Tibial torsion is a common cause of knee pain. It occurs when there is more tension in the lateral thigh muscles (biceps femoris and TFL) pulling on the fibula and lateral tibia, causing the tibia and fibula to rotate laterally relative to the femur. This puts torsional stress on the ligaments of the knee and on the cartilage and structures inside the knee.
Tibial torsion may be assessed when your client is supine by having the hip and knee both flexed to 90 degrees, then observing the direction the foot is pointing. If it is pointing laterally more than 20 degrees there may be torsional stress on the knee.
It is also important to assess the mobility of the head of the fibula. With your client supine and the knee flexed and the foot resting on the table, grasp the proximal fibula between your thumb and fingers. Try moving the fibula back and forth in an anterior and posterior direction to assess the mobility.
Tibial torsion may also be assessed with your client in a prone position. Flex your client’s knee and observe which way their foot is pointing.
If the head of the fibula is immobile have your client prone and work down the lateral hamstrings with your fingers doing a spreading motion as you work in a distal direction. When you reach the head of the fibula press in a distal and also anterior direction.
After releasing the head of the fibula you can apply traction to the knee by grasping your client’s ankle and internally rotating the calf while also pulling in a distal direction.
For tibial torsion have your client supine with their hip and knee both flexed to 90 degrees. Support the knee with one hand, then with your other hand turn their calf toward internal rotation. Keeping the calf internally rotated, move your client’s knee medially to the midline and beyond, and allow the knee and hip to extend. do this passively several times, then have your client work to actively extend their knee and hip while you hold the calf in internal rotation.
Self Care Exercise
Tibial Torsion Exercise is in the free section of the library.
I am indebted to James Waslaski for this information and I highly recommend his workshops and DVDs.
Photos of variations in skeletal structure may be seen at