## 4 Discussion
In symptomatic individuals, such as those with hip pain or gait abnormalities, excessive femoral torsion can alter joint mechanics and increase the load on the hip joint, potentially leading to discomfort or further joint degeneration. This altered internal rotation creates compensatory mechanisms that may not only affect the hip but also other regions, such as the knee and lumbar spine, as these areas attempt to maintain functional movement. In rehabilitation, addressing femoral torsion is critical for symptomatic patients, as it directly influences joint stability and muscle function during activities like walking. Therapeutic strategies might include exercises aimed at improving hip alignment, joint stabilization, and correcting abnormal gait patterns to prevent excessive internal rotation and reduce pain. By focusing on these biomechanical abnormalities, clinicians can tailor rehabilitation to the specific needs of symptomatic patients, aiming to restore balanced hip mechanics and prevent further complications. However, these studies were conducted on healthy subjects, suggesting the need for future studies to include symptomatic patients with excessive femoral anteversion, who might exhibit more pronounced compensatory mechanisms to prevent pain. [PERSON] (2018) [33] studied children and adolescents, highlighting that torsional deformities at both the femoral neck and diaphysis levels increase compressive and medio-lateral contact forces in the hip and patellofemoral joints. Patients in this study had torsional deformities in both femurs and tibas with a mean femoral neck anteversion of 38\({}^{\circ}\)\(\pm\) 9\({}^{\circ}\), a mean neck-shaft angle of 133\({}^{\circ}\)\(\pm\) 5\({}^{\circ}\), and a mean external tibial torsion of 40\({}^{\circ}\)\(\pm\) 10\({}^{\circ}\). These subjects showed an increased hip internal rotation ROM of 13\({}^{\circ}\) (95% CI: 7\({}^{\circ}\)-19\({}^{\circ}\)), decreased external rotation ROM of 19\({}^{\circ}\) (95% CI: 13\({}^{\circ}\)-25\({}^{\circ}\)), increased abduction ROM of 11\({}^{\circ}\) (95% CI: 6\({}^{\circ}\)-16\({}^{\circ}\)), and increased knee extension ROM of 4\({}^{\circ}\) (95% CI: 2\({}^{\circ}\)-6\({}^{\circ}\)) compared to controls. Increased external tibial torsion during the stance phase, if associated with ligamentous laxity, can lead to knee pain and patellar instability. Thus, femoral anteversion, through altered kinematic strategies and muscle activations, can lead to altered contact forces and an increased risk of joint damage, necessitating comprehensive and functional assessments. The third group of studies examines the effect of acetabular anteversion relative to femoral neck anteversion. [PERSON] et al. (1983) [50] reported no relationship between femoral and acetabular anteversion in subjects with oxcarthrosis. However, empirical reasoning and the results of other included studies suggest that pelvic retroversion is correlated with increased acetabular anteversion and hip extension but not with femoral torsion. The lack of correlation in [PERSON]'s study may have been due to the presence of oxcarthrosis, suggesting that osteoarthritis deformities of the femoral neck could confound the results, presenting a different acetabulum-femoral neck relationship in the non-coxarthrotic population. This reasoning suggests a potential linear relationship between pelvic anteversion/retroversion and femoral torsion, particularly in relation to hip mobility and compensatory mechanisms. However, future research should focus on specific areas such as symptomatic populations (e.g., patients with osteoarthritis or hip dysplasia) to determine if the biomechanical alterations observed in asymptomatic subjects apply to these conditions. Additionally, the use of dynamic imaging techniques, such as dual fluoroscopy, could provide a more detailed understanding of how changes in pelvic tilt affect hip biomechanics during functional activities.