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Hip Anteversion – Assessment and Implications for Strength and Conditioning Programs

Written on February 29, 2012 at 7:31 am, by Eric Cressey

Today, we have a guest blog from former Cressey Performance intern Eric Oetter, who is well on his way to a great career in physical therapy. Eric is an extremely bright up-and-comer from whom you’ll be hearing a lot in the years to come.  Here’s a little sampling.

 

As part of the “pre-launch” phase for his new collaborative project, Elite Training Mentorship, Eric posted an outstanding video covering the lower-extremity assessment protocol he uses at Cressey Performance. For those who haven’t yet seen it, follow the link here; you won’t regret it.

In the video, Eric mentions three different factors that can contribute to mobility deficits at the hip: muscular restrictions, capsular restrictions, and bony restrictions. While the first two – muscular and capsular – can be relatively easy to decipher based on the test position of the hip, identifying bony restrictions can be tricky unless you’ve got access to a client’s radiological imaging. For this reason, it’s important to appreciate any structural variations in the skeletal system that can underlie joint malalignment at the hip.

The focus of this piece is a structural variation called hip anteversion. We’ll be covering the joint morphology associated with anteversion, along with a quick orthopedic test and some implications for programming.

What is hip anteversion?

Excerpted from the 2002 text Diagnosis and Treatment of Movement Impairment Syndromes, Shirley Sahrmann describes hip anteversion as the following:

“ … the angle of the head and neck of the femur is rotated anteriorly, beyond that of the normal torsion with respect to the shaft. The result is a range of medial hip rotation that appears to be excessive, whereas the lateral rotation range appears to be limited.”

Essentially, clients who present with this structural abnormality were born with, or have acquired, a more internally oriented neutral position for their femurs as they sit in the acetabulum (or hip socket). To be classified as anteverted, the femoral head and neck must be rotated more than 15° anteriorly with respect to the plane of the femoral condyles (Sahrmann 2002). (Conversely, a posterior rotation of the femoral head and neck would constitute a retroverted hip.)

When observed standing, clients with hip anteversion will often present with femoral adduction and genu valgum – the classic “knock-kneed” posture. As kids, these clients likely eschewed “indian-style” for W-sitting – a position much more congruent with their natural femoral alignment.

 

While some might also classify “pigeon-toes” as an indicator for anteverted hips, this is not always the case. In the presence of anteversion, some clients – especially athletes – will develop a tibial torsion as a result of the applied stresses to the lower extremities. This adaptation allows for a neutrally aligned sub-talar joint in the face of morphological changes up the kinetic chain.

The largest implication of hip anteversion or retroversion is a significant discrepancy between hip internal and external rotation. As described in the Sahrmann quotation above, hip anteversion creates an apparently large amount of internal rotation (IR) with a reciprocal loss of external rotation (ER).

I liken these morphological changes to those seen in the retroverted shoulder of an overhead throwing athlete.  The total hip range of motion (IR + ER) can present at around 90°, or “normal”, but these measures are drastically skewed in one direction of rotation.

Whereas a retroverted shoulder presents a favorable adaptation in baseball, the same cannot always be said for the athlete with anteverted hips.

If undiagnosed or mismanaged, hip anteversion can create pathology.  Expect issues like knee pain, back pain, and hip instability (Sahrmann 2002). For this reason, it’s imperative to recognize anteversion when it presents and apply the programming modifications necessary to accommodate this structural abnormality.

So how can I test for it?

Although checking IR and ER in both supine and prone can highlight limitations in the capsule or surrounding hip musculature, you’ll need an extra orthopedic test at your disposal to clear the skeletal system. For this purpose, we’ll use the Craigs’s test.

Assuming you’re following the assessment outlined in Eric’s video, the best time to perform a Craig’s test is immediately after you’ve assessed a client’s hip rotation in prone, especially if you detect a glaring asymmetry between IR and ER.

Note the client in the photos below – here, we see an excessive amount of IR (~50°) met with limited ER (only ~20°). With a rotational deficit of ≥30°, this client may have some torsional issue at play; thus, a Craig’s test indicated.

With the client remaining in prone the knee held in flexion, the Craig’s test is performed by first palpating the same side greater trochanter, a landmark on the femur that protrudes laterally about 5 inches below the iliac crest. Make sure to apply flat-hand contact with the pads of the fingers – this posture allows for greater sensory feedback and precision. Once this position is assumed, begin internally and externally rotating the femur through its full range of motion.

As you rotate the leg, you’ll notice the greater trochanter tracking against your fingertips, becoming more or less prominent depending on the direction of rotation. Start shortening your oscillations until you determine the position at which the trochanter is most prominent laterally and pause once you locate it. At this range of rotation, the femoral head is optimally situated within the acetabulum.

We get a positive Craig’s test when the hip rotation at the point of ideal femoral alignment is ≥15° into IR. Also, we can now classify the hip as anteverted, providing useful insight for the dexterous coach.

Check out the video below to see a Craig’s test performed on our client from above.

 

One thing worth noting – a 1992 study by Ruwe et al. showed the Craig’s test to be more reliable than radiological techniques in the assessment of femoral torsion. So, even if you have client X-rays available, a Craig’s test is still worth administering.

If the Craig’s test is positive, how should I alter programming?

Now that we’ve performed a Craig’s test and determined whether or not any torsional qualities exist, it’s time to write an effective program that respects our findings. Here are a few do’s and don’ts to consider when programming:

DON’T stretch the hip into external rotation – this only creates impingement. We wouldn’t force the retroverted shoulder of a pitcher into an end-range sleeper stretch, so we need to take the same approach with an anteverted hip. Even though the hip is a much more durable joint, there’s no reason to drive motion that a client simply doesn’t have, as this only serves to jam the femoral head against the acetabulum.

DO increase the amount of core work in clients with femoral torsion. When someone is stuck in internal rotation at the hip, the kinematics of the lower-extremities become predisposed towards a pronation pattern (sub-talar pronation, tibial/femoral IR, and anterior pelvic tilt).

The hip external rotators often become excessively stiff and overused, as they are constantly checking motion into adduction, internal rotation, and flexion. While increasing external rotator strength will improve the first two, we can employ the posterior fibers of external oblique and rectus abdominis to aid in flexion control, creating a more stable pelvis. By doing so, we’re also increasing stiffness at the lumbar spine, fighting any compensatory motion created by the hip external rotation deficit.

As far as exercise selection goes, focus on half-kneeling chops/lifts and anti-extension – both integrate the hips and core simultaneously to check hip flexion ROM. I especially like rollout variations for clients with hip anteversion, which are highlighted in Eric’s video below.

DON’T introduce quad-dominant lifts until the client shows dramatic improvements in hip stability. The pronation pattern I described above is essentially a cookbook for ACL and MCL injuries. In a population that is likely anteriorly tilted at the pelvis and anterior weight bearing, the last thing we want to do is make them even more reliant on their quads. An adroit posterior chain should precede any anterior chain-focused movement.

DO hammer the posterior chain as if your life depended on it. While this statement could serve as a mantra for most general population programming, it is even more important when dealing with anteversion of the hip. These clients sometimes present with femoral control so poor, our first goal is to simply get them to baseline.

Mastering stability in the sagittal plane takes precedence. Start bilateral with deadlift and box squat variations and increase stability demands as the client advances. Great second tier progressions include single-leg RDLs, single-leg hip thrusts, and bowler squats, all of which introduce frontal and transverse plane stability.

Lastly, exercises that force the femur into an abducted and externally rotated state are contraindicated – sumo deadlifts provide a great example. Even though pulling sumo is a fantastic variation for hip strength, it can create malalignment in the acetabulum if the hip is anteverted. In this case, it’s safer to stick with either trap bar deadlift or conventional deadlift variations.

Conclusion

Hip anteversion isn’t something you’ll likely see in every client. Johns Hopkins Medical School reports the prevalence to be ~8-10%, but that number varies based upon cultural norms and neurodevelopmental patterns, which can alter skeletal growth.

Regardless, it is an important structural variation to recognize and program for, especially in an athletic population. Taken as supplement to Eric’s lower-extremity video, I hope this article provides you another piece towards building a better assessment.

About the Author

Eric is currently a senior at the University of Georgia majoring in Exercise and Sport Science, with plans to pursue a Doctorate of Physical Therapy. After concluding a Division-1 football career at the Georgia Institute of Technology, Eric has ardently pursued his passion for coaching, garnering experience with clients of all ages and ability levels through internships at both Indianapolis Fitness & Sports Training and Cressey Performance. His articles can be found on EricCressey.com, 8weeksout.com, and in Fighting Fit magazine.  You can follow him on Twitter or reach him via email at ecoetter@gmail.com.

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29 Responses to “Hip Anteversion – Assessment and Implications for Strength and Conditioning Programs”

  1. Jordan Syatt Says:

    Eric,

    Fantastic piece. Very well done!

    -J

  2. Trevor Says:

    Have you noticed, or have you seen research suggesting differences between sides? Just as in the shoulder, I would expect structural adaptions during childhood could cause some anteversion. For example a child kicking a soccer ball and the stance leg being internally rotated.

  3. Francisco Says:

    Great article Eric! I couldn’t believe when I got to the end of the article that you are “still” completing your exercise science degree since I just learned about all this stuff in PT school. Keep it up!

    I just wanted to add an interesting piece of information that Piva et al found in 2006 that the femoral anteversion test has poor reliability for those with a BMI over 25 but a good reliability for those with a BMI of 24.9 or less. Something to keep in mind, particular for those who work with a more “general” population.

    http://www.biomedcentral.com/1471-2474/7/33

  4. Naomi W. Says:

    Yes, this is me! I’ve had this condition my entire life, and now I can finally put a name to it. (When I fell off a ski-lift I immediately dropped into the “W” sit, and all the employees ran over because they thought I had broken my legs.)

    I actually discovered the proper “cure”/techniques on my own through trial and error. You’re right, working the posterior chain is a must for me as far as keeping me injury free through my hips and lower back.

  5. Stephen Thomas, PhD, ATC Says:

    Eric nice post! Just some things to think about. The original study using this technique that you posted included 9 year old children mainly with CP. This population is extremely thin and very easy to palpate the greater trochanter. In an athletic population there is much more soft tissue that may restrict your measurement accuracy. As a gross screening tool I think it can be useful but if your are trying to obtain accurate measures to document the contribution of either bony or soft tissue restrictions it may be difficult. These is a current technique using ultrasound to measure this as well. This will be much more accurate in an athletic population (http://www.ncbi.nlm.nih.gov/pubmed/16391259).

    Also I am unclear how it is easy to decipher between musculotendinous restrictions and capsular restrictions. Even when changing test positions the capsule still restricts end range motion unless you have a hard end feel then it is clearly a bony limit. Since you can never completely remove one or the other from the equation I find this very difficult to determine.

  6. Andreas Hessner (Denmark) Says:

    Great article Eric

    You point out that moving the femur into an abducted and externally rotated position is contraindicated for people with anteverion of the hip.
    In terms of the squatting-pattern (for eg. the box squat) how would you have client perform them?
    I normally emphacise a knees-out cue when teaching clients to squat, but reflecting on this i can see the issues with this for the anteverted population.

  7. pat elias Says:

    Great post Eric.Having worked in peiatric orthopedics in the past, there are tons of young athletes with this condition.Surgeons are very reluctant to correct excessive femoral anteversion.This population tends to present later on in life with labral tears, CAM, Pincer lesions, especially the athletes forced into too much ER work.

  8. Bill Weissert, PT, CSCS Says:

    Please note that the Craig’s test has been shown to have only “fair” reliability in determining femoral anteversion:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1557500/

    Great topic and good overall post. Especially the strengthening and core stability recommendations.

    I do use the Craig’s test, but only as a quick screen, in my practice. Many males have retroverted hips, in which a bony torsion causes a lack of hip internal rotation. In these cases, stretching into internal rotation is a risky proposition.

    Acetabular labral tears are not increasing in number because our bodies our changing; we as professionals are just getting better at diagnosing joint lesions about the hip.

    I encourage everyone to re-think how much we’re stretching our clients’ hips into internal or external rotation.

  9. Amanda Russell Says:

    Fascinating. I use to sit pretzel style when I was little. I guess that made a difference haha.

    Amanda Russell
    http://www.youtube.com/user/AmandaRussell/featured
    http://amanda-russell.com/

  10. Jay Says:

    Eric

    Any tips (or intention to write a future article) on the opposite issue?

    I was under the impression a lack of internal hip rotation is also common, like me

    Jay

  11. Al Coleman Says:

    OMG!! I’m so happy someone has written about this.

    I’m one of the few who were born with this issue. I have the deficit in my right hip and it didn’t help that I was a right handed pitcher for 25 years of my life.

    I do have one question: Will the corrective exercises above lead to the ability to actually increase hip external rotation or will they only not make the deficit worse?

    Thx-Al

  12. Matt Says:

    Great post. Any future posts in the works for people with a severe lack of internal rotation? I am unfortunately a member of that group.

  13. Jim Says:

    Excellent post. I personally don’t have an issue with this but a kid I work with does and this will be very helpful to have him read and be able to know how to better work with him.

  14. Sherry Says:

    Finally! I’ve read something that explains what I’ve noticed about my body for years! I’m a 35 year old female who happens to be slightly knocked-kneed, can sit in the W position if asked, has had my right ACL replaced and has noticed a weird right side hip flexor area issue for as long as I can remember. I also “tilt” to the right when doing squats in the lowest position. There are a few exercises I do that seems so easy for everyone else but for me are terribly awkward….and I think this article finally gives me a name for it! So thank you for writing this. Question though, I don’t have any pain or any terrible discomfort other than what I’ve mentioned…so should I be doing anything about it? The exercises you mentioned, perhaps? Will they help stretch or strengthen so I have more mobility on the right side? Thanks again.

  15. Janet Says:

    My 9 year old daughter has just been diagnosed with this. She is a gymnast and so far has no limitations or pain from this. She does get deductions for the intoeing. She is a candidate for surgery since the left leg is 45 degrees and the right is 35 degrees. They would do both legs ay once if we opt to have this surgery. Should we? It is a major surgery and would take her out of competition for 6 months. She does get teased for it and it is very noticeable. She has trouble ob the bars keeping her legs tight together. I worry about problems with her knees,, back and hips down the road if we don’t do the surgery but it is elective. Any advice appreciated.

  16. Eric Cressey Says:

    Janet,

    That’s a very tough call. I hesitate to recommend surgery for anyone – especially a kid – unless it’s absolutely necessary. I guess it depends heavily on how far she’d like to take her gymnastics career.

  17. Janet Says:

    Thanks for the quick reply!! We are researching and praying, getting a second opinion, and consulting with a pediatric orthopedist as well. We want to do the right thing. She is VERY competitive and loves gymnastics and competing. They say she is a natural. My husband thinks we should do it if this is her dream. But surgery is SURGERY with risks. Appreciate your opinion. I am also doing a lot of research online and talking to people who have had this surgery done and getting all the pros and cons. Really what I want to know is do you see altheletic people limited or getting knee and hip injuries because they have femoral anteversion?
    The three reasons we r even considering the surgery is competitive gymnastics, self esteem/ cosmetic, and to prevent hip, back, and knee problems down the road.

  18. Eric Cressey Says:

    Janet,

    I’m sorry to say that I haven’t seen any folks come my way who have had the surgery. I’d encourage you to reach out to a number of experienced physical therapists who may have seen more than I have. One guy I’d recommend is Bill Hartman; you can check in with him at http://www.billhartman.net. Eric Oetter (who wrote this article) works closely with Bill on a daily basis. Good luck!

  19. Taylor Levick Says:

    Eric,

    I have been dealing with what seems to be posterior FAI for several years, but only during heavily weighted squats and deadlifts. A quick Craig’s test reveals that I actually have a little femoral retroversion on the affected side (greatest prominence at ~5 degrees of external rotation). Needless to say I have modified my training to stay out of these painful positions (front squats and rack pulls still allow me to train heavy but pain free). I have employed most of the training recommendations you have made for those with anteversion (just chalking this up as a sound S&C regimen) but are there particular training modifications do you recommend for femoral retroversion? As a soon-to-be practicing chiro I just have to say I get more out of reading your website than I did out of 3 years of chiro schooling. Thanks for what you do man!

  20. Eric Cressey Says:

    Taylor,

    I’d check to see whether it’s all osseous restriction or if you have some muscular restriction as well. If you can get a little bit of IR back, great. However, if you can’t, you don’t want to be powering through it with aggressive mobility work. Regular soft tissue work on hip external rotators won’t hurt, either.

  21. debbie Says:

    My daughter had her femurs rotated (r) 25* and (l) 30* when she was 6 years old. She is now 31 and a beautiful skier. Parallel vs perpetual snowplough. Skating was impossible. She has a competitive nature and being “handicapped” would have been torture to her “sitting on the bench”. The right leg could have used more correction as was pointed out by a physio therapist years later. I had a second opinion before the surgery – a female sports medicine doctor told me it was purely cosmetics. I didn’t take her advice. I went with the advice of the DND doctor who would have dealt with adults and saw what happens to older people when biomechanics go wrong. Daughter is now a physio therapist herself and can relate to young children she sees. I sometimes wonder if I did the right thing – she assures me it was the right thing to do and not look back.

  22. Brad Says:

    So how do we fix it? I have been to doctors for 10 years and none of them even are willing to consider that I may have some alignment issue, so for now I’m on my own.

  23. Eric Cressey Says:

    Brad,

    It’s the way you’re built; you won’t “fix” it. You’ll just learn to work around it.

  24. Katie H. Says:

    Eric, thank you for this article. I was just diagnosed with femoral anteversion, and I have a labral tear (anterior) that was caused by this. That means I am limited for exercise, but I still want to do some strengthening exercises like you discuss above. Do you have any beginner exercises that someone with a labral tear can do? I don’t think the roll outs are going to work for me.

    You say to avoid strengthening the quads. Could you highlight which muscles I should be strengthening instead? Thank you so much!

  25. Eric Cressey Says:

    Katie,

    It’s really difficult to make specific recommendations without seeing you. Where are you located? I might be able to put you in touch with a good fitness professional near you.

  26. Brad Says:

    If it’s the way I’m built, why does it seem to keep getting worse? And I only got a diagnosis after 9 years if seeing doctors and begging them to consider I have something else wrong. But I wonder if they didn’ see it because it wasn’t as severe.

    Squatting at 16-20 years old felt perfect. Towards the latter end of that I was basically fully grown. Why would everything feel perfect until 20 years old, then slowly feel worse and worse, with associated visible structural changes if it was how I was built?

  27. Tevia Says:

    Thank you for this article. I was born with FAI and diagnosed as a baby. I’m 35 now. As a kid sitting in “w” was the most comfortable for me. I have chronic pain in both hips which didn’t start until I was in my early 20’s. I have also had tendinitis in both knees, which fortunately went away after a lot of treatment. For my hips I’ve gone to PT, chiropractic, acupuncture, sports massage, yoga, Pilates, and strength training. Nothing seems to really work. A recent MRI showed lab real tears in both hips. I’m at a loss as what to do. An orthopedic doctor is thinking surgery. Is there anything else I can do to avoid surgery? Any thoughts would greatly be appreciated.

  28. Susan Says:

    Tevia, after several years of physical therapy I am so thankful I finally had hip surgery. Check out Dr. Philippon in Vail, Colorado who does the labral repairs arthroscopically. After your surgery you will need to be diligent about always doing your Physical therapy exercises for the rest of your life to keep your hips stable but it is possible to improve the pain. Good luck

  29. Tammy H. Says:

    Hi Eric,

    I am 44 years old and had surgery when I was 9 or 10 for being “pigeon toed”. I have had extreme pain in my hips and knees for about 18 years or so. I ended up having a TKR on my left knee at age 41. I am in need of a replacement in my right knee plus my right ankle now. I somehow got an infection in the left knee and ended up having the replacement removed and had an antibiotic spacer put in for 5 months, and then another replacement. My question is, have you heard of patients that have ended up with joint problems after having the hip surgery, later in life??

    Thank you so much!!

    Tammy

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