Femoral anteversion

Right now, you probably have lots of questions: How serious is femoral anteversion? Does my child need treatment? What do we do next? We’ve provided some answers to your questions on this site, and our experts at Children’s Hospital Boston can explain your child’s condition in detail when you meet with us.

Background: the normal hip joint

The hip joint is one of the body's most reliable structures, providing movement and support without pain or problems in most people for a lifetime. The hip’s simple ball-and-socket anatomy—with the ball-shaped femoral head rotating inside a cup-shaped socket called the acetabulum—usually works well with amazingly little friction, and little or no wear.In toddlers and young children, walking with pigeon-toes is a normal part of your baby's hip and walking development, even when it’s caused by femoral anteversion. The anteversion usually straightens itself out as a baby learns to walk.

What is femoral anteversion?

Femoral anteversion is an inward twisting of the thigh bone (called the femur—the bone located between the hip and the knee). The condition causes your child's knees and feet to turn inward and have a "pigeon-toed" appearance.

Because your child’s knees and feet turn in, her legs look like they’re bowed. This bowed leg stance actually helps her achieve greater balance as she stands. Her balance is unsteady when she tries to stand and walk with her feet close together or with her feet turned out, so she may trip and fall quite a lot.

When does femoral anteversion usually become obvious?

Femoral anteversion usually shows up when a child is between 2 to 4 years old, since inward rotation from the hip tends to increase during that time. The condition is at its most obvious when a child is age 5 to 6 years old.

What causes femoral anteversion?

Femoral anteversion is usually considered to be a developmental variant, and the reasons for excessive femoral anteversion in some are unknown. The majority of patients are normal.

What are the signs and symptoms of femoral anteversion?

• Some signs and symptoms can include:
• pigeon-toed walking—the child is unable to walk with her feet close together and legs straight
• running with legs swinging out
• tripping and falling often
• sitting in a “W”-shaped position, with the child’s knees bent and her legs splayed out behind her

How common is femoral anteversion?

As the most common cause of kids walking with toes pointing inward (in-toeing) after age 3, femoral anteversion occurs in up to 10 percent of children.

Is my child in pain?

No, femoral anteversion doesn’t usually cause a child any pain.

How serious is femoral anteversion?

For the vast majority of children with femoral anteversion (some experts estimate as high as 99 percent), the condition usually self-corrects and normalizes by adolescence. Very few cases are severe enough to need surgery.

Do splints, braces or special shoes help correct femoral anteversion?

No, studies show that these devices don’t usually lead to faster improvement of this condition.

Who’s at risk for developing femoral anteversion?

• Most cases of femoral anteversion are sporadic (by chance) with no clear reason.
• There’s some evidence that femoral anteversion may be more common in girls than boys.
• Rarely some babies may be born with femoral anteversion (congenital).

How does a doctor diagnose femoral anteversion?

Tools for diagnosing femoral anteversion may include:

• a complete medical history and physical exam, including several measurements for the degree of in-toeing
• CT (CAT) scan—the chief imaging test for confirming a diagnosis of femoral anteversion (faster than MRI, more detailed than x-rays)
• MRI (magnetic resonance imaging) 
• x-rays

How does Children’s treat femoral anteversion?

Specific treatment for femoral anteversion is determined by your child’s doctor based on:

• her age, overall health and medical history
• the degree of her in-toeing

Doctors treat most children who have femoral anteversion with close observation over the course of several years, since the twisting-in of the thigh bone usually corrects by itself with time. As a child grows, normal or near-normal walking patterns typically resume by 8 to 10 years of age, or by the time the child becomes a teen.

In a very few cases, the twisting-in may be severe and may not self-correct. For children with severe, unresolved femoral anteversion, doctors may perform surgery to reposition the femur at a more normal angle.

Should I be concerned with my baby's progress in walking?

Walking with pigeon-toes is a normal part of your baby's walking progress, even when caused by femoral anteversion, which should straighten itself out as your baby learns to walk. If it doesn't by the time she’s about 4 years old, consult your baby's doctor.

Will my child be OK?

Femoral anteversion has a very good prognosis. Most cases correct themselves as a child grows, reaching normalcy or near-normalcy by the time the child is 8 or 9 years old, or by the time she reaches adolescence.

What new research is Children’s doing regarding lower extremity and developmental hip conditions?

The clinical and basic science researchers in Children’s Orthopedic Center are recognized throughout the world for their achievements in the field. Our breakthroughs mean that we can provide your child with the most innovative care available.

Some developmental hip conditions, such as hip impingement, slipped capital femoral epiphysis, hip dysplasia and Legg-Calve-Perthes disease, can lead to premature arthritis in young adults, with resulting pain and disability. Children’s many research studies focus on understanding the mechanical forces (pathomechanics) that adversely change the hip’s structure and function. With better understanding, we can improve existing therapies and develop new therapies for these conditions.

For more on Children’s extensive orthopedic research, see Research & Innovation.

FAQ

Q: What is femoral anteversion?

A: Femoral anteversion is an inward twisting of the thigh bone (femur), which causes your child's knees and feet to turn inward and present a "pigeon-toed" appearance.

Q: If my child has femoral anteversion, will she be OK?

A: The prognosis for femoral anteversion is very positive. Most cases correct themselves during a child’s growth years, reaching normalcy or near-normalcy by the time the child is 8 or 9 years old, or by the time she reaches adolescence.

Q: How does Children’s treat femoral anteversion?

A: Treatment for femoral anteversion includes:

• close observation for most cases
• surgery for severe cases that don’t resolve on their own

Q: If my child has femoral anteversion, what should I ask my Children’s doctor?

A: Some of the questions you may want to ask include:

• Could you describe what’s wrong with my child’s leg(s)?
• Are other tests needed to confirm this diagnosis?
• Is there, or could there be, damage to her tissues or blood vessels?
• Does my child need treatment? Does she need surgery?
• Will femoral anteversion affect her growth plate or the normal growth of her leg?
• Could there be long-term effects? Pain? Arthritis?
• Could this condition affect my child’s ability to walk, run or play sports?
• How long should my child be followed by her care team?

Q: How is femoral anteversion usually diagnosed?

A: Besides a complete medical history and physical exam with measurements for the degree of in-toeing, tests for femoral anteversion may include:

• CT (CAT) scan—the chief imaging test for confirming a diagnosis of femoral anteversion (faster than MRI, more detailed than x-rays)
• MRI (magnetic resonance imaging)
• x-rays

Q: If my child has femoral anteversion in one femur, can she develop it on the other side, too?

A: Femoral anteversion often develops symmetrically in both thigh bones, although it can develop on just one side.

Q: If my child has femoral anteversion, is she at risk for early arthritis?

A: No, femoral anteversion typically does not lead to arthritis or any other future health problems.

Q: What are the causes and risk factors for femoral anteversion?

A: Femoral anteversion is usually considered to be a developmental variant, and the reasons for excessive femoral anteversion in some are unknown. The majority of patients are normal. There’s some evidence that femoral anteversion may be more common in girls than boys. Some babies may be born with femoral anteversion (congenital).

Q: What’s the long-term outlook for a child who has femoral anteversion?

A: The long-term outlook for femoral anteversion is very positive. Most of the time, the condition corrects itself during a child’s growth years, reaching normalcy or near-normalcy by the time the child is 8 or 9 years old, or by the time she reaches adolescence.

Q: What is Children’s experience treating hip problems in children and teens?

A: At Children’s, we’re known for our clinical innovations, breakthrough research and leadership in treatment for hip impingement and other hip problems. Children’s Orthopedic Center offers the most advanced diagnostics and treatments—several of which were pioneered and developed by Children’s own researchers and clinicians.

Teens and young adults with hip problems usually need unique diagnostic and surgical techniques different from what’s indicated for younger children. As the only program of its kind in the world, our Child and Adult Hip Preservation Program offers the extensive experience and advanced techniques of clinicians and researchers dedicated to finding better ways to care for adolescents and young adults with hip problems.

Causes

Femoral anteversion is usually considered to be a developmental variant, with the reasons for excessive femoral anteversion in some unknown. Most patients are normal.

• Most occurrences of femoral anteversion are sporadic (by chance) with no clear reason.
• The condition may be more prevalent in girls than boys.
• Some babies may be born with femoral anteversion (congenital).

Signs and symptoms

Some signs and symptoms can include:

• pigeon-toed walking—the child is unable to walk with her feet close together and legs straight
• running with legs swinging out
• tripping and falling often
• sitting in a “W”-shaped position, with the child’s knees bent and her legs splayed out behind her

When to seek medical advice

Contact your child’s doctor if she:

• walks with a pigeon-toed gait
• can’t walk with her feet close together and legs straight
• runs with her legs swinging out
• trips and falls more often than her peers
• likes to sit in a “W”-shaped position, with her knees bent and her legs flung out behind her

Questions to ask your doctor

If your teen or child is diagnosed with femoral anteversion, you may feel a bit overwhelmed. It can be easy to lose track of the questions that occur to you. Lots of parents find it helpful to jot down questions as they arise—that way, when you talk to your child’s doctors, you can be sure that all your concerns get addressed.

Some of the questions you may want to ask include:

• Could you describe what’s wrong with my child’s leg(s)?
• Are other tests needed to confirm this diagnosis?
• Is there, or could there be, damage to her tissues or blood vessels?
• Does my child need treatment? Does she need surgery?
• Will femoral anteversion affect her growth plate or the normal growth of her leg?
• Could there be long-term effects? Pain? Arthritis?
• How long should my child be followed by her care team?

Who’s at risk

• Most cases of femoral anteversion occur sporadically (by chance) with no clear reason.
• Femoral anteversion may be more common in girls than boys.

Some babies may be born with femoral anteversion (congenital).Complications

Complications

Surgery for femoral anteversion is uncommon because most of the time it goes away on its own. But if it’s needed for severe cases, the vast majority of surgeries for femoral anteversion at Children’s are successful and occur without major complications. After surgery, patients are at a very small risk for infection, bleeding or poor bone healing (malunion).

Long-term outlook

The long-term outlook for this condition is very positive. Most cases of femoral anteversion correct themselves during a child’s growth years, achieving normalcy or near-normalcy by the time the child is 8 or 9 years old, or by the time she becomes a teen.

Femoral anteversion glossary

• acetabulum: hip socket; a part of the pelvis
• arthritis (osteoarthritis): joint inflammation and damage, resulting in pain, swelling, stiffness and limited movement. Arthritis can occur when a joint’s cushioning cartilage wears away. Femoral anteversion doesn’t typically lead to arthritis.
• The Center for Families at Children’s: dedicated to helping families find the information, services and resources they need to understand their child’s medical condition and take part in their care
• cartilage: smooth, rubbery tissue that cushions the bones of a joint and other areas; allows the bones to move easily without pain
• congenital: present at birth
• CT scan: a diagnostic imaging test that uses x-ray equipment and powerful computers to create detailed, cross-sectional images of your child's body
• diagnosis, diagnostics: identifying disease or injury through examination, testing and observation
• femoral anteversion: an inward twisting of the thigh bone, causing a “pigeon-toed” gait
• femoral derotation osteotomy:a surgical procedure for severe cases of femoral anteversion, in which the surgeon cuts the femur, rotates the ball of the femur in the hip socket to a normal position, and reattaches the bone.
• femoral head: round-headed top of the thigh bone (femur)
• femur: the thigh bone, the longest and strongest of your child’s bones. The rounded top of the femur (femoral head) joins the hip socket (acetabulum) to form the hip joint
• in-toeing: walking with toes pointing inward; femoral anteversion is a the most common cause of a child’s in-toeing beyond the age of 3
• MRI (magnetic resonance imaging): a diagnostic imaging test that uses a combination of large magnets, radio frequencies, and a computer to produce detailed images of organs and structures within the body
• onset (of signs or symptoms): the first appearance of signs or symptoms
• open reduction surgery: a procedure in which the doctor repositions the thigh bone through an incision into the patient’s body
• orthopedic surgeon, orthopedist: a doctor who specializes in surgical and non-surgical treatment of the skeletal system, spine and associated muscles, joints and ligaments
• orthopedics: the medical specialty concerned with diagnosing, treating, rehabilitating and preventing disorders and injuries to the spine, skeletal system and associated muscles, joints and ligaments
• sporadic: by chance
•  "W" shaped sitting position: child sits with knees bent and legs spread out behind her; sitting position often adopted by children with femoral anteversion
• x-rays: a diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film

See our extensive glossary of orthopedic terms.