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Hip Rotation and In-Toeing Gait

A Study of Normal Subjects From Four Years Until Adult Age


SVEIN SVENNINGSEN, TERJE M.D., TERJESEN, M.D., MARIA" AUFLEM, M.D., AND VIDAR BERG, M.D.

In a selected population, from four years old up to adult age, the function of 1522 hips of 761 apparently normal subjects of both genders were studied to define: (1) the lower and upper limits of normal hip rotation; and (2) the frequency of in-toeing gait related to age and gender. Internal and external rotation were measured with the subject lying prone with flexed knees. Presence of in-toeing gait was noted. A significant reduction of internal rotation with age was found in both females and males. In all age groups, females had significantly higher range of internal rotation than males. External rotation did not show the same age and gender dependency. Sixteen percent of all subjects had an in-toeing gait. The frequency decreased from 30% in the four-year-old group to 4% in adults. The subjects with in-toeing had a significantly increased internal rotation and decreased external rotation.

In-toeing is a very common orthopedic disorder in children. In spite of this, few studies have dealt with the problem. Controversy exists regarding the evaluation and management of children with an in-toeing gait and increased femoral anteversion. The cause of in-toeing could be an increased femoral anteversion, internal tibia1 torsion, adduction of the forefoot, or a combination of these factors. The most common
' ~ ' ~ 3 ~

From the Department of Orthopaedics, Trondheim University Hospital, Trondheim, Norway. Reprint requests to Svein Svenningsen, M.D., Department of Orthopaedics, Trondheim University Hospital, N-7006 Trondheim. Norway. Received: August 3, 1988.

factor is said to be increased femoral anteversion. It is not clarified whether in-toeing gait can lead to other disabilities, although studies suggest that increased femoral anteversion is a predisposing factor in osteoarthritis of the hip j ~ i n t ' ~and' that internal torsion of the ,~ tibia can lead to osteoarthritis of the knee joint.2' In children older than three years, there is a positive correlation between internal rotation of the hip and femoral a n t e ~ e r s i o n . 4 ~ ~ ~ ' ~ Hip rotation is, however, dependent not only on the degree of femoral anteversion but also on the spatial orientation of the acetabulum, the hip capsule, and the muscles surrounding the hip.' While femoral anteversion is greatest in children younger than two years of age, external hip rotation exceeds internal rotation at this age.7 One is often uncertain whether the measured range of hip rotation is within the normal range related to age and gender. Thus, the aims of this study were: (1) to define the upper and lower limits of normal hip rotation in a studied age group from four years old to adulthood, in females and males; (2) to evaluate the distribution of in-toeing gait in the different age groups; and ( 3 ) to look for any relation between in-toeing gait and tQe. pattern of hip rotation. The authors started with children four years of age because this is the age at which

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TABLE 1. Age and Gender Distributions (Number of Subjects)


AgC

Females

Males

4 years old 6 years old 8 years old I 1 years old I5 years old Adult Total

52 52 50 69 57 104 384

51

50 52 65 57 102
377

these patients are usually first seen in the out-patient clinics. Also, four-year-olds cooperate fairly well.
MATERIALS AND METHODS The pattern of hip joint rotation was studied in I522 hips in 76 1 apparently normal subjects. The age and gender distributions are shown in Table 1. The children four and six years of age were examined in 14 kindergartens. The older children were pupils in one elementary school: the 15-year-old group was in one intermediate school. The subjects in the adult group were students from the nursing school (59 females and nine males) and from the technical school (93 males and 45 females). In the adult group, the average age for females was 23 years (standard deviation, SD, 5.5 years) and for males, 23 years (SD, 2.7 years). All subjects were examined at the kindergartens or schools in a separate room made available for the study.

Hip rotation was measured with the subject prone on an ordinary examination bench with the hips extended and the knees flexed to a right angle. The pelvis was stabilized by the examiners hand to prevent rotation of the pelvis. Measurements were taken by two examiners: one performing the motion and the other measuring the arc of motion with a goniometer. The authors measured the passive motion, with no power executed to increase the range of motion. An ordinary goniometer with long limbs was used. The average value for both hips of each subject was employed in all measurements. The gait was observed with the subject walking as naturally as possible over the floor several times, and any in-toeing was noted, bilateral or unilateral. The authors did not try to quantify the degree of in-toeing. In children eight to 15 years of age, height and weight were measured. Students t-test, chi-square test, and Pearsons correlation test were used. The p values below 0.05 were regarded as significant.

RESULTS Table 2 shows the mean values for internal rotation, external rotation, and total rotation of the hip in females and males of the different age groups.
INTERNAL ROTATION

The changes in internal rotation according to age for both genders are shown in Figure 1. Females had significantly higher values than

TABLE 2. Normal Hip Rotation (in Degrees) Related to Age and Gender
4 Yews
Roiarion

6 Years Mcun
SD

8 Ycars Mean SD

1I Yews
M.n ca

15 Ycars
Meun SD

Adz&
Mean SD

Mmn

SD

SD

Internal Females Males External Females Males Total Females Males

60 51 44 48 104 99

10.2 7.6 9.6 7.8 7.5 9.1

58 51

8.5 9.0 7.6 9.1 8.4 7.7

57 51 43 42 99 94

8.2 9.5 7.9 9.9 7.7 6.9

50 46
42 42 92 88

8.9 7.2 7.4 7.9 7.8 8.3

48 41 42 43 90 84

8.7 7.7 7.0 7.1 7.5 8.1

52 38 41 43 92 81

9.2 7.6 7.7 7.3 9.6 7.4

44 47 102 98

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Hip Rotation and In-Toeing Gait

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70

60Y)

;
0

50.

----__

ZI,,

40

___-__ ---

30L

FIG. 1 . Internal rotation related to age (in years).

males in all age groups. The pattern differed between genders: in females there was a small but significant decrease in internal rotation from four to eight years. From eight to 11 years the reduction was highly significant 0,< 0.0005). From 1 1 to 15 years there was a nonsignificant reduction, and from 15 years to adult age a small but significant increase was found (0.01 < p < 0.025). From four years to 15 years the internal rotation decreased by 12". In males there was no change in internal rotation from four to eight years of age. From eight years on, the internal rotation decreased significantly between each age group up to adult age. The total decrease from four years to adulthood was 13". EXTERNAL ROTATION The patterns of external rotation in the different age groups for females and males are shown in Figure 2. Males had a significantly higher external rotation than females in the four-year-old and six-year-old groups and in adults. In the other groups, no gender differences were found. In females there was no significant difference with age. The values decreased from six to eight years in males, but thereafter no difference between the age groups occurred. TOTAL ROTATION Females had significantly higher total rotation than males in all age groups (Fig. 3).

From four years to 1 5 years a decrease of 14" was found. The greatest decrease was between eight and 1 I years. In males, total rotation decreased steadily from four years until adult age and totalled 18". SIDE DIFFERENCES There was no significant difference between the motions of the right or left hip at any age. The right-left differences in rotation per pair of hips are shown in Table 3. The difference exceeded 10" in 5%. The highest difference for internal rotation was 15" and for external rotation was 20". IN-TOEING GAIT One hundred twenty-nine subjects ( 1 6%, 81 females and 48 males) had an in-toeing gait. In-toeing was bilateral in 1 16 cases and unilateral in I3 cases. In unilateral in-toeing,

120
110

W
0

9080

70

I
4
6
AGE

'I

15

I
ADULTS

FIG.3. Total rotation related to age (in years).

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TABLE 3 . Right-Left Differences in Rotation Der Pair of Hius (in Degrees)


Internal Rotairon
A p

Extmml Rotation
Mean

Mean

SD

SD
4.0 3.9 3.8 4.8 4.9 4.4

4 years old 6 years old 8 years old 1 1 years old 15 years old Adult

3.5 3.7 2.8 4.7 3.0 3.8

3.5 3.8 3.6 4.5 3.9 3.9

3.5 3.6 3.7 5.3 4.4 4.6

three were right-sided and ten were leftsided. In-toeing occurred in 30% of the fouryear-old group as opposed to 4% in adults (Fig. 4). In the subjects with an in-toeing gait, internal rotation was significantly increased and external rotation was decreased (p < 0.0005; Table 4). There were no significant differences in height, weight, or height/weight ratio of children with and without in-toeing. There was also no correlation between these parameters and internal rotation in any age group in either gender. DISCUSSION This study showed a significant reduction in internal rotation with age in both females and males. In all age groups, females had a significantly higher range of internal rotation than males. The patterns for the two genders were, however, different. In females the reduction came to a stop between I 1 and 15 years, as opposed to males in whom the values decreased right up to adult age. The reason for this difference is probably that girls reach the growth spurt earlier than boys, therefore boys have more remaining years in reducing the degree of femoral anteversion. Assuming that the mean value plus two standard deviations is the upper limit for normal internal rotation, it is remarkable that a four-year-old girl must have an internal rotation greater than 80" and an adult

woman an internal rotation greater than 70" before it can be regarded as pathologic. For external rotation, it is striking that the lower limit is approximately 25", independent of age and gender. The patterns of decrease in internal rotation and total rotation were very similar. This shows that the reduction in internal rotation with age is not associated with increased external rotation, but with a decrease in total rotation. Cyvin5 examined 100 normal children four to six years of age. His values for internal rotation of the hip were very consistent with the findings of the present study. For external rotation, he found 5" lower values than the present authors did. In the same age group, Staheli et a1." examined children and found 5"-10" lower values for internal rotation but similar values for external rotation compared to the present study. For the age groups that were eight years to adulthood, the findings of Staheli et ~ 1 . are ' ~ similar to the present findings. Roaas and A n d e r ~ s o nexamined 105 men between 30 '~ and 40 years of age and found 5 decrease in internal rotation and 10" decreased external rotation compared to the present study. One probable reason for this discrepancy is the older average age in their study. Boone and Azen2 found 6" greater internal rotation but the same external rotation compared to the present study. However, they measured the hip rotation with 90" flexion of the hips.
O

40

15

ADULTS

AGE

FIG.4. The frequency of in-toeing gait related to age (in years).

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TABLE 4. Internal Rotation (in Degrees) in Subjects With and Without In-Toeing
~

4 Years

6 Years

8 Years

11 Years

1.5 Years

Adult

Variable
In-toeing Noin-toeing

Mean Range Mean Range Mean Range Mean Range Mean Range Mean Range

66 51

45-80 35-70

64 51

50-75 33-70

65 51

50-85 35-70

60 47

45-70 30-65

60 43

50-70 28-65

63 44

50-80 20-65

The right-left differences in hip rotation per pair of hips (Table 3 ) are in agreement with Brouwer et al.3 For all age groups and for both external and internal rotation, mean plus two standard deviations exceeded 10". Thus, when evaluating results after treatment of femoral fractures, rotational differences have to be 15" or greater if they are regarded as rotational deformities. The degree of in-toeing was not quantified in the present study. The method is subjective, making the in-toeing data somewhat inaccurate. This is especially true in the four- and six-year-old groups due to limited cooperation. However, the quantitative methods'8 also involve significant uncertainty." Staheli et al.'s subjects walked only a few steps, so there is a greater possibility of walking properly than in the present study, in which the subjects walked several times across the room. Sixteen percent of the subjects had an intoeing gait. McSweenyi2 reported in-toeing in 13% of the children. Although he did not mention their mean age, the majority were apparently younger children. Thus, the gait pattern was more toward in-toeing in the present study. The preponderance of women with in-toeing is in accordance with the results of Staheli,I7 as is the majority of leftsided in-toeing in unilateral cases. The frequency of in-toeing decreased from 30% in the four-year-old group to 4% in the adults. The reasons for the decreased frequency of in-toeing with age are several. First, femoral anteversion decreases with age, as shown by Fabry et aL6 It is also maintained that subjects with increased femoral anteversion develop a compensatory exter-

nal rotation of the lower leg. This has been difficult to prove,I3partly because the torsion of the tibia is difficult to measure exactly. However, Kobyliansky et a1.I' found a correlation between femoral anteversion and lateral torsion of the tibia in dry bones. In the study of Fabry et a1.,6more than 50% of children with increased anteversion and in-toeing had a normal gait at maturity, despite the persistence of increased anteversion. They postulated that compensatory external rotation of the tibia was responsible for the observed improvement of gait. The correlation among in-toeing gait, internal rotation of the hip, and femoral anteversion is disputed.8,22 The subjects with intoeing in the present study had significantly increased internal rotation and decreased external rotation. The same results were found by Crane.4 In children older than three years of age, a positive correlation between femoral anteversion and internal rotation of the hip has been rep~rted.'.'~ decrease in inThe ternal rotation with age in the present study was very similar to that found for femoral anteversion.6 However, Cyvin' warned against evaluating femoral anteversion on clinical examination alone, as the correlation was rather weak.
REFERENCES

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