Femoral Anteversion and Retroversion: The Hip Pain Factor Almost No One Tests For

Not all thigh bones are shaped the same. Some twist slightly inward, some twist outward, and that shape changes how your hip, knee, and back should move. It isn’t routinely assessed in most hip-pain evaluations.

Rick Olderman, MSPT is an orthopedic physical therapist with 30 years of clinical experience, former owner of an orthopedic PT clinic, and author of the Fixing You book series, including Fixing You: Hip & Knee Pain and the award-winning Pain Patterns (2025 NIEA Award winner). He created an APTA-approved continuing education course teaching other clinicians his systems-thinking approach to chronic pain.

The piece potentially driving your hip pain

If you’ve read the first and second articles in this series, you already know that a lot of hip pain traces back to your glutes losing control of the head of the thigh bone in the socket — anterior femoral glide syndrome. What we haven’t covered yet is why some people’s glutes are fighting an uphill battle from the start.

Not all thigh bones are shaped the same. Some are naturally twisted inward at the hip, a shape called femoral anteversion. Others are twisted outward, called femoral retroversion. Neither shape is a problem by itself. But if you don’t know which one you have, and you move as though your thigh bone is neutral, you’re fighting your own anatomy every single step. In this article, I’ll show you how to test yourself and what to do about it depending on which shape you have.

Figure 1a, b. a. Femoral anteversion. b. Femoral retroversion.

Important: Always follow the guidance of your medical team. What follows isn’t a diagnosis. Femoral anteversion and retroversion are normal anatomical variations, not conditions, and this article is about how to move well given your own shape — not about correcting it.

Watch the video version: the self-test below, demonstrated.




Test for Femoral Anteversion or Femoral Retroversion — watch on YouTube

The self-test: which shape do you have?

This test isn’t as accurate as having a clinician or MRI measure for you, but it can give you a useful clue about whether your femur may be more internally or externally oriented. It’s best to either video yourself or ask someone to take pictures of your angles to assess them.

Figure 2a, b, c, d. a. Beginning position for testing femoral version. b. Feet move out angle. c. Right leg move in angle. d. Left leg move in angle.

The test

Reading your result

• If your feet fall out much farther than they fall in, your thigh bone rotates inward more easily than it rotates outward. That points to femoral anteversion.
• If your feet fall in much farther than they fall out, your thigh bone rotates outward more easily. That points to femoral retroversion. (You can see above that my feet fall inward significantly more than outward. I have femoral retroversion.)
• If in and out are roughly equal, your thigh bones are close to neutral.

It’s entirely possible to have one shape on one side and the opposite shape on the other. Don’t be surprised if your left and right results don’t match. One particularly dramatic example from my practice: an NFL lineman I treated for chronic ankle and knee pain had exactly this asymmetry. Once I showed him how to use his legs better, according to his thigh bone shape, nine years of chronic pain melted away in about three weeks.

This isn’t only relevant if you have hip arthritis or a labral tear. It applies just as much to highly trained performance athletes. Elite competitors are often searching for a one or two percent edge over the field, and understanding how your own femoral shape should change your foot position, your stance, and your movement strategy can have significant implications for performance, not just for pain.

What are femoral anteversion and retroversion, and why do they matter for hip pain?

Femoral anteversion means your thigh bone is naturally rotated inward at the hip. Femoral retroversion means it’s rotated outward. Both are normal variations in how the thigh bone develops, described in the movement-impairment literature by researcher Shirley Sahrmann.1

Neither shape is inherently a problem. The trouble starts when you move as though everyone’s thigh bone is the same (neutral), because most people — and most of the advice they get — assume exactly that. In my clinical population, I see femoral version play an important role surprisingly often in people with persistent hip, knee, back, and foot problems.

Because the gluteus maximus contributes to external rotation, an internally oriented femur changes the mechanical position in which the muscle has to work.2 Think of trying to lift a heavy weight with a biceps curl. The straighter your elbow at the beginning, the harder it will be for the biceps to lift it. In my clinical experience, some people with anteversion need considerably more gluteal control to keep the femur from collapsing further inward during weight-bearing.

Retroversion, an externally rotated thigh bone, creates a different problem. These people should point their feet out to the side a few degrees to align the foot position with the thigh bone shape. However, they often feel self-conscious walking with their feet turned out (frequently called “walking like a duck”), so they force their feet to point straight ahead — which recreates the excessive internal rotation problem we spoke of above, just by a different route.

Clinically, I see femoral anteversion in more females and femoral retroversion in more males. Average anteversion tends to run somewhat higher in women than in men in several studies too, roughly 18 degrees versus 14 degrees in one commonly cited series,3 though findings across studies vary. Retroversion is also relatively common in the general population, found in over a fifth of white men and in more than 14% of women across ethnic groups in one large trauma-center study.4

If you have femoral anteversion

Why this causes pain

Since the gluteus maximus externally rotates the thigh, an already-anteverted femur asks that muscle to work from a lengthened position on every step. If the glutes can’t keep up, the thigh bone drifts into more internal rotation than the hip and knee joints tolerate well — feeding the same anterior femoral glide pattern covered in the first article of this series, and increasing compression at the hip and knee.

I had one patient with poorly controlled right femoral anteversion who had developed hip, knee, and new low back pain, his right leg visibly rotating inward every time he stepped on it. Once we addressed the glute control behind it, his pain resolved in two to three sessions. (Watch that case: Thigh Bone Alignment Causing Back, Hip & Knee Pain?)

Sylvia, whose story opened the first article in this series, also had anteverted femurs. Because her thigh bones were already rotated in, she needed stronger glutes than most people to control that internal rotation — which is part of why her butt pump exercise eventually progressed to 15 to 20 pounds of ankle weight rather than stopping at bodyweight.

What to do

• Strengthen your glutes. The butt pump, the elbows-and-knees exercise from the first article, retrains this. If you can’t feel your glute engage, try rotating your knee slightly outward as you lift it — a cue I call “peeing on the fire hydrant.” It temporarily biases the glute to turn on. As you get stronger, work back toward doing the exercise without that rotation, since that’s closer to how you’ll actually walk.
• Reprogram your gait using the tiptoe-walking cue from the first article. An anteverted thigh bone makes consistent glute activation during walking even more important than it is for someone with a neutral femur.
• Experiment with your feet turning out. This biases the glutes to turn on. Once they get going, you can always turn them back in again as long as the butt muscles are working.

If you have femoral retroversion

Why this causes pain

With retroversion, walking with your feet pointed straight ahead — the socially expected position — requires relatively internally rotating an already outward-rotated thigh bone. That takes constant muscular effort, and it tends to create chronic tension through the inner thighs, hips, and low back, along with the same glute-shutdown pattern seen with anteversion. It’s like covering everything in cement, just much stiffer.

I had one patient with a retroverted femur who developed a labral tear in his right hip while habitually forcing his foot forward. I can’t prove the foot position caused the tear, but the mechanics were compelling enough that changing his foot position became an important part of his treatment. His walking pattern also shut off the glutes controlling that hip’s tracking. He’s since started turning that foot out significantly to get off the damaged tissue, and it worked, but by then the damage was already done. His left side also began developing new back pain, from now weight-bearing more heavily on it while protecting the injured right hip. (Watch that case: Hip Labral Tear & Low Back Pain from Gait Mechanics)

Research on femoral retroversion and hip damage is mixed. A systematic review found retroversion associated with hip pain and impingement, and reported it in 5 to 11% of patients who eventually needed a hip replacement, but the same review concluded the evidence that retroversion itself causes hip osteoarthritis is still weak.5 In my clinical experience, it’s less the shape itself and more what you do with it — specifically, forcing a retroverted leg into a foot-forward position — that seems to matter.

What to do

• Let your feet turn out. If your natural stance has your feet angled slightly outward, that’s likely your femur shape asking to be respected, not a posture problem to correct.
• Stretch your inner thighs, which tend to chronically tighten from years of holding a forced, unnatural foot position.
• Tiptoe walk to begin turning on the gluteals naturally while walking.

Putting it together

Anterior femoral glide syndrome, covered in the first article in this series, is about how your thigh bone slips around inside your hip socket during activity. The compensation patterns covered in the second article are about what happens to the rest of your body while you wait to fix any of this. Femoral anteversion and retroversion are the pieces underneath both: the actual shape you’re working with before you take a single step.

Knowing your shape informs how you should be using your lower body system to ultimately improve gluteal function and reverse the AFGS. Someone with anteversion needs to build unusually strong glutes. Someone with retroversion needs to stop forcing their feet forward and let their natural stance do some of the work.

Across this series, you’ve now got three pieces of the puzzle: the movement pattern (anterior femoral glide), the compensation (what happens elsewhere while you wait), and the anatomy (femoral anteversion or retroversion). Knowing the pieces isn’t the same as knowing which ones apply to you and how they interact in your body. That’s what the testing throughout my home program 7 Days to Better Hips and my recent book, Pain Patterns, are built to sort out.

Did the self-test show anteversion, retroversion, or something closer to neutral? Did one side surprise you? Please leave your results in the comments section below, and let me know if this article helped. Thanks.

See it for yourself

• Watch the femoral anteversion/retroversion self-test on YouTube, then follow up with the video that matches your result: femoral anteversion or femoral retroversion.
• 7 Days to Better Hips. My home program, which includes testing for femoral torsion alongside the anterior femoral glide pattern covered earlier in this series.
• Pain Patterns: Why You Are in Pain and How to Stop It. My 2025 National Indie Award winning book, which walks through femoral shape and the rest of this systems-thinking approach in detail.

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