䢇

Update

Determination and Significance of

Femoral Neck Anteversion

F
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў

emoral neck anteversion (FNA) describes the normal torsion or twist

present in the femur. Femoral neck anteversion is defined as the angle
between an imaginary transverse line that runs medially to laterally
through the knee joint and an imaginary transverse line passing
through the center of the femoral head and neck (Fig. 1).1,2 In adults without
pathology, the femur is twisted so the head and neck of the femur are angled
forward between 15 and 20 degrees from the frontal plane of the body.1,2 In
some instances, the FNA angle is directed forward or backward well beyond
this angle. Some researchers3– 8 suggest that FNA angles outside this 15- to
20-degree average are a contributing factor in many different orthopedic
problems in the lower extremity that are commonly seen by physical therapists.
The purpose of this Update is to describe how FNA is related to hip rotation, how
hip rotation range of motion can be used to predict abnormal FNA, and how
asymmetries in hip rotation may be used to identify patients who may be at risk
for developing various orthopedic problems in the hip and lower extremity.

Femoral neck anteversion sometimes is called “medial femoral torsion.”2,3 It is

thought to result from medial (internal) rotation of the limb bud in early
intrauterine life.3 In postnatal development, a reduction of the FNA angle
usually occurs during growth.2,3 In the newborn, the average FNA angle is 31
degrees.2 The average FNA angle is 26 degrees by 5 years of age, 21 degrees
by 9 years of age, and 15 degrees by 16 years of age.2 The FNA angle,
therefore, diminishes about 1.5 degrees a year until about 15 years of age.2 In
the adult, average femoral head and neck torsion forward of the body’s frontal
plane is about 15 degrees, a little less in men (less than 15°) and a little more
in women (18°) (Fig. 1).2,4 Femoral neck anteversion angle is typically
symmetrical from the left side to the right side.5

In contrast to FNA, femoral neck retroversion is present when the head and
neck of the femur are angled less than the average FNA angle (15°–20°) along
the frontal plane of the body (Fig. 1).6,7 In some cases, the femoral head and
neck may even be angled backward from the frontal plane of the body.

[Cibulka MT. Determination and significance of femoral neck anteversion. Phys Ther. 2004;84:550 –558.]

Key Words: Femoral neck anteversion, Femoral neck retroversion, Hip rotation, Medial femoral torsion.

Michael T Cibulka
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550 Physical Therapy . Volume 84 . Number 6 . June 2004


How FNA Develops
What stimulates the femur to undergo torsion or twist is
not understood. The current opinion is that the femur
twists from torsional forces applied perpendicularly to
the epiphyseal growth plate.9 According to the Heuter-
Volkmann Law of epiphyseal pressure, increases in pres-
sure across the epiphysis will decrease its growth,
whereas decreases in pressure will increase its rate of
growth.8 In adults, the epiphysis is closed and the
Heuter-Volkmann Law cannot explain bone remodel-
ing. Wolff’s Law explains the remodeling or change in
adult bone. Wolff’s Law states that every change in the
form and the function of a bone is followed by changes
in the bone’s internal and external architecture in
accordance with mathematical laws.8,9 Remodeling of
the FNA also may occur because of changes in the stress
placed on the adult femur’s diaphysis by torsional forces.
What creates torsional force on the femur? Muscle, by
either its passive elastic connective tissue or its contrac-
tile force, contributes the greatest stress on bones.9
Animal studies10 –13 suggest that uneven forces, either by
maintaining the hip joint in medial or lateral (external)
rotation or by resecting the hip rotator muscles, can
produce changes in the FNA angle. Bernbeck,11 Salter,12
and Wilkinson13 showed that, when the hind limbs of
animals were held fixed in lateral rotation, the FNA
angle decreased, whereas when the hind limbs were
fixed in medial rotation, the FNA angle increased.
Unilaterally resecting the hip medial or lateral rotators
alters the torsional muscular forces acting on the femur.
Haike10 has shown that increased or decreased femoral
anteversion resulted after resecting either the medial
rotator or the lateral rotator muscles of the hip.
MT Cibulka, PT, MHS, OCS, is Physical Therapist and Owner, Jefferson County Rehab & Sports Clinic, 1330 YMCA Dr, Ste 1200, Festus, MO
63028-2647 (USA) (mcibulka@earthlink.net).
Physical Therapy . Volume 84 . Number 6 . June 2004
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An increased or a decreased femoral
neck anteversion angle has been
linked to many different lower-
extremity problems.
Published reports1,3–5 have suggested that habitual sleep-
ing and sitting postures, in which the hip is held at or
near the end of medial or lateral rotation, may produce
changes in the FNA angle. These extreme postures often
will produce an increase in hip rotation in one direction,
with a corresponding decrease in hip motion in the
opposite direction. As expected, hip joint motion
increases in the direction the hip is held. Habitually
adopting a sleeping or sitting position in which the hip
is held in extreme lateral rotation, therefore, favors an
increase in lateral rotation motion with an equal loss of
medial rotation (Figs. 2 and 3). Maintaining an extreme
hip posture also produces changes in the soft connective
tissue surrounding the hip, shortening the hip joint
capsule and muscles on one side and lengthening the
hip joint capsule and muscles on the other side. These
asymmetrical changes in soft tissue around the hip likely
will create uneven torsional forces placed on the femur.
Examination of children with hemiplegia also lends
support to the theory that changes in hip muscle force
are related to an abnormal FNA angle. Staheli et al14
looked at the hips of children with hemiplegia and
found that the FNA angle on the nonhemiplegic side is
normal, whereas the FNA angle was increased on the
hemiplegic side, as was the motion of medial rotation
when compared with the normal side.
Cibulka . 551

Figure 1.
Illustration of normal, increased, and decreased femoral neck anterver-
sion (FNA) angle.
Measuring the FNA Angle Using Imaging
Techniques
Although FNA was anatomically described as early as the
19th century, the first method used to measure FNA was
the biplane radiograph. Perhaps the most often used
technique is the method described by Magilligan in
1956.15 The Magilligan method consists of taking an
anteroposterior radiograph and a true lateral radio-
graph of the hip and an anteroposterior radiograph of
the knee. Three lines are used to determine the FNA
angle—the long axis of the femur, the axis of the
femoral neck, and the axis of the knee. The long axis of
the femur is defined as a line that connects 2 points—the
center of the base of the knee and the center of the base
of the femoral head. The axis of the femoral neck is defined
by a line drawn from the center of the femoral head to
the center of the base of the femur. The axis of the knee is
a line drawn from the medial to the lateral posterior
femoral condyles. The angle formed between the axis of
the femoral neck and the axis of the knee is measured
(Fig. 4). Given this angle, the true angle of torsion is
then derived from a graph produced by Magilligan.15
Other researchers16 –18 have modified this technique
slightly over the years.
Most femoral torsion problems are evaluated with com-
puterized tomography (CT). The method described by
Murphy et al18 is often used, with slight variations
described by others.19 –22 This CT technique involves 3
images or scans—2 proximal and 1 distal. Murphy’s
method is based on strict geometrical reconstruction of
the angle of anteversion. The patient is positioned in the
scanner so that the long axis of the femur is parallel to
the long axis of the scanner. One image defines the
location of the center of the femoral head, the second
image defines the base of the femoral neck, and the
third image defines the distal femoral condylar axis
(Fig. 4). The angle in the transverse plane between the
intersection of the plane of anteversion and the condylar
plane defines the angle of anteversion. Murphy et al18
showed the accuracy of CT by comparing CT measure-
ments with direct measurements of 32 dried femoral
bone specimens that were used as a gold standard.
Murphy et al18 found that measuring anteversion with
552 . Cibulka
computerized tomography was accurate within 1 degree
when compared with measuring the femoral bone spec-
imens directly.
A Clinical Method to Determine the FNA Angle
The idea for using passive hip rotation to determine
abnormal femoral torsion arose from observations of
children who had an in-toeing or out-toeing posture or
gait. In 1957, Sommerville23 reported that extreme dif-
ferences between hip medial and lateral rotation are
related to femoral torsion problems in children. Crane1
found that differences between hip medial and lateral
rotation were associated with change in FNA and with
the toeing-in and toeing-out of the lower extremity.
Crane also discovered that children who toe-out had a
low FNA angle and had medial rotation of the hip of 20
degrees or less, whereas lateral rotation exceeded 60
degrees. Those children with a high FNA angle had
medial rotation of the hip exceeding 60 degrees and
lateral rotation less than 30 degrees, and they tended to
toe-in.
Early observations of children who toed-in or toed-out
suggested that passive hip rotation could be used clini-
cally to predict an abnormal FNA angle in children. Few
studies have looked at the relationship between the FNA
angle and passive hip rotation in adults. In 100 adult
subjects, Braten et al24 observed that the FNA angle
increased as medial rotation increased and lateral rota-
tion decreased. Because subjects without impairments
were used, differences were small but significant. Tonnis
and Heinecke25 examined 152 adult patients and also
found that hip rotation was related to the FNA angle.
Patients with greater lateral rotation than medial rota-
tion had femoral neck retroversion, whereas those with
greater medial rotation than lateral rotation had FNA.25
Although the hip motion and the FNA angle were
smaller in the group of adults than in the group of
children, the FNA angle still correlated well with the
difference between medial and lateral rotation of the hip
in both groups.25
A limitation in using passive hip rotation to determine
the FNA angle is that a precise FNA angle cannot be
determined from clinical measurements. A precise FNA
angle, however, is only needed in the selection of
patients and preoperative planning for a derotation
osteotomy of the femur.5,6,8 Because physical therapists
do not perform femoral neck operations, determining a
precise FNA angle is not of vital importance. Determin-
ing the existence of an abnormal FNA angle is of
potential importance to physical therapists when dealing
with patients with lower-extremity orthopedic problems
commonly related to increased or decreased FNA.24,26 –29
Because studies show that the FNA angle appears closely
linked to differences between hip medial and lateral rota-
Physical Therapy . Volume 84 . Number 6 . June 2004

Figure 2.
Sitting in the “W” or reverse tailor position with maximum hip medial
rotation.
tion, I suggest that physical therapists use this information
to predict when an abnormal FNA angle might exist.
Researchers have attempted to determine the upper and
lower limits for normal hip rotation. Most clinical studies
measured hip rotation in the prone position with hips
extended and knee flexed to 90 degrees.26,30 –38 The
pelvis is stabilized, and the hip medially or laterally
rotated by grasping the ankle. When a firm end point is
reached, the hip angle is measured. Studies performed
on subjects without impairments26,33 have consistently
shown that hip rotation is consistently equal from the
left to right sides, especially when looking at a specific
motion such as medial rotation. Differences in hip
rotation between the left and right side rarely exceed 10
degrees (Tab. 1).30 The mean difference in hip rotation
in adults between the left and right sides is about 8
degrees (Tab. 1). Using a cutoff of 2 standard deviations
above or below the mean (a common method used to
identify the upper and lower limits of abnormality in a
normally distributed measure), an abnormal motion
exists when left and right measurements are more
than 16 degrees apart in an adult. For example,
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Figure 3.
Sitting in the tailor position with maximum hip lateral rotation.
findings of 40 degrees of left hip medial rotation and
60 degrees of right hip medial rotation would be
considered abnormal.
In patients with suspected abnormal FNA, observing the
difference between the left and right sides for a specific
movement such as hip medial rotation is not as impor-
tant as observing the difference in motion between
medial and lateral rotation of the hip on one side.
Studies that have examined hip motion on subjects
without impairments have found only small differences
between medial and lateral rotation. Svenningsen et al26
examined children and adults without impairments and
found the greatest disparity between hip medial rotation
and lateral rotation (Tab. 1). Svenningsen and col-
leagues found that medial rotation exceeded lateral
rotation by 2 to 16 degrees, with the greatest differences
occurring in the 4- and 6-year-old groups. Staheli and
colleagues’ examination of children without impair-
ments31 showed that females had little difference
between medial and lateral rotation of the hip, whereas
males had differences ranging from 3 to 11 degrees, with
medial rotation exceeding lateral rotation (Tab. 1). In
adults, Staheli et al,31 Roaas and Andersson,33 Ellison
and colleagues,35 and Chesworth et al36 found little
Cibulka . 553
Table 1. The finding of diminished lateral rota-
Hip Rotation Medial Rotation/Lateral Rotation (SD)a tion with increased medial rotation and
a large FNA angle also is consistent with
Age (y) many clinical observations.1,3–5,8 A
Study 4 6 8 11 15 Adults trade-off in medial and lateral rotation
of the hip appears to occur—as one
Svenningsten et al34
Males 51/48 51/47 51/42 46/42 41/43 38/43 (8) movement or direction increases, the
Females 60/44 58/44 57/43 50/42 48/42 52/41 (8) other usually decreases—while the total
Roaas and Andersson33 hip motion remains equal. For exam-
Males * * * * * 32/34 (8) ple, as medial rotation increases, lateral
Ellison et al35 * * * * * 38/36 (11) rotation usually decreases. The results
of the study by Swanson et al8 suggest
Staheli et al31
Males 42/45 52/44 51/40 45/38 46/38 40/38 (8) that femoral torsion deformity exists
Females 43/45 44/42 40/40 42/38 39/39 33/38 (8) when medial rotation exceeds lateral
Chesworth et al36 * * * * * 43/42 (9) rotation by more than 30 degrees and
a
that an abnormal FNA exists when lat-
Asterisk indicates not measured. SD⫽standard deviation.
eral rotation exceeds medial rotation
by more than 30 degrees.

A Clinical Test to Accurately Determine FNA?

Figure 4.
Illustration showing “cuts” used to determine the femoral neck anterver-
sion angle using computerized tomography scan.
difference between medial and lateral rotation of the
hip, ranging from as little as 1 to 5 degrees of difference.
Studies That Examined the Relationship
Between FNA and Passive Hip Rotation
Hip rotation often is used to estimate FNA in clinical
settings.39 Recent studies24,26 –29 have shown that the FNA
angle, measured radiographically using the method
described or adapted by Magilligan, is related to the
difference between medial and lateral rotation of the
hip. In most studies, hip rotation was measured with the
subjects positioned prone, with the hip extended and
the knee flexed to 90 degrees. Patients with a high FNA
angle tended to have more medial rotation of the hip
and less lateral rotation of the hip (Tab. 2). In contrast,
patients with a low FNA angle tended to have more
lateral rotation of the hip and less medial rotation of the
hip. Total hip rotation usually remained the same. Only
in a study by Gelberman et al40 did some patients exhibit
a complete reversal in how the hip was limited. In that
study, the patients’ hips showed an increase in medial
rotation and less lateral rotation in the fully extended
0-degree position, whereas the motion was reversed
when the hips were flexed.
Two groups of investigators30,38 have studied the tro-
chanteric prominence angle test (TPAT) or Craig test,
and the reports show conflicting data on the validity of
measurements this test provides. In 1992, Ruwe et al30
evaluated FNA preoperatively in 59 patients (91 hips),
and based on their findings, they claimed that the TPAT
can be used to accurately and validly measure the FNA
angle of the femur. Femoral neck anteversion was deter-
mined at the time of the operation by Magilligan radio-
graphs and by CT scanning using the Murphy technique.
The FNA values were then compared with the clinical
TPAT measurements. The TPAT was performed with the
patients lying prone. The examiner palpated the
patients’ greater trochanter with one hand while pas-
sively rotating the hip with the other hand. The accuracy
of TPAT depends on having the greater trochanter at its
most laterally prominent position—with the femoral
neck axis parallel to the condylar axis at the knee. The
amount of hip medial rotation when the greater tro-
chanter is at its most laterally prominent position, there-
fore, should equal the FNA angle. The reliability of the
TPAT measurements was not assessed. Ruwe and col-
leagues30 showed that the TPAT predicted the FNA,
measured intraoperatively, more accurately than either
the CT or Magilligan method. The mean differences
between direct clinical measurements and those deter-
mined by intraoperative measurements were 4.1 degrees
(SD⫽3.2) on the left (Pearson r ⫽.88) and 3.5 degrees
(SD⫽3.9) on the right (Pearson r ⫽.93). The differences
between measurements obtained from the Magilligan
radiographs and measurements found on operation
were 9.5 degrees (SD⫽9.1) on the left side and 9.6
degrees (SD⫽8.4) on the right side.
Davids et al38 studied the TPAT on 20 children with
cerebral palsy. Davids et al used a retrospective case

554 . Cibulka Physical Therapy . Volume 84 . Number 6 . June 2004

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Table 2.
Studies That Examined the Relationship Between Femoral Neck Anteversion (FNA) and Passive Hip Rotationa

Study N Age (y) MR LR FNA e-FNA

Svenningsen et al26 30 7 (4–10) 74 (6.8) 19 (7.2) 42 (5.5) 23

30 10 (7–13) 60 (7.2) 27 (7.8) 36 (6.3) 20
30 16 (15–21) 53 (8.5) 37 (5.9) 28 (8.4) 16
Kozic et al27
MR⫽LR 1,030 8–9 44 43 24 (4.3) 24
MR⬎LR 86 8–9 65 30 36 (7.3) 24
LR⬎MR 24 8–9 23 58 14 (7) 2
Reikeras and Bjerkreim28
1st exam 24 7.7 (6–9) 78 (8) 16 (8) 47 24
16 7.3 (6–8) 76 (10) 28 (10) 45 24
2nd exam 24 16.5 (14–18) 52 (12) 43 (10) 30 15
16 15.7 (14–16) 63 (11) 30 (10) 31 15
Control 26 16.3 (14–19) 50 (9) 41 (8) nm 15
Study N Age (y) MR1 MR2 LR1 LR2 FNA e-FNA
Gelberman et al29
MR⬎LR 16 5.2 (5.1) 80 (5) 78 (5) 10 (5) 45 (13) 49 (10) 26
LR⬎MR 8 5.5 (5.5) 71 (4) 46 (7) 18 (7) 32 (6) 32 (6) 26
MR⫽LR 20 5.1 (5.2) 51 (8) 50 (7) 54 (9) 55 (9) nm 26
Braten et al24
IR⫽ER 100 35 (16–65) 48 (10) 36 (8) 38 (7) 43 (9.6) 18/14 18/14
a
MR⫽hip medial rotation, LR⫽hip lateral rotation, e-FNA⫽expected FNA angle for age using data from study by Fabry et al,2 nm⫽not measured. Standard
deviations or ranges of values are shown in parentheses. In study by Reikeras and Bjerkreim,28 one control group and one time-series group were examined twice.
In study by Gelberman et al,29 hip MR and LR were measured with hip extended and with hip flexed to 90 degrees. In study by Gelberman et al, superscript 1
measurements were taken with the hip extended to 0 degrees, and superscript 2 measurements were taken with the hip flexed to 90 degrees. In study by Braten
et al,24 superscript 1 measurements are for female subjects, and superscript 2 measurements are for male subjects.

series design to show the relationship between the TPAT
and a modified Murphy CT analysis performed before
surgery. No data on tester reliability were given. Davids
et al concluded that the TPAT performed poorly by
either overestimating or underestimating FNA by more
than 5 degrees in 24 hips and by more than 10 degrees
in 14 hips. They also concluded that the application of
the TPAT is restricted by variable anatomy and soft
tissue, especially in patients who are obese. As noted
previously, for the TPAT to be accurate, the tangent to
the most prominent portion of the greater trochanter
must be perpendicular to the axis of the femoral neck;
however, Davids et al rarely found this to be true and
noted considerable variability in the children with cere-
bral palsy they studied (Tab. 3). With only 2 studies
performed on the TPAT, additional research is needed
to determine whether this test can accurately predict the
FNA angle. Because physical therapists do not need a
precise FNA angle measurement, I believe either the
TPAT or passive hip rotation values can be used to help
predict FNA.
The Clinical Importance of Increased or
Decreased FNA
An increased or decreased FNA angle has been associ-
ated with a variety of lower-extremity problems in new-
borns, children, and adults. The interest in determining
the precise FNA angle began in the early 20th century
with the observation that newborns with congenital hip
dislocation often had an increased FNA angle.1,3,5,6,8
Soon after, children with an in-toeing or out-toeing gait
were noted to have an increased or decreased FNA
angle.1–7,9 Excessive in-toeing or out-toeing has been
shown to be related to many different compensatory
problems of the lower extremities, including tibial
torsion, genu valgum, genu valgus, pes planus, pes
equinus, and metatarsus varus.1– 6,8,23 Many other
studies1,3– 8,14,23,25,28,29,31,41– 49 have shown the relation-
ship between an increased or decreased FNA angle and
other orthopedic problems of the lower extremity.
Gelberman et al29 showed that a diminished FNA angle
in adolescents is often associated with slipped capital
femoral epiphysis of the hip. The FNA angle in patients
with slipped capital femoral epiphysis was 1 degree
(normal FNA angle⫽15°–20°) in the worst cases and 2.5
degrees in more moderate cases.29 Alterations in the
alignment of the proximal part of the femur have been
considered capable of redistributing the forces that are
applied across the proximal femoral epiphysis. Gelber-
man and colleagues29 suggested that the forces that tend
to cause a slipped capital femoral epiphysis act in the
same direction as the forces that are responsible for the
physiological decrease in the angle of anteversion dur-
ing growth. Decreased FNA or hip retroversion can
create unequal force distribution on the proximal fem-

Physical Therapy . Volume 84 . Number 6 . June 2004 Cibulka . 555

Table 3. erately decreased FNA was defined as an angle between 10
Data From the Study by Davids et al38 on the Trochanteric and 14 degrees. Severely decreased FNA was defined as an
Prominence Angle Test (TPAT)a
angle less than 10 degrees. Moderately increased FNA was
defined as an angle between 21 and 25 degrees. Severely
FNA
Patient Age Angle TPAT
increased FNA was defined as an FNA angle greater than
No. (y) Sex Side (°)b (°)c 25 degrees.25 Tonnis and Heinecke25 looked at the FNA
angle in 118 patients who had arthritis of the hip. Passive
1 12 M R 19 20 hip rotation also was measured. They found decreased
L 35 40
hip medial rotation and increased lateral rotation were
2 12 F L 53 35 related to diminished FNA. For example, patients who
3 14 M R 30 15 had a severely decreased FNA angle (less than 10°) had
L 47 20 an average range of 17 degrees of medial rotation and an
4 9 F L 43 50 average external rotation of 40 degrees. Tonnis and
5 8 F R 44 55 Heinecke25 found that patients who had decreased
L 48 60 FNA angles also were more likely to have osteoarthritis
6 8 M L 29 35 of the hip.
7 10 M R 39 30
L 37 40 Changes in femoral anteversion that result in an
8 13 F R 40 40 increased or decreased FNA angle can alter the congru-
L 34 60 ence of the hip joint.25 A change in acetabular antever-
9 10 M L 50 50 sion also can alter the congruence of the hip joint.50 Hip
10 13 F R 67 40
joint incongruence is the most commonly cited cause of
L 57 40 osteoarthritis in the hip joint.25,48,50 The congruity of the
11 10 M R 16 ⫺5
hip joint depends on the relationship between FNA and
anteversion of the acetabulum.25 A change in hip ante-
12 13 M R 46 30
L 53 25
version requires a similar adjustment in the acetabulum
to keep hip joint congruity.
13 10 F R 55 30
L 30 20
A diminished FNA angle has been associated with a torn
14 8 F R 24 30
L 28 45
acetabular labrum of the hip.49 Ito and colleagues49
studied 24 patients with hip pain and evidence of a labral
15 10 M R 39 40
L 34 25
tear of the hip, and they showed that the patients with
labral tears had a mean reduction in the FNA angle.
16 15 F R 34 30
L 33 20
Their data showed the mean FNA angle in patients with
labral tears was 9.7 degrees compared with 15.7 degrees
17 10 M R 24 20
L 27 20
in patients without impairments.49 Hip rotation was not
measured in this study. Ito and colleagues49 suggested
18 13 M R 12 20
L 44 35
that repetitive impingement of the acetabulum can
injure the labrum when a hip with decreased femoral
a
M⫽male, F⫽female, R⫽right, L⫽left. joint anteversion changes the head and neck angle of
b
FNA⫽femoral neck anterversion (measured with biplane radiography).
c
TPAT was measured with subjects positioned prone. the femur. Reduced surface area in the hip results in
increased force on the acetabular labrum, which may
predispose the labrum to injury. Moreover, a torn ace-
oral epiphysis. Some adolescents may be unable to resist tabular labrum is thought to be a precursor to degener-
the physiological shearing forces across the epiphysis ative hip joint disease.49 Thus, an increase or decrease in
resulting in a slipped capital femoral epiphysis. A the FNA angle that may alter the hip’s congruity will
decreased FNA, therefore, has been proposed to be a place abnormal stress on the acetabular labrum and
factor in developing slipped capital femoral epiphysis.29 possibly lead to injury.
More research is needed.
Conclusion
Studies7,25,46,47 also have shown that an increased or Assessing passive hip medial and lateral rotation can be
decreased FNA angle is associated with degenerative hip a useful guide in determining if an increased or
joint disease. Tonnis and Heinecke7,25 have shown the decreased FNA angle exists. An increased or a decreased
relationship between reduced FNA (femoral neck retro- FNA angle has been linked to many different lower-
version) and degenerative disease of the hip. They extremity problems, including osteoarthritis of the hip,
defined abnormal FNA using 4 grades, assuming that a coxa plana, slipped capital femoral epiphysis, congenital
normal FNA angle is between 15 and 20 degrees. Mod-

556 . Cibulka Physical Therapy . Volume 84 . Number 6 . June 2004


hip dysplasia, acetabular labral tears, and in-toeing and
out-toeing of the lower extremities.1,3– 8,14,23,25,28,29,31,42– 49
Identifying when an increased or decreased FNA angle is
present may help physical therapists recognize patients
who may be at risk for developing hip or other problems
associated with in-toeing or out-toeing. Moreover, asym-
metries in hip joint rotation also have been associated
with low back and regional pain in the sacroiliac
joint.43,51
Because the difference between medial and lateral rota-
tion of the hip are related to the FNA angle, I believe
that physical therapy interventions aimed at restoring
symmetry in hip motion is a reasonable approach in
trying to manage hip problems. Differences greater than
16 degrees between the left and right sides for a specific
movement or differences of more than 30 degrees
between hip medial and lateral rotation on one side may
help physical therapists identify patients who may
develop future hip or lower-extremity problems associ-
ated with in-toeing or out-toeing. Physical therapists also
should consider factors that may contribute to differ-
ences in hip medial and lateral rotation. For example,
sitting or sleeping postures where the hip is habitually
placed in extreme hip rotation may change muscle and
joint capsule length (Figs. 2 and 3). Although there are
no studies on restoring hip motion symmetry and the
FNA angle, I believe these studies would be beneficial,
because restoring motion and muscle force is an impor-
tant part of physical therapist practice.
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