An abnormal increase in external tibial torsion was one of the components of the “Miserable Malalignment” syndrome described by Stan James in 1979.10 It is becoming recognized that these various miserable malalignment components: increased femoral anteversion, squinting patella, genu varum, patella alta, increased Q-angle, external tibial rotation, tibia varum and compensatory pronation of the foot, described by James may exist independent of one another and they may independently contribute to anterior knee pain and to patellar instability.
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