Femoral Retroversion

FEMORAL RETROVERSION
By:  Robert H. Sheinberg, D.P.M., D.A.B.P.S., F.A.C.F.A.S. 

Femoral retroversion is a positional deformity caused by contracture of the external rotator muscles of the hip.  It becomes apparent as the child starts to stand or cruise between 6 and 9 months.

CAUSE:

  • Tightness of the muscles of the hip that cause the hip to rotate excessively to the outside. 
  • Primarily caused by in utero position.
  • Rarely caused by bone deformity in which there is an actual external twist of the lower portion of the upper leg bone (femur) relative to the upper portion of the upper leg bone (femur). 

SIGNS AND SYMPTOMS:

  • With weightbearing the entire extremity appears to be externally positioned.  While the child lies on their back the outside of the leg appears to be touching the bed they are lying on.  The outside of the foot (small toe side) lies flat on the bed.  While the child starts to cruise or stand the child appears unsteady or imbalanced due to a diminished base of support.
  • Usually will be a late walker.
  • Usually associated with flatfeet.
  • Due to the significant external foot progression angle (foot pointing extremely to the outside) a flatfoot develops or worsens as the child is walking through the arch and not over the ball of the foot.
  • Extreme poor push off power.
  • Runs very poorly.
  • Fatigues prematurely with any type of activity.
  • Poor overall balance.
  • Lacks a desire to participate in sports or any type of activity.
  • Associated with poor coordination.

CLINICAL EXAMINATION:

  • Examination of the child off weightbearing laying in the supine (on their back) position reveals limited motion of the entire leg going internal and 80-90+ degrees of motion going externally.  
  • Usually symmetrical (occurs on both sides).
  • If unilateral hip dysplasia must be ruled out.
  • Must examine the lower leg to rule out external tibial torsion (external position of the lower leg on the upper leg bone) or other associated causes of out-toe.

TREATMENT:

  • Treatment of femoral retroversion can become very difficult.  The primary treatment is to attempt to stretch the muscle group in the hip to improve internal rotation.  This must be done aggressively at a very early age to try to improve the overall muscle balance in the hip. 
  • Avoiding having the child sleep on their stomach with the knees pointed out, which will perpetuate the deformity. 
  • Splinting of the legs, especially at night to stretch the external rotators and take stress off the internal rotators.
  • Exercises to help improve strength to the adductor muscles on the inner upper leg.
  • A custom molded orthotic for the shoe at a very early age to prevent the foot from breaking down even further and to provide support necessary for ambulation.
  • Getting a child into a sneaker at an early age will help to improve balance when the child starts to walk.
  • Assessing for external tibial torsion that may significantly complicate femoral retroversion. 
  • It may be necessary to place the leg in a cast to stretch the ligamentous and muscular structures on the outside of the knee, which can hold the lower leg externally positioned relative to the upper leg.
     

PROGNOSIS:

Prognosis is generally poor for femoral retroversion.  The child may be more limited due to a lack of coordination and poor push off strength during any type of activity.  Contractures of the lower leg relative to the upper leg (external tibial torsion) should be addressed if present to lessen the deformity.  An orthotic may also provide some benefit.

If the condition is causing significant problems and cosmesis is a concern surgery can be contemplated.  If associated with significant external tibial torsion a lower tibial osteotomy (cutting the lower leg bone and twisting it in) would provide some benefit.  Long-term studies are few in determining the best treatment outcome for this problem.  It is best to address as much of the deformity as possible (orthotic for foot, casting for external tibial torsion and stretching exercises to improve the overall leg position). 

Long term this condition may be associated with hip problems including arthritis.  In a young teenager with hip pain slipped hip growth plates (slipped capital femoral epiphysis) must be ruled out.