Femoral Anteversion and Retroversion: What Are They and Could They Be Causing Your Pain?
Femoral anteversion and femoral retroversion describe how the thighbone (femur) is twisted along its length. Too much forward twist is anteversion. Too little twist, or a backward twist, is retroversion. Both can change how your hip, knee and foot line up when you stand. This can lead to pain, stiffness or an unusual way of walking that only shows up on weight-bearing imaging.
Key points
- Femoral version is the natural twist in your thighbone. Everyone has some, but too much or too little can cause problems.
- Anteversion tends to make you walk with your toes pointing inward. Retroversion tends to make you walk with your toes pointing outward.
- Pain often shows up at the hip, knee or lower back, not where the twist actually is.
- Standard scans done lying down can miss the real alignment picture, because your muscles relax and gravity is taken away.
- A standing whole-body EOS scan shows the full chain, from your feet to your spine, under natural load.
What is femoral version and why does it matter?
Femoral version is the amount of twist along the shaft of your thighbone. Think of the femur as a long rod. At the top it angles into the hip socket. At the bottom it meets the knee. The natural twist between these two ends decides how your leg is turned when you stand and walk.
Everyone has a small amount of forward twist. This is normal anteversion. When there is too much forward twist, it is called excessive femoral anteversion. When there is too little twist, or the bone twists backward, it is called femoral retroversion.
Femoral anteversion vs retroversion
With excessive anteversion, the femoral head points further forward than it should. To keep the hip joint properly seated, your whole leg tends to turn inward. This is why walking with the toes turned in is one of the clearest everyday signs.
With femoral retroversion, the opposite happens. The femoral head faces further back, and the leg naturally turns outward. You may notice that you walk with your toes turned out, feel tightness at the front of the hip, or find it hard to sit cross-legged.
Both conditions change the mechanical load through your hip joint. Over time, this can contribute to cartilage wear, labral stress and early hip arthritis.
What are the signs of a femoral version problem?
Many adults with abnormal femoral version do not realise that the twist in their thighbone is behind their symptoms. The signs below are common, but none of them on its own confirms the diagnosis.
Your feet point clearly inward or outward when you walk, even though you are not doing it on purpose.
Aching at the front or side of the hip, especially after standing, walking or exercise.
The changed rotation alters the load on the knee. This sometimes causes kneecap tracking problems or strain on the inner knee.
Your spine makes up for the twisted leg alignment, which creates strain further up the chain.
These symptoms overlap with many other conditions. So a femoral version problem is often missed when imaging looks at only one area.
What causes femoral anteversion or retroversion in adults?
In most adults, abnormal femoral version is a developmental variant. This means the natural twist present from childhood did not fully correct during growth. Less commonly, it can follow a healed fracture, hip surgery or a condition affecting bone development.
The thighbone twist present at birth did not fully reduce during growth.
Bone healing or the placing of an implant can change the rotational profile of the femur.
Years of adjusting the way you walk can hide the twist underneath but cause pain elsewhere.
Your body is a connected chain from your feet to your head. A twist in the thighbone forces the knee, ankle and even the lower back to make up for it. That is why pain often appears far from the actual cause, and why whole-body imaging is so valuable.
How is femoral version checked when you are standing?
Femoral version is best checked when your body is bearing weight. That is when your muscles, joints and alignment work as they do in daily life. Standard imaging done lying down removes gravity and relaxes the muscles. It can hide the way a twisted femur affects the rest of your skeleton.
An EOS scan takes a full-length, standing image of your skeleton from head to feet in a single pass. It uses about 90% less radiation than a standard X-ray, around ten times less. The image lets a clinician see how your femoral twist relates to your hip socket, your knee alignment and your spine, all in one picture.
This matters for femoral version because the twist in the thighbone changes the way your knee tracks, the way your pelvis tilts and the way your spine curves above it. A scan of only the hip, done lying down, cannot show those connected effects.
If you have hip, knee or walking concerns and want to see how your alignment looks under real weight-bearing conditions, a standing EOS scan in London can show the full picture.
Book a free video consultationWhat can be done about femoral version problems?
The right approach depends entirely on how severe the twist is, how it affects your alignment and what symptoms it is causing. ScanAlign is a diagnostic imaging clinic, not a treatment centre. The goal is to give you and your clinician the clearest possible picture of what is happening.
In many cases, targeted physiotherapy can reduce symptoms. This focuses on hip and core strengthening, retraining the way you walk, and flexibility. For adults with significant femoral version problems that cause ongoing pain or joint damage, orthopaedic specialists may discuss a procedure called femoral derotation osteotomy, which corrects the twist with surgery. Accurate imaging of the full lower limb is essential before any such decision.
Whatever path is right for you, it starts with knowing exactly what your alignment looks like when you are upright and bearing weight.
Before you start a treatment, or change the one you are on, it is worth getting a detailed diagnosis. Knowing whether the cause sits in the pelvis, the legs or the spine changes what will actually help.
When is MRI the better choice? EOS shows bones, joints and alignment clearly. For soft-tissue problems such as labral tears, cartilage damage or nerve problems, MRI is usually the better tool. In many cases, the two types of imaging work well together.
Frequently asked questions about femoral version
Anteversion means the thighbone twists forward more than normal, which tends to make the leg and foot turn inward. Retroversion means it twists less than normal or even backward, which tends to make the leg and foot turn outward. Both change the way load passes through your hip joint and the rest of your leg.
Yes. Excessive anteversion changes the position of the femoral head inside the hip socket. This can create abnormal contact, impingement and more wear. It may cause deep groin pain or pain at the front of the hip, especially with activity.
It can. When the thighbone is twisted differently, the knee joint has to make up for it. This can lead to abnormal kneecap tracking, overload on the inner or outer side of the knee, and long-term wear. That is why whole-body imaging is important: it shows how the hip twist affects the knee below it.
Lying down removes gravity and relaxes the muscles. Your leg may naturally turn into a comfortable position that hides the effect of the twist. A standing scan shows how your bones actually line up when carrying your full weight, which is when the twist has a real impact.
An EOS scan is a standing, full-length X-ray that captures your whole skeleton from head to feet. It uses about 90% less radiation than a standard X-ray, around ten times less. Because it images you upright, it shows the real-life effect of femoral twist on your hip, knee and spine alignment. You can learn more about how an EOS scan works.
Yes. It uses about 90% less radiation than a standard X-ray, around ten times less. You can find more about safety and what to expect on the ScanAlign FAQs page.
No. ScanAlign is a private, self-pay clinic. You can refer yourself. The process starts with a free video consultation to discuss your symptoms and confirm that a scan is right for you.
For patients travelling from abroad, the price is confirmed during the free video consultation. You can also visit the ScanAlign FAQs page.
It is a surgical procedure in which an orthopaedic surgeon cuts and rotates the thighbone to correct the abnormal twist. It is generally considered only when non-surgical measures have not helped and the version problem is causing significant symptoms or joint damage. ScanAlign does not perform surgery, but the imaging can help your surgeon plan if this option is being discussed.
In many cases, physiotherapy, walking retraining and strengthening work can improve how you walk and reduce related pain. The first step is finding out whether the walking pattern is being driven by the twist in the thighbone. That needs accurate whole-body alignment imaging.
Understand your alignment, standing up
If hip pain, knee pain or an unusual way of walking has not been explained by earlier scans, a standing whole-body EOS image in London may show the missing piece. Start with a free video consultation from home.
Book a free video consultationLearn more about hip alignment and how EOS imaging can help.
Sources
- Tönnis D, Heinecke A. Acetabular and femoral anteversion: relationship with osteoarthritis of the hip. Journal of Bone and Joint Surgery (American). 1999;81(12):1747-1770.
- Sangeux M, et al. Femoral anteversion and tibial torsion in adult populations. Journal of Orthopaedic Research. 2015;33(9):1381-1387.
- National Institute for Health and Care Excellence (NICE). Osteoarthritis: care and management. Clinical guideline CG177. 2014 (updated 2022).
Written by Abbas Dhami (Specialist Diagnostic Radiographer)
This page is general information and not a diagnosis.
ScanAlign is the trading name of CoreMed Solutions Ltd and operates under The Harley Street Hospital's CQC licence.