Manual Therapy 20 (2015) 206e211

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Manual Therapy
journal homepage: www.elsevier.com/math

Case report

Hip and low back pain in the presence of femoral anteversion. A case
report
Paula Tansey*
Physiotherapy Department, Connolly Hospital, Blanchardstown, Dublin 15, Ireland

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 20 March 2014
Accepted 8 April 2014

A change in hip morphology, such as femoral anteversion may be a factor in patients with lower quadrant
pain. This case study highlights the importance of angle of torsion assessment and consideration of a
patients individual angle in designing rehabilitation programs. A patient who had a four year history of
hip pain and a one year history of low back pain, in the presence of femoral anteversion is presented. She
was successfully treated by altering her lower limb position as well as performing exercises in this
alignment.
2014 Elsevier Ltd. All rights reserved.

Keywords:
Hip
Femoral anteversion
Angle of torsion
Exercise therapy

1. Background
Structural variations of the femur are potential contributing
factors to lower limb pain. One such variation can occur in the angle
of torsion (AOT) which is the inclination of the axis of the femoral
neck with reference to the transcondylar plane at the distal end of
the femur (Ruby et al., 1979).
The reported normal hip AOT in adults can vary from 10 to
20
(Brten et al., 1992; Tnnis and Heinecke, 1999, Hetsroni
et al., 2013). An increased angle is considered to be femoral
anteversion, whilst femoral retroversion refers to a decreased
angle. Increased anteversion effectively increases the range of
functional internal rotation while correspondingly reducing the
range of external rotation (Bedi et al., 2011). It is widely
accepted that females have a 4e5
larger AOT than males
(Brten et al., 1992).
Excessive femoral anteversion has been associated with
increased risk of anterior dislocation post total hip arthroplasty (Di
Schino et al., 2009; Sariali et al., 2012). The AOT is therefore an
important consideration when planning orthopaedic hip surgery.
However, evidence of it being considered in the evaluation of hip
pain and the planning of rehabilitation is limited.
It is reasonable to assume that the hip AOT has an inuence on
biomechanical movement patterns of the lower limb because of the
consequent reduction in available range of hip internal or external
rotation. During functional activities, adjusted movement patterns

* Tel.: 353 862351455.

E-mail address: paula.tansey@hse.ie.
http://dx.doi.org/10.1016/j.math.2014.04.006
1356-689X/ 2014 Elsevier Ltd. All rights reserved.

may need to occur in the kinetic chain to compensate for the restriction in hip movement. This case report describes the evaluation
and management of a patient with hip and low back pain (LBP) in
the presence of an increased AOT.
2. Case description
2.1. Patient history and subjective examination
The patient was a 23 year old female pharmacy student,
referred to a physiotherapy orthopaedic triage clinic for evaluation
and treatment of a four year history of right groin pain and LBP.
Pain episodes varied from one week to four months. Some painfree periods of up to three months occurred between exacerbations. The groin pain severity was rated 9/10 on the Numerical
Rating Scale (NRS). Over the previous year she had developed
some LBP which she rated at 3/10 on the NRS (Fig. 1). Episodes of
groin pain triggered by prolonged periods of studying were reported. Standing for periods of 8e10 hours in her pharmacy course
resulted in particularly severe groin pain in the evenings. She had
previously partaken in ballet and zumba classes, which she felt
were also aggravating her pain. The LBP was worse in the mornings, whereas the groin pain worsened as the day went on. She
had no signicant past medical history. She took ibuprofen on
average 3e4 days per week when her pain was severe. Investigations (blood tests and MRI scans) by a Rheumatologist one
year previously eliminated any inammatory condition. Physiotherapy one year previously, which focussed on core strengthening exercises, helped her symptoms at the time but did not
prevent recurrence of pain.

P. Tansey / Manual Therapy 20 (2015) 206e211

207

Fig. 3. Patients available range of internal and external rotation.

Fig. 1. Body chart illustrating area of symptoms on initial assessment.

2.2. Physical examination

In standing both knees were in a valgus position. She had pronated feet and in the feet forward position her right patella faced
anteromedially relative to the left side (Fig. 2). This was her usual
lower limb stance position.
Lumbar range of motion was full and pain-free. Neurological
examination (myotomes, dermatomes and reexes) was normal.
Straight leg raise and prone knee bend neural provocation tests
were negative. On hip examination, there was no restriction in
range or pain provoked with exion or extension. Hip internal
rotation measured 60
in both 90
and 0
of hip exion bilaterally.

She had only 15
of hip external rotation bilaterally and deep right
groin pain was reproduced at end of range (Figs. 3 and 4).
Muscle strength of the hip abductors and internal and external
rotators was weaker on the right at 4/5 on manual muscle testing.
Tenderness was elicited on central palpation of the L5 spinous
process. Tenderness was also reported on palpation of the region of
her right iliopsoas muscle.
Her AOT was measured in prone using the trochanteric prominence test as described by Ruwe et al. (1992). With her knee exed
to 90
, passive hip internal rotation angle at the point of maximum
greater trochanter prominence was measured using a handheld
goniometer (Fig. 5). Her pelvis was stabilised throughout the
manoeuvre. Her AOT measured 40
on both the right and left sides.
Ruwe et al. (1992) reported stronger correlations between this
method of femoral anteversion measurement and intra-operative
measurements than with CT scanning and X-ray.
2.3. Clinical impression
Based on the patients history and examination ndings, a
working diagnosis of biomechanical hip pain due to reduced
external rotation range in the presence of a greatly increased AOT
was developed. In the patients natural foot forward stance position,
the signicantly anteverted hip joint assumes a position towards
the end range of external rotation. This has implications in terms of
increased loading of her hip joint (Heller et al., 2001) and
dysfunction of muscle forces in the pelvis and hip region (Nyland

Fig. 2. Patients normal lower limb alignment.

Fig. 4. Patients available range of internal and external rotation.

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P. Tansey / Manual Therapy 20 (2015) 206e211

et al., 2004). Furthermore a history of participating in ballet, which

emphasises a turn out position of her lower limbs, in the presence
of a severe restriction of hip external rotation may have predisposed her hips to the development of pain.
LBP has also been associated with changes in hip rotation range
of motion (Van Dillen et al., 2008). A reduction in external rotation
range in this patient may have contributed to increased forces and
compensatory motion of the lumbopelvic area leading to the onset
of LBP.
2.4. Physiotherapy intervention
The patient was educated regarding the altered position of her
hip and demonstrated that when she assumed a standing position
with her feet pointed slightly inwards, there was greater range of
movement of her lower limb into the direction of external rotation.
She was encouraged to adopt an in-toeing position of her lower
limbs (Fig. 6) with prolonged standing, sitting, gait and ascending
stairs. It was felt that this would allow her hip to function in a more
neutral position.
A tailored exercise program was designed to improve control
and strength of her hip joint in its new position. The program
included theraband strengthening exercises into internal rotation
in a prone position, standing in internal rotation with arm exercises
in order to activate her pelvic stabilising muscles, wall squats and
bridges internally rotating against a ball (Figs. 7e9). Manual therapy involved trigger point release of her right iliopsoas muscle.
Visit 2: Two weeks following the initial treatment, adopting the
new lower limb position in her daily life and performing the
rehabilitation exercises, she reported being pain-free. Exercises
were then progressed to include activation of hip external rotators
and abductors from an internally rotated position to neutral,

Fig. 5. Trochanteric prominence test.

Fig. 6. Modied lower limb alignment.

avoiding end of range external rotation. Balance board exercises in

an internally rotated lower limb position were also performed
(Figs. 10 and 11).
Visit 3: Five weeks following initial assessment the patient reported that she continued to be pain-free in terms of hip and back
pain but had developed some medial knee pain. It was hypothesised that internal rotation was creating an increased valgus force
on her knee joint. Simple anti-pronatory orthotics were prescribed
to counteract this.
Visit 4: Nine weeks following initial assessment the patient was
pain-free and her knee pain had resolved with the use of the orthotics. She had continued her home exercise program and
increased the repetitions of each exercise to improve muscle
endurance. Single leg stance and step-up exercises in an internally
rotated position were added to her exercise program (Figs. 12 and
13). On examination, there continued to be a large difference between internal and external rotation of her hip, which is consistent
with a structural variation of her hip joints. Hip external rotation

Fig. 7. Rehabilitation exercises.

P. Tansey / Manual Therapy 20 (2015) 206e211

209

Fig. 10. Rehabilitation exercises.

Fig. 8. Rehabilitation exercises.

and palpation of iliopsoas and L5 spinous process were now painfree. Strength of her right hip muscles had improved to 5/5 on
manual testing.
Long Term Follow-Up: On telephone follow-up the patient reported no recurrence of pain in the rst year following treatment.
On 2 year follow-up she reported that she had two episodes of hip
pain in that year. One episode occurred when she walked on
average 8e10 hours per day for 5 days when on holidays. The other
episodes occurred when she was required to stand for greater than
10 hours in her job. She was satised that her episodes of pain were
not as severe or frequent as prior to her course of physiotherapy

Fig. 9. Rehabilitation exercises.

Fig. 11. Rehabilitation exercises.

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P. Tansey / Manual Therapy 20 (2015) 206e211

Fig. 12. Rehabilitation exercises.

Fig. 13. Rehabilitation exercises.

treatment. She continued to adopt an in-toed position of her lower

limbs with daily activities. She was aware of minimising activities
that require an externally rotated position of her lower limbs e.g.
ballet turn-out and swimming breaststroke. She felt that this
knowledge was giving her good control over her pain and was
responsible for reducing her episodes of pain.
3. Discussion
This case study looked at the effect of exercise and modication
of lower limb alignment on a patient with hip pain and LBP when
her individual AOT was taken into account. By increasing the internal rotation alignment of her lower limbs during her activities of
daily living and performing lower limb strengthening exercises in
the new alignment, this patient with a four year history of episodic
pain had a resolution of her symptoms at one year follow-up and a
reduced number of episodes in the second year following
treatment.
The AOT is an important consideration in the physiotherapy
assessment of lumbar and lower limb pain. Measurement of this
angle can readily be performed clinically using the trochanteric
prominence angle test (Ruwe et al., 1992). This patients AOT at 40

was signicantly outside the normal reported range of 10e20
. This
test has been shown by Souza and Powers (2009) to have high
levels of intra- and inter-rater reliability, but only moderate
agreement with MRI measurements. Alternatively, a large
discrepancy between medial and lateral rotation range of hip motion can highlight an altered AOT. Kozic et al. (1997) found that a
45
difference between internal and external rotation on clinical
examination predicted an abnormally high anteversion angle. In
this patients case the difference in range between internal and
external rotation was 45
, indicating the presence of hip
anteversion.

Although not extensively studied, there is some evidence that an

altered AOT is associated with hip and knee pain. Reikerls et al.
(1983) found that femoral anteversion was increased by 6
in patients with primary hip osteoarthritis compared with controls and
the change in femoral angle was not compensated for by a decrease
of acetabular anteversion in symptomatic patients. There has also
been some suggestion that hip anteversion has a relationship with
patellofemoral pain. Eckhoff et al. (1994) found in 20 patients with
anterior knee pain who failed conservative treatment, that the
average AOT was 23
(SD 12) compared to controls 17
(SD 7). It
was hypothesised that the pathological entity may not be the patella but the underlying torsion of the femur, leading to increased
patellofemoral contact pressure. The relationship of an altered AOT
with hip and knee pain warrants further research.
Following four physiotherapy sessions over nine weeks, the
patient experienced a resolution of hip pain and LBP at one year
follow-up. It is difcult to ascertain whether the change in her
symptoms was primarily related to a positional change in her hip
joint with adopting an in-toeing position or whether it was related
to an increase in lower limb muscle strength as a consequence of
the exercise programme. A reduction in hip joint loading is a likely
factor. Heller et al. (2001) found that hip contact forces during
walking and stair climbing were increased by up to 28% in patients
with increased hip anteversion. According to Bedi et al. (2011)
increased femoral anteversion can result in pain from chondral
overload of the anterosuperior femoral head and acetabular dome
as well as the anterior capsule and psoas tendon. By adopting a
relatively internally rotated position of her lower limbs on a daily
basis these forces on the patients hip joint structures may have
been reduced. Furthermore, this lower limb alignment would
reduce movement into end of range hip external rotation,
decreasing the likelihood of compensatory movement in her lumbar spine. It is noteworthy that there was an elimination of this

P. Tansey / Manual Therapy 20 (2015) 206e211

patients LBP with treatment solely directed at hip biomechanics

and strength.
An increase in muscle activity and strength is also likely to be
relevant to her change in symptoms. Exercises directed at activation and strengthening of the hip rotators, abductors and extensors,
as well as the quadriceps muscles, were prescribed for this patient,
in a position of greater hip internal rotation than she had previously
used. Although strength of hip internal rotators and extensors has
not been studied in relation to hip anteversion, activation of the
gluteus medius and vastus medialis of the anteverted hip has been
found to be diminished by 34% and 27% respectively (Nyland et al.,
2004). By activating the surrounding muscle groups it is likely that
this patient had improved static and dynamic control of her hip
joint.
4. Conclusion
This case highlights the importance of considering variations in
the hip AOT in designing exercise programs. This patient had a
substantial reduction in hip pain and a resolution of LBP following
treatment. This was not in keeping with the pattern over the previous four years of episodic pain. Therefore, the change in symptoms may be attributed to altered biomechanics and the treatment
received. Clinical research is necessary to explore the validity of this
approach. It would also be relevant to consider whether this
strategy of altering lower limb alignment in the presence of
increased femoral torsion has any future implications in terms of
knee, foot and ankle mechanics.
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