II. Epidemiology
- Femoral Anteversion is most common cause for In-Toeing for school aged children
- More common in girls (2:1)
- Most common onset ages 3-5 years (most severe for ages 4 to 7 years old)
III. Definitions
- Anteverted hip (Femoral Anteversion)
- Femoral head significantly anterior to Femoral neck
- Associated with Toeing-In (normal in young child)
- Antetorsion used to describe abnormal anteversion
- Normal hip
- Femoral head slightly anterior to Femoral neck
- Retroverted hip
- Femoral head posterior to Femoral neck
- Associated with Toeing-Out
IV. Mechanism
- Excessive medial rotation of the femur
- Normal Femoral Neck Anteversion angles
- Adults: 15-25 degrees
- Children
- Age 3-12 months: 39 degrees
- Age 1-2 years: 31 degrees
V. Symptoms
- Standing appearance: "Kissing Patellae"
- Clumsy gait
- Running appearance: "Egg-Beater"
- In-Toeing feet ("Pigeon-Toed")
- Sitting position: "Inverted W"
- Sitting with hips flexed and internally rotated (feet at either side of hips)
- Contrast with most children who would typically sit cross legged
- Does not worsen Femoral Anteversion
VI. Signs
- Observe lower extremity via tunnel view
- Observe child's gait
- See Foot Progression Angle (Gait Rotational Angle)
- Patellae and feet point inward (kissing Patellae)
- Results in a clumsy, Circumduction Gait
- Measure rotation of hip
- See Hip Rotation Evaluation in Children
- Increased internal hip rotation (60 to 90 degrees)
- Decreased external hip rotation (10 to 15 degrees)
VII. Differential Diagnosis
- See Toeing-In
- Infants
- Congenital Hip Dysplasia
- Cerebral Palsy or other neuromuscular disorder
- Toddlers
- Teen and pre-teen
VIII. Diagnosis
- Biplanar Radiography
- Used to Measure Femoral Anteversion
IX. Management
- Watchful waiting until age 8 years
- Avoid non-helpful measures
- Shoe Modifications
- Night splints
- Dennis-Browne splint
- Twister cables
- Passive StretchingExercises
- Physical Therapy
- Femoral Rotational Osteotomy Indications
- Comorbid neuromuscular disease (e.g. Cerebral Palsy) or
- Severe functional Disability at age > 8 (0.1% of cases)
- Femoral Anteversion >50 degrees
- Internal rotation >80 degrees
X. Complications
- Chondromalacia Patellae (Patellofemoral Syndrome)
- No known association with hip or knee Arthritis
- Does not significantly affect Running or walking
XI. Course
- Spontaneously resolves to normal range in 80% of cases by age years
- Unlikely to resolve after age 8 years
- Compensatory lateral tibial torsion may occur
XII. Patient Resources
- Hughston Sports Medicine Foundation
XIII. References
- Pediatric Database Homepage by Alan Gandy, MD
- Hoppenfeld (1976) Physical Exam, Appleton-Lange
- Bates (1991) Physical Exam, Lippincott
- Rerucha (2017) Am Fam Physician 96(4): 226-33 [PubMed]