | Journal of the Pediatric Orthopaedic Society of North America |
| spelling | doaj-art-601cb94a33b84ab5af61fd7aacfc20202025-08-20T02:45:53ZengElsevierJournal of the Pediatric Orthopaedic Society of North America2768-27652025-02-011010015110.1016/j.jposna.2024.100151Clinical Measures Associated With Tibial Torsion in Ambulatory Children With Cerebral Palsy and Pes ValgusEva Ciccodicola, PT, DPT, PCS0Oussama Abousamra, MD1Veronica Beltran, BS2Susan A. Rethlefsen, PT, DPT3Tishya A.L. Wren, PhD4Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA; Corresponding author: Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, 4650 Sunset Blvd., MS 69, Los Angeles, CA 90027, USA.Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA; Keck School of Medicine, University of Southern California, Los Angeles, CA, USAJackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USAJackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USAJackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA; Keck School of Medicine, University of Southern California, Los Angeles, CA, USABackground: Transverse plane alignment deviations in individuals with cerebral palsy (CP) contribute to lever arm dysfunction. The cause of this is often multifactorial. External tibial torsion and pes valgus are both possible causes. Tibial torsion could be missed without detailed clinical exam. The purpose of this study was to examine factors associated with external tibial torsion in patients with CP and pes valgus. Methods: We retrospectively examined patients with CP who had pes valgus. Participants underwent clinical examination, including transmalleolar axis angle (TMA). TMA >20° external was considered clinically significant external tibial torsion. The association of TMA and external tibial torsion to demographic and clinical examination data were examined. Results: Two hundred forty-seven patients were included with 422 valgus feet (175 bilateral). External tibial torsion was observed in 11.6% of limbs. Tibial torsion became more external with age (β = 0.12, 95% CI = [0.02, 0.22], P = .02). TMA was correlated with dorsiflexion (β = −0.10, 95% CI = [-0.18, −0.02], P = .02) and hindfoot inversion range of motion (ROM) (β = 0.19, 95% CI = [0.06, 0.31], P = .005). Tibial torsion was not correlated with gender, Gross Motor Function Classification System (GMFCS) level, plantarflexor spasticity, or knee extension ROM. Conclusions: External tibial torsion as a possible contributor to transverse plane malalignment needs to be considered in older patients with CP who have pes valgus with limited hindfoot inversion ROM. Our results highlight that external tibial torsion increases with age, increased dorsiflexion, and limited hindfoot inversion ROM. Overlooking external tibial torsion when correcting pes valgus could result in under correction of malalignment and continued functional limitations related to lever arm dysfunction. Key Concepts: (1) The causes of external foot progression are often multifactorial, including both external tibial torsion and pes valgus. (2) External tibial torsion needs to be considered as a possible contributor to transverse plane malalignment in older patients with CP with pes valgus and limited hindfoot inversion ROM. (3) Failure to recognize external tibial torsion may lead to undercorrection of lever arm dysfunction for patients with CP. Level of Evidence: IIIhttp://www.sciencedirect.com/science/article/pii/S2768276524009775Tibial torsionPes valgusCerebral palsy |
| spellingShingle | Eva Ciccodicola, PT, DPT, PCS Oussama Abousamra, MD Veronica Beltran, BS Susan A. Rethlefsen, PT, DPT Tishya A.L. Wren, PhD Clinical Measures Associated With Tibial Torsion in Ambulatory Children With Cerebral Palsy and Pes Valgus Journal of the Pediatric Orthopaedic Society of North America Tibial torsion Pes valgus Cerebral palsy |
| title | Clinical Measures Associated With Tibial Torsion in Ambulatory Children With Cerebral Palsy and Pes Valgus |
| title_full | Clinical Measures Associated With Tibial Torsion in Ambulatory Children With Cerebral Palsy and Pes Valgus |
| title_fullStr | Clinical Measures Associated With Tibial Torsion in Ambulatory Children With Cerebral Palsy and Pes Valgus |
| title_full_unstemmed | Clinical Measures Associated With Tibial Torsion in Ambulatory Children With Cerebral Palsy and Pes Valgus |
| title_short | Clinical Measures Associated With Tibial Torsion in Ambulatory Children With Cerebral Palsy and Pes Valgus |
| title_sort | clinical measures associated with tibial torsion in ambulatory children with cerebral palsy and pes valgus |
| topic | Tibial torsion Pes valgus Cerebral palsy |
| url | http://www.sciencedirect.com/science/article/pii/S2768276524009775 |
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