Rotational profile of the lower limb in 1319 healthy children

Michel Jacquemier, Yann Glard *, Vincent Pomero, Elke Viehweger,Jean-Luc Jouve, Gerard Bollini

Department of Pediatric Orthopaedics, Timone Children’s Hospital, Marseille, France

Received 29 August 2007; received in revised form 16 November 2007; accepted 25 November 2007

Abstract

Lower limb rotational profile in children may cause great concern to parents and relatives. In order to give parents clear information, there

is a need for referential studies giving normative data of lower limb rotational profile and its normal changes expected over growth. Our aim

was to collect a large clinical series of healthy children, out of a clinic, selected from a non-consulting population and to analyse Tibial Torsion

and Femoral Anteversion according to age and gender.

One thousand three hundred and nineteen healthy children underwent a clinical evaluation. Tibial Torsion was assessed using the method

described by Staheli and Engel, whereas Femoral Anteversion was assessed using the method described by Netter. Our results showed that

there was a significant difference between males and females in Femoral Anteversion, whereas there was no significant difference between the

right side and the left side. Femoral Anteversion was higher in females, and was markedly correlated with age in both genders. There was no

significant difference between males and females in Tibial Torsion, nor significant difference between the right side and the left side. Tibial

Torsion was slightly correlated with age in both genders. Normative data were statistically defined in this work using the �2 S.D. range. To

our knowledge, there is no large and comprehensive series in the English speaking literature that gives normative data of Femoral Anteversion.

Concerning Tibial Torsion, our results compared to those published in the literature.

# 2007 Elsevier B.V. All rights reserved.

Keywords: Femoral Anteversion; Tibial Torsion; Children

www.elsevier.com/locate/gaitpost

Available online at www.sciencedirect.com

Gait & Posture 28 (2008) 187–193

1. Introduction

Lower limb rotational profile in children may cause great

concern to parents and relatives, and lead to a consultation in

a paediatric orthopaedic outpatient clinic [1]. In most cases,

the rotational profile that appears abnormal to parents is

transient and will correct within the range of normality

without any treatment [2]. In order to provide parents with

clear information, reference studies including normative

data of lower limb rotational profile and its normal changes

during growth are required. Most of the series published in

the literature attempting to address this issue have significant

drawbacks, and to date, there is no comprehensive clinical

series available: some series are not based on sufficient

* Corresponding author at: Service de Chirurgie Orthopedique Infantile,

Hopital d’Enfants de la Timone, 245 Rue St Pierre, 13385 Marseille Cedex

5, France. Tel.: +33 4 91 38 69 05.

E-mail address: yann.glard@gmail.com (Y. Glard).

0966-6362/$ – see front matter # 2007 Elsevier B.V. All rights reserved.

doi:10.1016/j.gaitpost.2007.11.011

numbers to be significant, e.g. the one from Staheli [2,3].

Furthermore, Staheli used internal and external hip rotation

to describe the torsional alignment of the femur. In some

others (Craxford et al. [4]), patients were not divided

according to their gender, despite the established difference

in the lower limb morphology between males and females.

Some studies are only radiological (Fabry et al. [5]), while

others focussed only on the rotational range of motion of the

hip, without any assessment of the Femoral Anteversion

(Svenningsen at al. [6], Cheng et al. [1]). Our aim was to

collect a large clinical series of healthy children, outside

clinical practice, selected from a non-consulting population

and to analyse the distribution, according to age and gender

of Tibial Torsion and Femoral Anteversion,

2. Materials and methods

The senior author (MJ) performed the clinical evaluation, after

agreement from parents and educational authorities. This work has

M. Jacquemier et al. / Gait & Posture 28 (2008) 187–193188

also been approved by the ethical committee related to our

institution. One thousand four hundred and thirty-five children

were considered for inclusion. The inclusion criterion was an age

between 3 and 10 years. Thirty-four children were not included

because of parental refusal. All these children had a previously

diagnosed pathological orthopaedic condition. One thousand four

hundred and one children underwent a clinical examination.

Clinical examination was carried out at school, class after class.

Males and females were examined separately. Children were

examined barefoot, wearing shorts. The patient was seated as

described by Staheli and Engel [7]: knee flexed, legs hanging from

the edge of the table with the thigh directly in front of the hip joint,

and heels against a flat vertical surface. The forefoot was held by

the examiner at right angle to the back wall in both the sagittal and

horizontal planes and the Tibial Torsion was assessed using the

method described by the above authors [7]. The patient was then

placed in the prone position, and the Femoral Anteversion was

clinically assessed using the method described by Netter (cited by

Ruwe et al. [8]). To measure the right hip, the examiner stood on

the contralateral side of the patient, and, with the patient’s knee

flexed to 908, the examiner used his left hand to palpate the greater

trochanter, while the right hand internally rotated the hip. At the

point of maximum trochanteric prominence, representing the

most lateral position of the trochanter, the neck of the femur

was parallel to the floor. The angle subtended between the tibia

and true vertical, representing the Femoral Anteversion, was

measured with a goniometer. Eventually, the child was asked

to walk on an 8 m � 40 cm surface. Any child with obvious gait

disturbance was excluded from the series. An ‘‘abnormal’’ foot

progression angle was not considered as a gait disturbance as far

as it did not cause any functional impairment. This visual gait

analysis was performed by the senior author (MJ). Eleven children

were excluded because of an obvious pathological orthopaedic

condition (Legg-Calve-Perthes disease, Cerebral Palsy, personal

history of lower limb surgery). Seventy-one children were

excluded because they were under 3 or over 10 years old.

Eventually, 1319 children were included. There were 695 males

and 624 females.

Fig. 1. Number of individuals in ea

In order to assess the intra-observer reliability of our clinical

evaluation, 3 months after the first evaluation a second set of

measurements was performed by the same observer in 18 randomly

chosen children. Outcome statistical evaluation was performed

using SPPS 11.0 Software. The reliability of the measurements

of Tibial Torsion and Femoral Anteversion was assessed using

paired sample t tests. A comparison of means of Tibial Torsion

between males and females, and between right and left side was

performed. In the same way, a comparison of means of Femoral

Anteversion between males and females, and between right and left

side was performed. The threshold of significant difference was

chosen at p > 0.05. A Pearson correlation matching age and Tibial

Torsion was performed. The same analysis was performed for

Femoral Anteversion. When significant correlations were identi-

fied, a linear regression was performed. In each cluster of age (see

Fig. 1) and gender, children were divided into groups according to

their Femoral Anteversion: children with a Femoral Anteversion

under �2 S.D. were classified into the low Femoral Anteversion

group, children with a Femoral Anteversion between �2 S.D. and

+2 S.D. were classified into the normal Femoral Anteversion group,

and children with a Femoral Anteversion over +2 S.D. were

classified into the high Femoral Anteversion group. Children were

then divided into three other groups according to their Tibial

Torsion: children with a Tibial Torsion under �2 S.D. (i.e. internal

Tibial Torsion) were classified into the low Tibial Torsion group,

children with a Tibial Torsion between �2 S.D. and +2 S.D. were

classified into the normal Tibial Torsion group, and children with a

Tibial Torsion over +2 S.D. were classified into the high Tibial

Torsion group (i.e. external Tibial Torsion). The rotational profile

was defined by combining these groups.

3. Results

Fig. 1 shows the distribution of our population in each

cluster of age and gender and summarizes the number of

children in each cluster of age.

ch cluster of age and gender.

M. Jacquemier et al. / Gait & Posture 28 (2008) 187–193 189

Fig. 2. Right Femoral Anteversion changes over time in males, and

females.

3.1. Reliability of measurements

The paired sample t-tests showed that there was no

significant difference between the two sets of measurements

in Femoral Anteversion and Tibial Torsion ( p < 0.05).

3.2. Comparison of means

Regardless of the age, the comparison of means of Tibial

Torsion showed that there was no significant difference

between males and females ( p > 0.05), or between the right

and left sides ( p > 0.05).

The comparison of means of Femoral Anteversion showed

that there was a significant difference between males and

females ( p < 0.01), whereas there was no significant

difference between the right and left sides ( p > 0.05).

Femoral Anteversion was higher in females ( p < 0.01).

3.3. Correlation with age

Tibial Torsion: Since there was no difference between the

right and left sides, only the right side was analysed further.

Fig. 3. Mean right Femoral Anteversion in males with the �2 S.D. threshold in each cluster of age.

M. Jacquemier et al. / Gait & Posture 28 (2008) 187–193190

Since there was no difference between males and females in

Tibial torsion, both genders were analysed together. The

Pearson’s correlation test showed that Tibial Torsion was

slightly correlated with age ( p < 0.05, Pearson’s coefficient

0.069, R2 = 0.01). Tibial torsion increased over time.

Femoral Anteversion: There was a difference between

males and females in Femoral Anteversion. Thus, genders

where analysed separately. In males, Femoral Anteversion

was markedly correlated with age ( p < 0.01, Pearson’s

coefficient �0.37, R2 = 0.11). In females, Femoral Ante-

version was markedly correlated with age too ( p < 0.01,

Pearson’s coefficient �0.35, R2 = 0.12). In both genders,

Femoral Anteversion decreased with age.

3.4. Normative data

Fig. 2 shows right Femoral Anteversion changes over

time in males, and in females. Fig. 3 shows the mean right

Femoral Anteversion in males with the�2 S.D. threshold in

each cluster of age, and Fig. 4 shows the mean right Femoral

Anteversion in females with the �2 S.D. threshold in each

cluster of age. Fig. 5 shows the mean right Tibial Torsion in

both genders with the �2 S.D. threshold in each cluster of

age.

Fig. 4. Mean right Femoral Anteversion in females w

3.5. Rotational profile

Table 1 shows the distribution of rotational profiles

according to age and gender.

Normal Femoral Anteversion and normal Tibial

Torsion profile: 84% (males, 8 years of age) to 98%

(males, 6 years of age) cases fell into this profile. This was

the most common profile seen in both genders, regardless

of age.

Normal Femoral Anteversion and low (internal) Tibial

Torsion profile: This profile was seen from 3 to 8 in

both genders, with a rate of occurrence between 1.9%

(males, 6 years of age) and 8.7% (males, 8 years of age)

cases.

High Femoral Anteversion and normal Tibial Torsion

profile: This profile was seen in almost every cluster of age,

more often in males, with a rate of occurrence from 1%

(females, 6 years of age) to 8.5% (females, 9 years of age)

cases.

High Femoral Anteversion and low (internal) Tibial

Torsion profile: quite uncommon, more often seen in

males from 4 to 5, with a rate of occurrence from 0.8%

(males, 4 years of age) to 1.5% (males, 5 years of age)

cases.

ith the �2 S.D. threshold in each cluster of age.

M. Jacquemier et al. / Gait & Posture 28 (2008) 187–193 191

Fig. 5. Mean right Tibial Torsion in both genders with the +/�2 S.D. threshold in each cluster of age.

Table 1

Distribution of rotational profiles according to age and gender

Age Gender Normal FAV and

normal TT (%)

Normal FAV and

low TT (%)

High FAV and

normal TT (%)

High FAV and

low TT (%)

3 M 92.78 5.15 2.06 0

F 94.12 4.71 0 0

4 M 90.08 6.11 3.05 0.76

F 92.93 7.07 0 0

5 M 88.97 2.21 7.35 1.47

F 95.37 4.63 0 0

6 M 98.06 1.94 0 0

F 93.81 5.15 1.03 0

7 M 89.09 5.45 5.45 0

F 96.36 3.46 0 0

8 M 84.06 8.7 7.25 0

F 93.22 5.08 1.69 0

9 M 93.33 0 6.67 0

F 91.53 0 8.47 0

10 M 93.44 0 6.56 0

F 95.24 0 4.76 0

M. Jacquemier et al. / Gait & Posture 28 (2008) 187–193192

4. Discussion

Lower limb rotational profile in children may cause great

concern to parents and relatives, often presenting to a

paediatric orthopaedic outpatient clinic [1]. Reference

studies would therefore be desired, to inform specialists.

Normative data were statistically defined in this work using

the �2 S.D. +2 S.D. range (Figs. 3, 4 and 5). Nevertheless,

some borderline patients may suffer some degree of

disability, even if they are statistically considered as normal.

Our series may be considered as a snapshot of a school

population. We chose to conduct our clinical evaluation at

school as an attempt to minimize selection bias. Parents

usually first present with concerns regarding lower extremity

torsional alignment when their child begins to walk.

Previous studies show significant changes in the coronal

and transverse plane prior to the age of 3 years [1,2,5,7,9].

Nevertheless, this is pre-school age. As an attempt to

minimize selection bias, we chose to start our series at age 3

in order to examine a homogenous school population.

This type of clinical survey would raise the problem of

intra- and inter-observer reliability, as pointed out by

Luchini and Stevens [10]. In an attempt to minimize this

bias, clinical evaluation was conducted by one single

observer, the senior author (MJ). The intra-observer

reliability was tested prior to any conclusion. The results

demonstrated that our intra-observer reliability was good.

This clinical method of assessment of Femoral Anteversion

and Tibial Torsion is certainly not ideal, but is feasible in

every day practice.

To our knowledge, there is no large and comprehensive

series in the English speaking literature providing

normative data of both Femoral Anteversion and Tibial

Torsion. In the series of Svenningsen et al. [6], and of Cheng

et al. [1], the authors assessed the hip rotational range of

motion without any clinical assessment of Femoral

Anteversion. Fabry et al. [5] described Femoral Anteversion

changes over time in normal condition using radiography.

These authors reported that Femoral Anteversion decreased

over time, which is in agreement with our study. In clinical

practice, however, Femoral Anteversion is assessed

clinically. Thus, there is a need for normative clinical data.

In the French literature, Femoral Anteversion had pre-

viously been studied clinically, using Netter’s method by

Bedouelle [11]. Our results are similar to those reported by

this author: there is a difference in Femoral Anteversion

between males and females, and in both genders, Femoral

Anteversion markedly decreases over time. To date, three

large clinical series focussed on Tibial Torsion changes

during growth in normal children. In 1976, Ritter et al. [9]

demonstrated that Tibial Torsion, assessed using a C clamp

goniometer changed from 58 at birth, to 118 at 2. The series

was prospective, but only 38 children were included. They

did not find any difference between males and females. In

1986, Hutchins et al. [12] published a series of 352 healthy

children. Tibial Torsion was assessed using a specially

designed torsiometer. The authors found a difference

between males and females. Tibial Torsion changed from

108 (in both genders) at 5 to 17.48 in males at 25, and 13.98 in

females at 25. Eventually, in 1991, Cheng et al. [1]

published a large series of 2630 healthy Chinese children.

Tibial Torsion was assessed using the Thigh–Foot angle.

The authors did not find any difference between males and

females, and Tibial Torsion changed from 158 at 2 to 358 at

12. Our results are quite similar to those of Cheng et al. We

pointed out that there was no difference between males and

females, and Tibial Torsion changed from 348 at 3 to 368 at

10 (Fig. 5). We chose a simple method of assessment of

Tibial Torsion: the transmalleolar axis [7]. We chose not to

use the thigh–foot angle because of the significant bias

raised by this method [1] (hindfoot varus or valgus, foot

adduction or abduction). The discrepancy observed

between our results and those published in the literature

may arise from the method of clinical assessment of Tibial

Torsion. Nevertheless, it is important to notice that Femoral

Anteversion changes over time were marked, whereas

Tibial Torsion changes were small.

We pointed out that all of the children from our

population fell into one of the following four rotational

profiles: normal Femoral Anteversion and normal Tibial

Torsion profile, normal Femoral Anteversion and low

(internal) Tibial Torsion profile, high Femoral Anteversion

and normal Tibial Torsion profile, and high Femoral

Anteversion and low (internal) Tibial Torsion profile. We

found that no patient in our population demonstrated normal

Femoral Anteversion and high Tibial Torsion profile nor

high Femoral Anteversion and high Tibial Torsion profile,

whereas these profiles were reported by Cahuzac et al. [13]

in his series. Patients in the series of Cahuzac et al. [13] were

all seeking medical advice because of gait disturbance

whereas patients in our series were all considered free of gait

deviations. This discrepancy highlights the need for

reference studies based on carefully collected normal

subjects in order to provide normative data.

Eventually, we did not find any external torsion, neither at

the femur (i.e. femoral retroversion) nor the tibia. Apparent

femoral retroversion is reported to be common in early

infancy [14,15]. It is due to contractures of the external

rotator muscles which resolve once the infant has begins to

ambulate, unmasking the actual underlying femoral Ante-

version. This is why apparent femoral retroversion is

reported to improve on its own during the first year of

walking [15]. The youngest children in our series were 3

year old. They were probably too old to demonstrate

significant femoral retroversion. In the literature, External

Tibial Torsion is seen between 4 and 7 years of age. It is

usually unilateral. The tibia rotates laterally with growth,

and Tibial Torsion deteriorates [14]. This external Tibial

Torsion may be considered by parents and care givers as a

pathological condition. This is possibly why we did not find

any case of external torsion in our normal population (34

parents refused their child to be included in our series

M. Jacquemier et al. / Gait & Posture 28 (2008) 187–193 193

because of a previously diagnosed pathological orthopaedic

condition).

In conclusion, this study provides normative data of lower

limb rotational profile (Femoral Anteversion and Tibial

Torsion) and the normal changes expected during growth in

children between 3 and 10 years of age.

Conflict of interest statement

None.

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