Intoeing/Miserable malalignment syndrome

What is miserable malalignment syndrome?

Miserable malalignment syndrome is a specific combination of rotational differences in the leg, where the thigh bone (femur) is rotated inwards and the shin bone (tibia) is rotated outwards. This “twisted” alignment causes the kneecaps to point inwards (sometimes described as “squinting patellae”) while the feet point outwards. It is most often recognised in adolescents and can cause Knee pain and an awkward gait.

Signs and symptoms

• Kneecaps that appear to point inwards when standing

• Feet that turn outwards

• Aching pain at the front of the knees, often worse with activity or stairs

• Patellar instability or subluxation

• An awkward or in-turned running style

• Difficulty with sport

How is it diagnosed?

Diagnosis begins with a clinical examination of the rotational profile of the legs — assessing how the hips, thighs and shins are aligned. Where symptoms are significant, rotational imaging (CT or MRI) may be used to measure the degree of rotation in the femur and tibia precisely.

Treatment options

Many young people are helped by non-surgical measures, including physiotherapy to strengthen the muscles around the hip and knee and to improve control of the kneecap. Activity modification and pain management may also help. Where the rotational malalignment is severe and is the clear cause of persistent pain and dysfunction, surgical correction (rotational osteotomy of the femur and/or tibia) can realign the limb. This is a significant operation reserved for carefully selected cases.

Outlook

Many adolescents improve with physiotherapy and time. For the smaller number who need surgery, careful assessment and planning give good functional and cosmetic results. Surgery is usually considered near skeletal maturity

When to seek advice

If your child has persistent knee pain, an awkward gait, or kneecaps that point inwards and this is affecting their activity, an assessment is worthwhile.

This information is for general guidance only and is not a substitute for a consultation with Mr Wadia. If you are worried about your child, please seek medical advice.