What would you do? This is what we did.

History:

This 7 year old girl is brought in by her mother because of knee misalignment while skiing, L > R. No history of trauma; normal term birth with no complications. No knee pain. Of incidental note, she is deaf in the left ear.

Exam findings:

She has bi-lat. external tibial torsion, left much worse than right (40 degrees transmallolear angle vs 22 degrees. for info on measuring torsions, click here). remember, you should be able to draw a line from the tibial tuberosity down through the 2nd metatarsal head. 

She has a 5mm anatomical leg length deficiency on the right (see top above left).

She has femoral antetorsion right side with very little external rotation, approximately 10 degrees,  internal rotation is in excess of 50.  Left side has normal femoral versions (for a review of femoral versions and torsions, click here).  See last 2 pictures which are full internal and external rotation respectively.

She has a mild uncompensated forefoot varus (cannot really see from the pictures, you will need to take our word for it) with a relatively cavus arch to her foot(see center and last picture on right.

Neurologically, she appeared to have integrity with respect to sensation, motor strength and deep tendon reflexes in the lower extremities.

Assessment:

Pathomechanical alignment as described.  Severe left external tibial torsion. MIld to moderate right. Femoral antetorsion right.

Plan:

We are going to build her a medium heel cup full length modified UCB orthotic inverting the cast bi-lat. left greater than right.  We gave her  balance and coordination exercises, heel walking, lift/spread/reach and one leg balancing. She will follow up for a dispense.  Her mother will try to get a better fitting ski boot as the one she has currently is two sizes too big. She will return for a dispense. She should consider wearing the orthotics in everyday footwear as well. We will do a follow up post in a few weeks. 

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