In a 2025 editorial commentary, Dr Jobe Shatrov discussed an important but often overlooked factor in kneecap pain and instability: femoral anteversion. This describes how much the femur twists inward. If that inward rotation is excessive, it can influence the path of the kneecap and increase pressure inside the patellofemoral joint.

The commentary highlights why femoral rotation matters, particularly in patients with recurrent patellofemoral instability.

Why femoral rotation matters

The kneecap does not move in isolation. Its tracking depends on:

• the shape of the trochlea

• the tension of soft tissues

• muscle control

• the rotational alignment of the limb

If the femur is excessively internally rotated, the kneecap may sit and move in a less favourable position. That can increase contact pressure and contribute to pain or instability.

What the commentary highlights

The commentary emphasises that increased femoral anteversion is commonly linked to:

• elevated patellofemoral contact pressures

• lateral overload in the kneecap joint

• a higher risk of instability in some patients

It also highlights a challenge in the research. While biomechanical studies support this relationship, many laboratory methods disrupt natural soft tissues, which can limit how directly the findings translate to real patients.

Why this matters for patients

Patients with recurrent patellar instability sometimes assume the problem lies only in the kneecap or the ligament. This commentary reminds us that the issue may also be bony and rotational.

That is important because it can influence the treatment plan. Some patients improve with physiotherapy. Some need ligament reconstruction. Others may need a more complex alignment-based solution if femoral rotation is part of the problem.

Why this remains a complex issue

One key message is that there is still no perfectly agreed threshold at which femoral anteversion becomes a surgical problem. That is why assessment has to be individual.

The decision is not based on one number alone. It also depends on:

• symptoms

• instability history

• imaging

• response to previous treatment

• the presence of other anatomical factors

What this means in practice

For patients, the practical takeaway is that kneecap instability is not always simple. If symptoms keep recurring, a surgeon may recommend a broader work-up that looks not only at the kneecap and ligaments but at the rotational alignment of the entire limb.

This supports a more personalised approach rather than treating every case of instability in the same way.

Key takeaways

• Increased femoral anteversion may raise pressure in the kneecap joint and contribute to instability.

• Patellofemoral problems are not always caused only by the kneecap or its ligaments.

• Some patients may need broader rotational assessment if standard treatments do not fully explain their symptoms.

Read the full paper: https://www.arthroscopyjournal.org/article/S0749-8063%2825%2900299-3/fulltext