In-toeing and out-toeing - Femoral Anterversion & Retroversion
The hip joint is where the femoral head (the top of the femur) meets the pelvis. In anatomy, the word “version” refers to the angle or rotation of all or part of an organ, bone or other structure in the body, relative to other structures in the body.
Femoral retroversion refers to an abnormal backward rotation of the hip relative to the knee. This condition can affect patients of all ages and leads to abnormal stress in the low back, hip and knee and abnormal gait. Femoral retroversion is a rotational or torsional deformity in which the femur twists backward (outward) relative to the knee. The opposite condition, in which the femur has an abnormal forward (inward) rotation, is called femoral anteversion.
Figure 1: In-toeing and Out-toeing - Physio Frenchs Forest, Physio Macquarie Park
Causes of retroversion and anteversion:
The exact cause of femoral retroversion is unknown.
Femoral retroversion is often a congenital condition, meaning it is present from birth and develops in the womb.
It also appears to be related to the position of the baby as it grows in the womb.
Sitting habits:
- Internal tibial torsion is commonly associated with sitting on the feet
- Increased femoral anteversion is associated with sitting i a “W” position.
Signs and Symptoms of retroversion:
Retroversion: Out-toeing or “duck walk” – walking with the feet pointing outwards
Anteversion: In-toeing (pigeon toe)
Learning to walk late
Flat Feet
Fatigues easily
Poor coordination particularly with running
Hip, knee and lower back pain
Arthritis of the hip
Limping, tripping and falling
When to see a Specialist:
Lack of hip external rotator movement
Faily history of hip dysplasia
Foot turning in or out only on 1 side
10-14 years old
If less than 10 years, only refer if symptomatic
Image 2: Hip retroversion and anteversion
Diagnosis of retroversion/anterversion:
Physical examination:
Observing gait: Observing out-toeing for retroversion and in-toeing for anteversion.
Hip range of motion:
Retroversion = Excessive external rotation of the hip, with a ratio of 3:1 in comparison to internal rotation
Anteversion = Excessive internal rotation of the hip, with a ratio of 3:1 in comparison to external rotation
X-ray
EOS Scan
CT Scan
In-toeing is caused by one of three types of deformity:
1) Metatarsus adductus
2) Internal tibial torsion (20-30 is normal)
• Internal tibial torsion is the most common cause of in-toeing.
• It affects males and females equally, and is often asymmetrical with the left side affected more than right.
• The cause is believed to be intrauterine position, sleeping in the prone position after birth, and sitting on the feet.
• The child with internal tibial torsion walks with the patella facing forward and the feet pointing inward. This results in an internal foot progression angle and an internal foot-thigh angle. In 90 percent of cases, internal tibial torsion gradually resolves on its own by 8 years of age.
3) Increased femoral anteversion (8-12 is normal)
• Femoral anteversion describes the normal position of the femur, which is medially rotated.
• The child with increased femoral anteversion walks with his or her patellae and feet pointing inward. The gait appears clumsy and the child may trip as a result of crossing his or her feet.
• The child will have strong tendency to sit in a “W” position.
• Physical examination reveals increased internal hip rotation (up to 90 degrees) and decreased external rotation.
Out-toeing is caused by one of three types of deformity:
1) Femoral Retroversion
• It becomes apparent when the pre-walking child stands with his or her feet turned out to nearly 90 degrees (this is sometimes called a “Charlie Chaplin appearance”).
• Femoral retroversion occurs more commonly in obese children.
• When femoral retroversion is unilateral, it is more common on the right side
• Physical examination reveals increased external rotation to almost 90 degrees and decreased internal rotation.
• If resolution is not evident and persistent external rotation is present on successive visits at two to three years of age, referral to an orthopedist is indicated because persistent lateral femoral torsion is associated with osteoarthrosis, increased risk of stress fracture of the lower limbs, and slipped capital femoral epiphysis.
2) External Tibial Torsion
3) Flat Feet
What is the recommended treatment and advice?
1) Let your hip do its thing
Too often I’m told by patients that their Person Trainer told them they have tight hip flexors or this is a great exercise to improve your hip internal rotation and they should do it. If you are changing a patient’s foot position and they have a retroverted or anteverted hip, then you could be causing structural damage and irritation to the hip, knee or ankle.
2) Don’t correct a child’s gait
As mentioned above, changing a child’s gait pattern could cause significant long-term issues.
3) Strengthen the gluteus medius
We now know we can’t change the morphology of the bones and we should not encourage exercises that feel uncomfortable due to lack of hip range of motion. The only other non-surgical treatment is to strengthen the hip, particularly the gluteus medius. The gluteus medius originates from the pelvis and attaches to the femur. Due to its attachment’s its help ensure the hip stays central in the hip socket and prevents over-stressing other area’s due to the deformity. It’s important to note hip thrusts and double leg squats are gluteus maximus exercises not gluteus medius exercises. See below for example of gluteus medius exercises.
See our expert Physiotherapy team at Frenchs Forest and Macquarie Park!
Exercise 1: Clam shells for gluteus medius
Exercise 2: Hip abduction for glutues medius