"Hip pain in kids: Legg-Calve Perthes Disease"-Issue 14

Legg-Calve Perthes disease is a condition in children in which the ball shaped head of the thigh bone loses its blood supply.  Without blood, the bone tissue dies and the bone collapses.  As the bone collapses, the head of the thigh bone becomes less rounded, changing the movement and stability of the hip.  This causes stiffness, inflammation and pain to occur.

         Often, the first noticeable sign of the condition is a child that begins to limp.  This limp can occur with or without pain and often has no incident of a fall or trauma to tie to it. Pain will typically be located in the hip, knee or groin.  This pain will typically increase with activity and calm with rest. 

Although any child can develop Legg-Calve Perthes, it typically occurs in active children between the ages of 4 to 8 years old. Research documents that boys are four times more likely to get the diagnosis than girls.   

As the condition runs its course, the body begins to absorb, or “clean up” the dead bone cells and replace them with new, healthier bone cells.  It is during this time that treatment by a physician and/or physical therapist becomes vital.

Early diagnosis and treatment allow as much time as possible for the bone to remodel itself back into a round shape.

Without proper or timely treatment, the condition becomes more serious and the bone is more likely to heal in an improper position or shape.  Studies indicate that if the ball does not reshape well, or fit well into its socket the child is at a high risk of developing degenerative arthritis at a very early age.

In contrast, with proper and timely treatment arthritis is typically not a concern later in life.

Treatment goals should include: controlling pain, maintaining hip range of motion, increasing hip strength and preventing any additional hip deformity as the bone reshapes.  This can typically be achieved through physical therapy treatment, limited activity and limited weight bearing.

Occasionally, surgery or bracing will also need to be implemented to resolve the condition. Children who are older than six or who have more severe cases of Perthes disease are more likely to benefit from surgery in addition to physical therapy. The goal of surgery is to prevent the dislocation or collapse of the hip.

The majority of children treated for Legg Calve Perthes have corrections that enable them to walk, grow and live active lives. Diagnosing and treating early in its development greatly increases the likelihood of a successful outcome.

Hip pain in children is always a cause for concern and should be immediately assessed by a physician to rule out potentially serious conditions such as this one. Any child who has been treated for a hip disorder should be followed periodically by his or her orthopedist until skeletal maturity is achieved.

QUICK TIPS:

Signs and Symptoms:

• Walking with a limp
• Complaints of pain in the hip, knee or groin
• Pain that aggravates with activity
• Pain that calms with rest

Who is most likely to get it? 

•  Boys are 4 to 5 times more likely to be affected
• More common in children exposed to second hand smoke
• Affected children are typically:

o   Between ages 4 -8

o   Very physically active

o   Smaller for their age

 References:
1.www.childrenshospital.org
2. Kim H. Legg Calve Perthes and Slipped Capital Femoral Epiphysis: Major Developmental Causes of Femoroacetabular Impingement. J Am Acad Orthop Surg. 2013. 21: 559-563.
3. Perry et al. Abnormalities of Vascular Structure and function in Children with Perthes Disease. Pediatrics. 2012. 130:126-131.

"Patellofemoral Pain Syndrome"-Issue 12

           Patellofemoral pain syndrome (PFPS) is the most common cause of chronic knee pain affecting young active adolescents.  It is estimated to account for 24-40% of all knee problems presenting to sports medicine clinics.  Symptoms usually consist of pain along the front part of the knee that increases with activities such as running, climbing stairs, squatting, kneeling, and sitting for prolonged periods of time.

            Knowledge of the anatomy of the patellofemoral joint is key to understanding why PFPS occurs. Normally, as the knee bends and straightens, the patella (or kneecap) slides up and down a groove formed in the thighbone.  This motion is controlled by a number of muscles, ligaments and tissue that surround the knee.

The exact cause of PFPS is not well understood.  Most researchers believe it is caused by a breakdown in the structures that control the motion of the kneecap. If the patella moves incorrectly through this groove, it creates the potential for pain and instability in the knee to occur.

Some of the more common reasons that contribute to this breakdown include: muscle tightness, weakness in the hip and an imbalance of the muscles in the front of the thigh.

The quadriceps muscles and ilio tibial band (ITB) tend to be tight in people with PFPS. If the quadriceps muscles are tight, they tend to pull the kneecap much closer to the thigh bone. This increase in tension leads to grinding of the kneecap against the thigh bone which can lead to changes along the surface of the patella causing it to track differently. The ITB has attachments to the outer side of the kneecap.  When it is tight, it pulls the kneecap in an outward direction shifting the kneecap away from its groove.

Recent research also shows PFPS is related to hip muscle weakness. The muscles located in the outer and back portion of our hips contribute tremendously to how our leg lands when we walk and run.  Normally, these muscles help to slow the leg down before it impacts the ground.  Weakness in these muscles can cause the leg to impact the ground with greater force, causing the knee to fall inward and stress the patellofemoral joint.  Repeated landing in this position can result in inflammation and poor tracking of the kneecap.  

Finally, poor tracking of the patella can also result from an imbalance of the muscles in the front of the thigh. The muscle along the inner part of the thigh called the vastus medialis oblique, or VMO can become weak with repeated landing in a poor mechanical position.  When this muscle becomes weak or inflamed, the muscles in the center and outer portion of the thigh begin to overwork causing the kneecap to pull up and out to the side.    

Treatment of patellofemoral pain is complex.  A thorough assessment by a physician or physical therapist to determine the structures involved is key to understanding how to resolve the pain.  Most studies show that physical therapy remains the treatment of choice for the management of PFPS. Surgery is typically indicated in cases where therapy has been ineffective or when changes to the surface of the patella are evident. 

To learn more about this injury and others, contact your local physician or physical therapist.

References:
1. Cowan et al. Physical Therapy Alters Recruitment of the Vasti in Patellofemoral Pain Syndrome. Med Sci Sports Exerci. 2002. 34:12;1879-1885.
2. Eng et al. Evaluation of Soft Foot Orthotics in the Treatment of Patellofemoral Pain Syndrome. Phys Ther. 1993, 73:2, 62-68.
3. Fagan et al. Patellofemoral pain syndrome: a review on the current associated neuromuscular deficits and current treatment opitions. Br J Sports Med. 2008;42:789-795.
4. Harvie et al. A systematic review of randomized controlled trials on exercise parameters in the treatment of patellofemoral pain: what works? Journal of Multidsciplinary Healthcare. 2011; 4:383-392.
5. Cerny K. Vastus Medialis Oblique/Vastus Lateralis Muscle Activity Ratios for Selected Exercises in Persons With and Without Patellofemoral Pain Syndrome. Phys Ther. 1995; 75(8):672-682.