[ research report ]

Anh-Dung Nguyen, PhD, ATC1 • Sandra J. Shultz, PhD, ATC, CSCS2

Sex Differences in Clinical Measures

of Lower Extremity Alignment

S
elected lower limb injuries and, in particular, those of the knee and rearfoot angle.5,75 Data for sex dif-
have been reported to occur in greater prevalence in females ferences in femoral anteversion8,63 and
tibiofemoral angle12,28,80 are inconclusive.
compared to males.4,29,49,60,61,85 Sex differences in lower extremity
The limitation with many of these stud-
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alignment (LEA) have been included among a myriad of ies is that, in most cases, clinical methods
risk factors as a potential cause for the prevalence of knee injury in were performed on sample sizes that were
females.21,29,34,33,47 Anecdotally, females have been cited as having greater relatively small and only select alignment
anterior pelvic tilt, femoral anteversion, tibiofemoral angle, quadriceps variables were examined. The use of clini-
cal methods are those immediately avail-
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

angle, genu recurvatum, tibial torsion,
and foot pronation.21,29 However, apart
from the measure of quadriceps angle,
there is little empirical data to sup-
port these sex differences in a healthy
population.
While the literature consistently dem-
t Study Design: Descriptive, cohort design.
Journal of Orthopaedic & Sports Physical Therapy®
onstrates greater mean quadriceps angles
in females,1,23,24,26,28,84 limited studies sup-
port a sex difference in mean pelvic tilt24
and genu recurvatum.81 Conversely, no sex
differences have been observed with mea-
sures of tibial torsion57,77 and foot prona-
tion as measured by navicular drop6,24,51,81
able to the clinician and we are aware of
no published studies that have reported
sex differences in a relatively large cohort
based on a comprehensive set of anatom-
ic alignment variables obtained from the
same individuals. Comparison of multiple
alignment characteristics is important if
we are to accurately define sex differences
in LEA and select appropriate variables

within-subject factor (side).

t Objectives: To comprehensively examine
sex differences in clinical measures of static lower
extremity alignment (LEA).
t Background: Sex differences in LEA have
been included among a myriad of risk factors as
a potential cause for the increased prevalence of
knee injury in females. While clinical observations
suggest that sex differences in LEA exist, little
empirical data are available to support these sex
differences or the normal values that should be
expected in a healthy population.
t Methods and Measures: The right
and left static LEA of 100 healthy college-age
to examine injury risk. Further, the lack
t Results: There were no significant sex-by-
of normative data by sex for many of
side interactions and no differences between
sides. Females had greater mean anterior pelvic these alignment characteristics makes it
difficult to determine what values should
tilt, hip anteversion, quadriceps angles, tibio-
femoral angles, and genu recurvatum than males be considered excessive for males versus
(P<.0001). No sex differences were observed in
females. Hence, the purpose of this study
tibial torsion (P = .131), navicular drop (P = .130),
was to comprehensively examine sex dif-
and rearfoot angle (P = .590).
ferences in static LEA as determined by
t Conclusion: Sex differences in LEA indicate clinical measurement methods.
that females, on average, have greater anterior
pelvic tilt, thigh internal rotation, knee valgus, and
METHODS
genu recurvatum. These sex differences were not
accompanied by differences in the lower leg, ankle,
and foot. Understanding these collective sex dif- Subjects

participants (50 males [mean 6 SD age, 23.3
6 3.6 years; height, 177.8 6 8.0 cm, body mass,
80.4 6 11.6 kg] and 50 females [mean 6 SD
age, 21.8 6 2.5 years; height, 164.3 6 6.9 cm;
body mass, 67.4 6 15.2 kg]) was measured.
Each alignment characteristic was analyzed via
separate repeated-measures analyses of vari-
ance, with 1 between-subject factor (sex) and 1
ferences in LEA may help us to better examine the
influence of LEA on dynamic lower extremity func-
tion and clarify their role as a potential injury risk
factor. J Orthop Sports Phys Ther 2007;37(7):389-
398. doi:10.2519/jospt.2007.2487
t Key Words: malalignment, posture, risk
factor assessment
A
convenience sample of 100
healthy adults (50 males [mean 6
SD age, 23.3 6 3.6 years; height,
177.8 6 8.0 cm, body mass, 80.4 6 11.6
kg] and 50 females [mean 6 SD age,
21.8 6 2.5 years; height, 164.3 6 6.9 cm;
body mass, 67.4 6 15.2 kg]) was recruited

1
Postdoctoral Research Associate, Applied Neuromechanics Research Laboratory, The University of North Carolina at Greensboro, Greensboro, NC. 2 Associate Professor and
Co-Director, Applied Neuromechanics Research Laboratory, The University of North Carolina at Greensboro, Greensboro, NC. The protocol for this study was approved by the
University of North Carolina at Greensboro Institutional Research Board for protection of human subjects. Address correspondence to Anh-Dung Nguyen, University of North
Carolina, Greensboro, Department of Exercise and Sport Science, 237 HHP Building, 1408 Walker Avenue, Greensboro, NC 27412. E-mail: a_nguyen@uncg.edu

journal of orthopaedic & sports physical therapy | volume 37 | number 7 | july 2007 | 389
 [ research report
from the University of North Carolina at
Greensboro and the surrounding com-
munity. Participants were predominantly
healthy college students with ages rang-
ing from 18 to 34 years. Subjects had no
current history of injury to the lower
extremity or any previous history that
would affect the alignment or motion of
the lower extremity joints. Prior to par-
ticipation, subjects read and signed a
consent form approved by the University
of North Carolina at Greensboro’s Insti-
tutional Research Board for protection of
human subjects.
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Procedures
Demographics of age, height, and body
mass were recorded for each subject, and
8 LEA measures were taken on both the
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
left and right sides (starting side coun-
terbalanced). All measurements were
performed in the University’s Applied
Neuromechanics Research Laboratory
and measurement procedures were based
on commonly accepted methods. All
standing measures were taken with the
subject assuming a stance that was estab-
lished through a standardized procedure.
Journal of Orthopaedic & Sports Physical Therapy®
Subjects were instructed to march in
place and then take a step forward, with
the feet as far apart as the acromia, and
toes facing forward. Subjects were also
instructed to look straight ahead during
all standing measures. All measurements
were performed 3 times by a single ex-
aminer. With the exception of standing
rearfoot angle, good to excellent59 mea-
surement consistency was established
on all measures in a previous study of 16
participants using the same equipment
and identical methods.73 To establish
measurement reliability of standing rear-
foot angle, measures were repeated 24
to 48 hours later on the first 15 subjects
enrolled in the current study. Consistent
with the previous study,73 the average of
3 standing rearfoot angle measurements
for each day was calculated and a repeat-
ed-measures analysis of variance (ANO-
VA) with 1 within-subjects variable (test
day) was used to calculate intraclass cor-
relation coefficients (ICC2,3) and standard
390 | july 2007 | volume 37 | number 7 | journal of orthopaedic & sports physical therapy
]
Examiner’s Previously Established
TABLE 1 Intratester Reliability for
Each Anatomical Measure
Anatomical Measure ICC2,3 (SEM)
Pelvic angle (°) 0.98 (0.5)
Hip anteversion (°) 0.97 (1.1)
Standing Q-angle (°) 0.98 (0.8)
Tibiofemoral angle (°) 0.87 (0.7)
Genu recurvatum (°) 0.97 (0.5)
Tibial torsion (°) 0.99 (0.8)
Navicular drop (mm) 0.97 (0.4)
Standing rearfoot angle (°) 0.89 (0.5)
Abbreviations: ICC, intraclass correlation coefficient; SEM, standard error of measurement.
errors of the measurement (SEM = SD × horizontal plane was measured with an
1 − ICC ).15 Table 1 reports the intraclass inclinometer (Performance Attainment
correlation coefficients (ICC2,3) and the Associates, St Paul, MN) (Figure 1).
SEMs obtained by this examiner for all Hip anteversion was measured using
alignment variables. the Craig’s test,46 with the subject prone
and the knee flexed to 90°. The examiner
Clinical Measures palpated the greater trochanter while
Pelvic angle was measured in standing passively rotating the hip until the most
using a modified technique described by prominent part of the greater trochanter
Gilliam et al.20 The inferior prominence reached its most lateral position. The an-
of the anterior superior iliac spine and gle between the true vertical (verified by
the most prominent portion of the pos- a bubble level) and the shaft of the tibia
terior superior iliac spine were palpated, was measured using a standard goniom-
and the angle formed by a line from the eter (Figure 2).
anterior superior iliac spine to the pos- Standing quadriceps angle was
terior superior iliac spine relative to the measured in the frontal plane using a
standard goniometer modified with an
extension rod attached to the stationary
arm to insure accurate alignment with
the anterior superior iliac spine. The
FIGURE 1. Measurement of pelvic angle. FIGURE 2. Measurement of hip anteversion.

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Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
FIGURE 3. Measurement of standing quadriceps angle.
inferior prominence of the anterior su-
perior iliac spine was palpated, and the
subject’s finger was carefully and firmly
placed over the prominence. The bound-
aries of the patella and tibial tuberosity
were palpated, and the center positions
were marked. With the goniometer axis
Journal of Orthopaedic & Sports Physical Therapy®
over the patella center, the angle formed
by a line from the anterior superior iliac
spine to the patella center and a line from
the patella center to the tibia tuberosity
was measured43 (Figure 3).
The tibiofemoral angle was defined as
the angle formed in the frontal plane by
the anatomical axes of the femur and tib-
ia.50 With the goniometer axis (modified
with an extension piece on the station-
ary arm) over the knee center (midpoint
between the medial and lateral joint line
in the frontal plane), the stationary arm
was aligned along a line from the knee
center to a proximal landmark (midpoint
between the anterior superior iliac spine
FIGURE 5. Measurement of genu recurvatum.
journal of orthopaedic & sports physical therapy | volume 37 | number 7 | july 2007 |
FIGURE 4. Measurement of tibiofemoral angle.
and the most prominent aspect of the
greater trochanter), and the movable
arm was aligned along a line from the
knee center to a distal landmark (mid-
point between the medial and lateral
malleoli) (Figure 4). While there is no
universally accepted proximal landmark
for clinical measurement methods of
tibiofemoral angle, the rationale for us-
ing the midpoint between the anterior
superior iliac spine and greater trochan-
ter was based on known anatomy, and
thought to more closely approximate
the anatomical axis of the femur com-
pared to either the greater trochanter
and anterior superior iliac spine, which
may overestimate and underestimate,
respectively, the measure.
FIGURE 6. Measurement of tibial torsion.
Genu recurvatum was measured with
the subject in supine and a bolster posi-
tioned under the distal tibia. The goniom-
eter axis was positioned over the lateral
joint line, the stationary arm aligned with
the greater trochanter, and the movable
arm aligned with the lateral malleolus.
The measurement was recorded while the
examiner applied a posteriorly directed
force to the anterior knee until passive
resistance was achieved (Figure 5).
Tibial torsion was measured using a
modified technique described by Stuberg
et al.78 With the subject in supine and the
knees extended, the subject rotated the
leg until the line between the femoral
epicondyles was parallel to the table. In
this position the axis of the goniometer
was aligned at the midpoint along the line
between the medial and lateral malleoli.
The angle formed by the line bisecting the
bimalleolar axis and the true vertical (ver-
ified with a bubble level) was measured
using a standard goniometer (Figure 6).
Navicular drop was measured using
a modification of a technique described
by Brody.9 The navicular tubercle was
palpated and marked with the subject in
a bilateral stance. Navicular height was
measured with a straight edge ruler, with
the subject in subtalar joint neutral, the
position in which the medial and lateral
aspects of the talar head were equally pal-
pable on both sides. The subject was then
instructed to relax the stance, and the dif-
ference in millimeters between the height
of navicular in subtalar joint neutral and
relaxed stances was recorded (Figure 7).
FIGURE 7. Measurement of navicular drop.
391
 [ research report ]
40
F
F
M

30
F F
M

Degrees/Millimeters
M F
20 M F F
M
M
M F
10 M

−10
PA HA QA TFA GR TT ND RFA
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Alignment Variable

FIGURE 9. Box plots for LEA measures of the right limb by sex. Abbreviations: GR, genu recurvatum; HA, hip anteversion; ND,
FIGURE 8. Measurement of standing rearfoot angle. navicular drop; PA, pelvic angle; QA, standing Q-angle; RFA, standing rearfoot angle; TFA, tibiofemoral angle; TT, tibial torsion.

Standing rearfoot angle was mea- el may mask individual differences that scores. While the median value is lower
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

sured using a modification of a technique
described by Picciano et al.58 The midline
of the distal one third of the lower leg
was drawn between marks that bisected
the lower leg at 15.2 and 20.3 cm proxi-
skew the data, we also calculated median
and range statistics for each variable.
RESULTS
than the mean for female genu recurva-
tum values (indicating that there were
relatively few who had extremely high
values in the range), the higher median
value in females as compared to males

mal to the calcaneus (determined with
a caliper). The medial and lateral bor-
ders of the calcaneus were palpated to
visually estimate the longitudinal mid-
Journal of Orthopaedic & Sports Physical Therapy®
M
eans and standard deviations, (more than double the value in males)
medians, and ranges (minimum still supports a clear sex difference. Box
and maximum) values for each plots are provided for these variables on
measure by sex and side are summarized the right limb to further describe these

line.17 With the subject in subtalar joint in Table 2. ANOVA results revealed no sig- data (Figure 9).
neutral (defined in the same manner nificant sex-by-side interactions and no
as navicular drop), the goniometer axis differences between sides. Females had DISCUSSION
was positioned over the bimalleolar axis significantly greater mean values than

(midpoint between the medial and lat-
eral malleoli), the stationary arm aligned
with the midline of the distal lower leg,
and the moveable arm aligned with the
midline of the calcaneus. Subjects were
then instructed to relax their stance, and
the difference between the angles in sub-
talar joint neutral and relaxed stances
was recorded (Figure 8).
Statistical Analysis
The 3 measurements taken for each
measurement variable and side were
averaged for analysis. Each alignment
characteristic was analyzed via separate
repeated-measures ANOVA, with 1 be-
tween-subject factor (sex) and 1 within-
subject factor (side), to examine sex and
side differences. As comparisons based on
mean differences using an ANOVA mod-
males for pelvic angle, hip anteversion,
standing quadriceps angle, tibiofemoral
angle, and genu recurvatum (P,.0001).
Males and females were not different on
navicular drop (P = .130), standing rear-
foot angle (P = .590), and tibial torsion
(P = .131). Median and range statistics
reported in Table 2 confirm that these sex
differences are not a result of 1 or a few
individual outliers. With the exception
of genu recurvatum, which was twice as
high in females, and to some extent pel-
vic angle, hip anteversion, and standing
quadriceps angle, the distribution of val-
ues was similar across males and females.
The median scores for pelvic angle, hip
anteversion, and standing quadriceps
angle are very close to their mean scores,
confirming that the higher mean in fe-
males is not biased by a few extreme
O
ur primary finding is that fe-
males, on average, had greater
anterior pelvic tilt (pelvic angle),
femoral internal rotation (hip antever-
sion), knee hyperextension (genu re-
curvatum), and knee valgus (standing
quadriceps angle and tibiofemoral angle)
compared to males. Sex differences in
LEA were only evident in the proximal
structures of the kinetic chain (pelvis,
hips, and knees), as we did not identify
sex differences in static alignment of
the lower legs, ankles, or feet (tibial tor-
sion, navicular drop, standing rearfoot
angle). While the reasons contributing
to these sex differences are not entirely
known, there is evidence to suggest that
many of these sex differences are devel-
opmental in nature, emerging after pu-
berty.11,13,48,69,79,82 The following discussion

392 | july 2007 | volume 37 | number 7 | journal of orthopaedic & sports physical therapy
 may potentially explain the sex difference
Mean (SD), Median, and Range Values in pelvic angle, as females have been ob-
TABLE 2 for Lower Extremity Alignment served to have decreased strength in hip
Variables in Males and Females* abduction,7,10,40,53 extension,10 and exter-
nal rotation,10,40 and increased lumbar
Male Female lordosis14,16,19,20,37,42 compared to males.
Anatomical Measure Mean (SD) Median Range Mean (SD) Median Range
Pelvic angle (°)†‡ Hip Anteversion
Right 8.6 (4.2) 8.5 –1.0-17.0 12.2 (5.2) 12.0 3.0-24.7 Hip anteversion develops with age and is
Left 8.7 (4.0) 9.0 –1.0-17.3 11.8 (4.5) 11.2 –1.7-22.0 greatest at birth (approximately 35°-40°),
Hip anteversion (°)† gradually decreasing to approximately 12°
Right 8.9 (5.3) 8.0 0.3-19.3 18.0 (6.7) 18.7 5.7-33.3 to 15° in adulthood.13,48,79 Our mean hip
Left 8.6 (5.0) 7.5 2.0-23.3 17.2 (6.6) 16.8 4.0-35.0 anteversion values are within the range of
Standing Q-angle (°)† normal values reported in healthy adults
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Right 9.0 (4.1) 9.0 1.7-20.3 12.8 (4.7) 12.0 4.0-23.0 (7°-18°), as measured by both clinical and
Left 8.9 (4.0) 8.2 4.0-22.3 13.0 (4.5) 12.5 3.3-23.7 diagnostic methods.8,36,63,65,71,72 Our find-
Tibiofemoral angle (°)†‡ ings of greater hip anteversion in females
Right 8.5 (2.6) 8.3 4.3-14.3 10.3 (2.6) 10.0 5.0-15.7 as compared to males agree with those of
Left 9.3 (2.4) 9.7 4.3-14.7 11.1 (2.4) 11.0 5.0-16.7 other studies8,63; but the magnitude of
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Genu recurvatum (°)† the sex difference is much larger in the

Right 2.1 (2.0) 2.2 –3.3-7.7 5.8 (4.1) 4.7 –1.0-19.0 current study (approximately 9° versus
Left 2.4 (2.2) 2.3 –2.0-10.7 6.3 (4.3) 4.8 0.0-21.0 2°-4°). This disparity may be explained
Tibial torsion (°) by differences in measurement methods,
Right 20.8 (6.8) 21.5 4.7-32.3 18.7 (6.4) 19.3 7.3-35.0 as the previous studies report measures
Left 20.1 (7.7) 20.2 2.0-35.3 18.4 (6.2) 19.0 4.7-35.0 on cadavers or with ultrasound and the
Navicular drop (mm) current study used clinical measures in
Right 6.1 (2.7) 6.5 0.3-11.3 7.1 (3.5) 6.3 1.0-17.0 healthy subjects. To our knowledge, only
Left 6.5 (3.2) 6.5 0.0-14.7 7.5 (3.6) 7.0 1.0-18.0 1 study compared males and females in
Journal of Orthopaedic & Sports Physical Therapy®

Standing rearfoot angle (°)‡ measures of hip anteversion using the

Right 5.2 (1.8) 5.3 1.0-9.7 5.0 (1.8) 5.3 –2.0-8.3
Left 5.5 (1.8) 5.3 1.0-11.0 5.3 (1.9) 5.7 –3.0-8.7
* There was no significant sex-by-side interaction or differences between sides (P..05).
†
Females greater than males (P,.0001).
‡
Positive values for pelvic angle, tibiofemoral angle, and standing rearfoot angle represent anterior
pelvic tilt, valgus angle, and rearfoot eversion, respectively.
will compare our findings with previously difference was also noted in a retrospec-
reported normative data by sex and con- tive study of anterior cruciate ligament
sider the potential influences that may (ACL) injury risk factors, regardless of
lead to excessive angulations and the sex injury status.24 Thus, normal values ap-
differences observed. pear to be sex dependent, with mean val-
ues of approximately 9° for males and 12°
Pelvic Angle for females.
Our mean pelvic angle values are similar The muscles that control the pelvis
to those of other reports on healthy adult (ie, abdominals, erector spinae, gluteal
subjects (range, 9°-12°), regardless of the muscles, and hip flexors) can all affect the
measurement method used.2,14,19,20,42,73 Of position of the pelvis. Muscular tightness
the few studies reporting mean values and shortening of the erector spinae and
based on both males and females, sex hip flexors, and elongation and weaken-
differences were not examined.2,20,73 We ing of the abdominals and gluteals have
observed a significant difference between been suggested to result in greater an-
sexes, with females having 3° to 4° greater terior pelvic angle.27,37 The relationship
anterior pelvic angle than males. This sex between pelvic angle and these muscles
same clinical measurement method and
reported no sex difference.36 However,
these results were based on examination
of a military population that included
only a very small sample of females (57
males, 6 females).
Larger hip anteversion has been
suggested to result from inadequate re-
gression of anteversion from infancy to
adulthood.48 While reasons for a lack
of regression are unknown, heredity
has been suggested to play a role, as in-
creased hip anteversion is frequently
present in the mother of children with
increased hip anteversion.76 Behavioral
factors that increase stress on the medial
femoral growth plate through childhood
have also been suggested to contribute to
excessive hip anteversion. These include
sitting in the “reverse tailor’s” position
and frequent in-toe belly sleeping.48 This
lack of developmental regression may
contribute to greater hip anteversion ob-

journal of orthopaedic & sports physical therapy | volume 37 | number 7 | july 2007 | 393
 [ research report
served in females as compared to males.
However, it is unknown if females have
greater hip anteversion during infancy,
or if the regression is slower than it is in
males during puberty, secondary to an
increased prevalence of the behavioral
factors mentioned.
Tibiofemoral Angle
Longitudinal studies have demonstrated
that tibiofemoral angle follows a pattern
of development from infancy to adoles-
cence, beginning with a varus deformity,
progressing to a valgus deformity with
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the start of bipedal walking, and finally
regressing from valgus deformity.69,82 It is
reported that a varus deformity is present
in children less than 1 year old and tends
to decrease, with the knee straightening
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
at approximately 1 to 1.5 years of age. The
progression towards valgus continues,
becoming most pronounced at around 2
to 3 years of age, then decreasing towards
varus by the age of 6 to 7 years. Due to
differences in measurement methods,
comparisons of our tibiofemoral angle
values to previously reported values are
difficult, as normal values are unclear and
Journal of Orthopaedic & Sports Physical Therapy®
dependent on whether the anatomical or
mechanical axis of the femur is used for
measurement. In the adult population,
studies that used the anatomical axis
of the femur (as did the current study)
reported mean values of a valgus align-
ment,11,28,73 while the mean values of stud-
ies using the mechanical axis of the femur
(a line from the center of the head of the
femur to the knee joint center) indicated
a varus alignment.12,50,80 The primary rea-
son for this disparity is likely due to the
fact that the anatomical axis of the femur
has a normal valgus angulations of 5° to
7° relative to the mechanical axis.56
Using the anatomical axis of the fe-
mur, our values reflect a valgus align-
ment, with females demonstrating
greater valgus angles compared to males.
Mean values for tibiofemoral angle were
approximately 9° for males and 11° for fe-
males. This sex difference is in agreement
with one study that found greater valgus
angles in females using the anatomical
394 | july 2007 | volume 37 | number 7 | journal of orthopaedic & sports physical therapy
axis of the femur,28 while others using the
mechanical axis of the femur report no
sex difference.12,50,80 This discrepancy may
be attributed to the use of the mechani-
cal axis to represent the femur segment,
which does not account for structural ab-
normalities at the femoral neck that may
predispose an individual to knee valgus,
such as coxa vara (a neck-shaft angle of
less than 125°).62 While no sex differences
are present prior to adolescence,69,82 there
is evidence to suggest that sex differences
in the rate of development in tibiofemo-
ral angle are a result of changes occurring
during the adolescent years of growth.11
This is supported by findings that sex
differences are present in the decline of
valgus alignment through the adolescent
years: whereas boys continue to move to-
wards a varus or more neutral alignment,
with significant decreases in valgus align-
ment after the age of 13, girls maintain a
valgus alignment.11 While this may con-
tribute to the greater valgus alignment
found in females postpuberty, the under-
lying reasons for this difference in rates of
development are unknown.
Quadriceps Angle
Our findings are consistent with already
strong evidence to support greater mean
standing quadriceps angle in females
compared to males1,23,26,28,31,84; however,
there is poor agreement on what should
be considered an “abnormal value.” While
the American Orthopaedic Association3
considers a standing quadriceps angle of
10° to be normal and angles 15° to 20° to
be abnormal, these values appear to be
based on clinical observation and do not
account for differences by sex. Based on
their criteria, several of the mean values
reported in the aforementioned studies,
although measured in healthy subjects,
would be considered abnormal. This is
particularly evident with the mean values
reported in the female population. Nor-
mative values by sex reported in the lit-
erature range from 8° to 15° in males and
12° to 19° in females.1,23,26,28,43,73,84 When
these sex differences are considered, an-
gles greater than 15° for men and greater
]
than 20° for women have been suggested
as clinically abnormal.26,31 Our values
would appear to be somewhat consistent
with these outer limits, as mean values of
17° and 22° represent values that exceed
2 standard deviations of the mean for
males and females, respectively, in our
study population.
The previous thought of larger stand-
ing quadriceps angle in females resulting
from an increased hip width compared
to males has been disputed.23,26,38 In fact,
in one of the studies,26 which reported
no relationship between increased hip
width and standing quadriceps angle,
males were observed to have larger mean
hip widths compared to females. As the
standing quadriceps angle reflects a
composite measure of pelvic angle, hip
rotation, tibial rotation, patella position,
and foot position,27,32,62 sex differences in
standing quadriceps angle more likely
result from sex differences in these and
other lower extremity posture charac-
teristics that may change the position of
the anatomical landmarks of the patella
and tibia used in the standing quadri-
ceps angle measurement. For example,
increased hip anteversion would result in
movement of the patella medially relative
to the anterior superior iliac spine.62 Fur-
ther, hip anteversion has been shown to
be compensated for by an increase in ex-
ternal rotation of the tibia, which would
result in movement of the tibial tuberosi-
ty laterally.30 Increased tibiofemoral angle
also has the potential to alter the standing
quadriceps angle, as it would position the
tibial tuberosity more laterally. Due to the
influence of changes in any one of these
variables on standing quadriceps angle,
it is possible that sex differences in the
hip and knee may contribute to sex differ-
ence found in measurements of standing
quadriceps angle. This supports the need
to consider sex differences in alignment
of the entire kinetic chain, rather than in
a single alignment variable.
Genu Recurvatum
A range of 0° to 5° of genu recurvatum has
been suggested as normal45; however, it is
 unclear whether this applies to both sex-
es. Studies that report normal values by
sex are limited and provide a wide range
with mean values between 0.2° and 5.8°
in females and between –0.3° and 3.2° in
males.70,81 Of these 2 studies, 1 exclusively
examined a collegiate athletic population
that represents the lower range of mean
values reported.70 Considering the re-
maining study81 along with our current
study population, the range of mean nor-
mative values in a healthy population is
5.8° to 6.1° in females and 2.3° to 3.2° in
males. While it has been suggested that
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females have an higher incidence of genu
recurvatum than males,25,44 only 1 study
has reported sex differences,81 with mean
values for males within the suggested
normal range and mean values for fe-
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
males of greater than 5°, which would
be considered abnormal. However, a sex
difference was not observed in an athletic
population.70 Our findings also support a
sex difference, with females having ap-
proximately 4° greater hyperextension
compared to males (2.3° versus 6.1°).
While more studies are needed, these col-
lective findings suggest that normal genu
Journal of Orthopaedic & Sports Physical Therapy®
recurvatum values may be both sex and
population dependent.
As with many of the other alignment
variables, the reasons for a sex difference
in genu recurvatum are unknown. In-
creased laxity of the ACL has been sug-
gested to contribute to hyperextension at
the knee,55 because the ACL is taut when
the knee is in full extension.54 Greater an-
terior laxity of the knee, a motion largely
restricted by the ACL, has been reported
in females compared to males67,68,74 and
could potentially lead to greater genu re-
curvatum in females. In addition, general
joint laxity has been shown to be greater
in females than males, of which genu re-
curvatum of greater than 10° is one of the
criteria.35,64,70 Another possible explana-
tion for the sex difference found in genu
recurvatum may be a relationship to the
increased anterior pelvic tilt observed in
females. An excessive anterior pelvic tilt
has been suggested to create a flexion
moment at the hip that is counteracted
journal of orthopaedic & sports physical therapy | volume 37 | number 7 | july 2007 |
with an extension moment at the knee,
resulting in hyperextension at the knee
joint.37
Tibial Torsion and Subtalar Joint
Pronation
Normal tibial torsion at birth is reported
to be, on average, 4° of inward torsion,
which gradually transitions to an average
outward torsion of 20° in middle child-
hood and 25° in the adult population.77
Outward torsion increases the most in
the first 4 years of life and continues to
increase approximately 1° per year un-
til the age of 10.39 Our mean values for
tibial torsion observed in a healthy adult
population are lower than the mean val-
ue of 38° reported by a previous study39
using computed tomography, and are
slightly higher than the reported mean
value of 15° reported by a study74 using
clinical measures for males and females
combined. While these 2 previous stud-
ies were performed on relatively small
sample sizes (n = 26 and n = 16, respec-
tively) and may not be considered as
normative data, our data suggest that a
mean value for tibial torsion in healthy
males and females is approximately 19°,
which is more consistent with the lower
values reported in the studies that used
clinical measures73,77 than with the high-
er values in studies that used computed
tomography.39
Subtalar joint pronation, when mea-
sured in a weight-bearing position, is a
combination of calcaneal eversion with
adduction and plantar flexion of the ta-
lus.66 Clinically, pronation is commonly
examined by measures of navicular drop
and standing rearfoot angle. Normative
values in the adult population using sim-
ilar measurement methods report mean
values ranging from 6 to 9 mm for navic-
ular drop,6,18,58,73,81 and 4° to 8° of eversion
for standing rearfoot angle.5,83 Mean val-
ues from the current study, in both males
and females, are in close agreement with
these earlier reports.
While abnormal values for tibial tor-
sion have not been suggested, navicular
drop values greater than 15 mm are con-
sidered abnormal9; however, no quantita-
tive data were reported to support these
limits. Others have suggested navicular
drop values greater than 13 mm6 and 10
mm52 to be abnormal. Our values would
appear to be most consistent with the
suggestion of 13 mm of navicular drop as
abnormal,6 as this value represents those
that exceeded 2 standard deviations of the
mean for males and females in our study
population. In regard to standing rearfoot
angle, values greater than 5° of eversion
have been considered abnormal, as they
are thought to disturb the axis of the foot
and the normal distribution of pressure.41
Because there is little empirical data to
support this pathological limit, this ap-
pears to be based on clinical observation.
Our data suggest that 5° of eversion as a
pathological limit may be too low; both
healthy males and females in the current
study were found to have mean values of
approximately 5°, with values exceeding
2 standard deviations of the mean values
that were almost twice this limit (9°).
The current study did not identify sex
differences in either tibial torsion or in
subtalar joint pronation. These findings
are consistent with previous studies that
report no sex differences in tibial tor-
sion,57 navicular drop,6,24,51,81 or standing
rearfoot angle.5,75 The lack of evidence
to support a sex difference in these vari-
ables suggests that these variables alone
do not independently explain the greater
risk of knee injuries in females.24,45 The
interaction of a sex difference with other
alignment variables that differ between
males and females may more accurately
identify those at increased risk of injury.
For example, the interaction of subtalar
pronation with hip anteversion and tib-
iofemoral angle may result in a compen-
satory increase in internal tibial rotation
at the knee, possibly contributing to in-
creased internal femoral rotation and val-
gus angulation at the knee.62 Further, the
combination of subtalar joint measures
with anterior pelvic angle24 and genu re-
curvatum45 appears to be a stronger pre-
dictor of ACL injury risk than subtalar
pronation alone. Therefore, it may be the
395
 [ research report
collective posture of the lower extremity
that dictates injury risk, rather than a
single alignment variable.
Clinical Relevance
Identifying sex differences in LEA is an
important step toward examining move-
ment patterns that may potentially lead
to lower extremity injury. While it re-
mains unclear how static LEA influences
dynamic knee function and injury risk,
lower extremity malalignments have the
potential to cause abnormal stress pat-
terns or compensatory motions along
Downloaded from www.jospt.org at on March 19, 2024. For personal use only. No other uses without permission.
the lower extremity kinetic chain.22,27,37,62
These malalignments may be related to
muscle strength imbalances27,37 or influ-
enced by the integrity of ligaments, joint
capsule, or musculotendinous struc-
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tures.22 Hence, future studies should ex-
amine how these sex differences in static
LEA interact with one another along the
kinetic chain and collectively influence
dynamic hip, knee, and ankle function.
Identifying the sex differences that may
potentially lead to abnormal biomechani-
cal stresses and injury will aid clinicians
as they evaluate, manage, and ultimately,
Journal of Orthopaedic & Sports Physical Therapy®
work toward prevention of lower extrem-
ity injury in females.
This study is not without some limi-
tations. These findings are limited to
healthy, college-age adults, and should
not be generalized to children, adoles-
cents, or older adults. To better under-
stand the potential developmental factors
leading to sex differences in LEA, future
studies should examine LEA at various
maturation stages. These findings are
also limited to clinical measurement
methods taken by a single examiner with
known measurement reliability. It is well
accepted that clinical measures are not
without measurement error; even when
testers are trained in the same manner,
measurements can vary by clinician due
to factors such as experience or bias in
measurement techniques (eg, palpation
of landmarks).73 The benefit of using 1 ex-
aminer is that we could better ensure that
identical measurement methods were
used on each subject, thus reduce the
396 | july 2007 | volume 37 | number 7 | journal of orthopaedic & sports physical therapy
]
potential sources of measurement error
that would confound our ability to iden-
tify true sex differences. Hence, the ab-
solute values obtained in this study may
not be representative of all testers, and
comparisons made to these normative
values should be interpreted in that light.
Finally, we should acknowledge that the
examiner was not blinded to the sex of
the subject when obtaining the measure-
ment, thus we cannot completely rule out
some degree of unintentional bias.
CONCLUSION
T
hrough a comprehensive ex-
amination of static LEA, our results
indicate that females, on average,
have greater anterior pelvic tilt, thigh
internal rotation, knee valgus, and genu
recurvatum. Interestingly, these align-
ment differences occur primarily at the
hip and knee, as sex differences were not
observed in the lower leg, ankle, and foot.
Hence, with the exception of foot prona-
tion, our results largely support clinical
observations of sex differences in lower
extremity alignment21,29 and add to the
body of knowledge constituted of what
would be considered normal values in a
healthy population. t
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