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    Move Forward Guide

    Physical Therapist's Guide to Slipped Capital Femoral Epiphysis

    Slipped capital femoral epiphysis (SCFE) is the most common hip disorder seen in adolescents. It affects 10 in every 100,000 children in the United States. Although its cause is unknown, SCFE may be related to the onset of puberty, body mass and obesity, trauma, or other factors. The disorder occurs 2 to 3 times more in males than females, and affects both hips 40% of the time. A physical therapist can help with early diagnosis in a child with a limp, and provide treatment to maintain strength, joint motion, and stability of the hip before or after other treatments. A physical therapist also can help with a wellness program to diminish or prevent arthritic changes in the hip later in life.


     

    What is Slipped Capital Femoral Epiphysis?

    Slipped capital femoral epiphysis is a hip disorder that involves the long bone of the lower extremity (femur), the head of the femur (capital femoral epiphysis), and the growth plate at the end of the femur (physis). SCFE is described as the slipping of the head of the femur (the ball of the hip joint) through the growth plate and away from the thigh bone. Growth plates are made of cartilage, which is a weaker substance than bone. Once the head of the femur slips through the growth plate, or its relationship to the growth plate is compromised, the diagnosis of SCFE is likely.

     

    How Does it Feel?

    Symptoms associated with SCFE include:

    • Limping
    • Pain in the leg, hip, knee, or groin
    • Difficulty walking
    • Decreased range of motion (hip and leg movement)
    • Overall loss of function (in more severe cases)

    The most common symptom of SCFE is limping. Pain is typically observed around the hip, upper thigh, or inner knee. Hip pain is also frequently perceived in the groin or knee area. Motion at the hip is increased when pointing the foot outward (external rotation), but limited and painful when turning the foot inward (internal rotation). Muscle strength at the affected hip also is decreased.

    As SCFE progresses and inflammation and pain are present, the ability to perform everyday activities decreases, and the child may refuse to put weight on the affected leg. Not using the hip joint properly can result in muscle weakness in the hip and leg.

    Children with SCFE are typically male adolescents, aged 10 to 15 years, who are experiencing a growth spurt. The disorder usually begins with involvement of a single hip. In some cases, slippage of the second hip may occur 6 to 12 months later, even if the child has undergone treatment for the first hip.

    Unfortunately, a child’s symptoms may disappear for periods of up to 2 to 3 weeks. This pattern of pain and limping followed by no pain and no limping promotes uncertainty that a problem exists, and may cause the family to dismiss the urgency of the original symptoms. Children with symptoms should be seen by a health care provider as soon as possible.

     

    How Is It Diagnosed?

    A medical specialist, such as a pediatric orthopedic surgeon, is often the one to formally diagnosis SCFE. A physical therapist also may be one of the first professionals to observe symptoms and make a referral to a specialist. A diagnosis of SCFE is based on the child’s symptoms, a careful examination, and radiology reports. Although the disorder is typically confirmed with radiographs, an MRI or CT scan may be necessary to ensure an accurate diagnosis.

    A diagnosis of SCFE will fall under 1 of 2 categories:

    1. A stable condition is characterized by a mild slip of the head of the femur. A child is usually able to walk or use crutches for longer distances. Pain and stiffness may be present in the affected lower extremity, and a limp is usually observed. Rest often relieves the pain, but pain can easily return with activity.
    2. A significant slip of the head of the femur creates an unstable and serious condition. Immediate treatment is necessary to protect the tissues around the hip joint. An unstable condition is associated with an inability to walk. The child likely will refuse to walk on the affected leg, even when offered an assistive device, such as a crutch or walker. Any display of symptoms of unstable SCFE should be treated as an emergency.
     

    How Can a Physical Therapist Help?

    The hip is the body’s strongest and most stable joint. Any disability in the hip joint should always be examined as quickly as possible. A physical therapist may be one of the first health care professionals to identify the symptoms of SCFE, rule out other possible hip problems, make a referral to a physician, or treat the condition before or after surgery.

    Evaluation is very important for guiding the treatment of SCFE. Your physical therapist will conduct a thorough evaluation that includes taking a health history, having a detailed discussion of the child's pain symptoms, identifying risk factors associated with the condition, reviewing laboratory tests and imaging studies, observing the child's gait and functional mobility, and, most importantly, conducting a hands-on physical assessment.

    Physical therapists work closely with each child and their caregivers to develop an individualized treatment program, and promote a return to full mobility. Your physical therapist will work with you and your child to ensure the safe performance of daily activities, and recommend temporary movement restrictions in the child’s best interest.

    Treatment for SCFE includes keeping the head of the femur stable, and maintaining lower-extremity range of motion and strength in order to prevent the development of arthritic conditions in the future.

    Often, surgery is required to stabilize the bone and promote healing. After the initial diagnosis, a child may use crutches until the time of surgery, in order to protect the site until joint alignment is restored. After surgery, a follow up with the orthopedic surgeon is necessary to establish recovery and treatment guidelines. Physical therapy will begin after surgery in order to promote strengthening and return to activity.

     

    Can this Injury or Condition be Prevented?

    SCFE is a condition that cannot be prevented; however, the chances of developing it can be lessened by maintaining a healthy weight, especially during the adolescent years. A healthy diet and exercise are important for each child throughout their development. Consulting a physician or talking to a physical therapist for guidance is recommended to decrease the child's chances of developing SCFE. Early diagnosis is best to promote musculoskeletal health around the hip and decrease associated long-term complications, such as arthritis.

    Risk factors for SCFE include obesity, male gender, African American descent, Pacific Islander descent, and endocrinology disorders, such as hypothyroidism.

     

    Real Life Experiences

    Billy is a 12-year-old boy who enjoys socializing with his peers, but doesn't play sports or exercise. Billy is overweight for his age, and over a month ago, began complaining of pain in his left knee. Billy’s parents took him to his pediatrician, who referred him to a dietician for nutrition counseling. Billy’s family supported changes in his daily lifestyle. Billy began to eat healthier and was encouraged to be more active outdoors with his peers. His parents kept a journal of his diet and exercise regimen, and observed that Billy had begun to lose weight.

    Over the next month, Billy began to complain of increasing pain at his left knee that also extended into his hip. His physical education teacher sent a note home mentioning that Billy was limping during running and sport activities. The teacher also mentioned that he was "sitting out" from activities that he had previously enjoyed.

    Billy’s parents took him back to see his pediatrician. The physician ordered a left-knee radiograph, which came back negative. He recommended that Billy decrease some of his new exercise activities, and take a mild pain reliever. Three weeks later, Billy began limping throughout the school day, and even at home. His pain increased, and his parents noticed that he was turning his left leg outward when he walked. They alerted his pediatrician, who referred him to a pediatric orthopedic surgeon. The surgeon ordered a second radiograph and a CT scan. She diagnosed stable SCFE, but recommended that Billy undergo surgery 2 days later to prevent future complications to the hip.

    After surgery, Billy was seen in the hospital by a physical therapist to learn some gentle range-of-motion exercises, movement precautions, and how to use crutches at home. Six weeks following his surgery, Billy attended outpatient physical therapy sessions twice a week to improve his strength, range of motion, and functional mobility. Physical therapy treatments included lower extremity strengthening, standing balance exercise, stair training, and aquatic therapy sessions. Billy enjoyed therapy in the water, which helped him relax and feel lighter. He received regular checkups from his orthopedic physician, as his physical therapy treatments progressed.

    Billy initially returned to school a few weeks after surgery, using a wheelchair to get around, and using crutches in his classroom. Eight weeks after his surgery, Billy was pain free and walking independently in his school environment. Billy’s physician released him to participate in a physical education class 3 months after surgery, but educated Billy on the importance of being pain free during any activity. Activity restrictions were fully addressed with Billy and his family by the physician throughout the recovery period. His surgeon recommended that Billy see her for a regular checkup and radiograph once a year to ensure that his hip stays healthy.

    Just last week, Billy went on a camping trip and a short hike with his family. He was discharged from physical therapy services, but continues a strength-training program at home. Billy’s family strives to encourage his physical fitness through bike riding, trips to the park, and regular visits to the pool. Billy’s hard work and his family’s support have promoted his full rehabilitation—and his achievement of a healthier, more active daily routine.

     

    What Kind of Physical Therapist Do I Need?

    All physical therapists are prepared through education and experience to treat patients with SCFE. However, you may want to consider the following:

    • A physical therapist who is experienced in pediatrics, developmental disorders, and orthopedics. Some physical therapists have a pediatric practice and will work with you and your child in the clinic, home, school, or community environment.
    • A physical therapist who is a board-certified clinical specialist or who has completed residency, fellowship, or training in pediatric or orthopaedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to orthopedic and developmental conditions, such as SCFE.
    • Experienced pediatric physical therapists who also understand the importance of working with other health care professionals to maximize outcomes for children with SCFE.
    • A physical therapist who focuses on treating children with developmental orthopedic disorders.

    You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

    General tips when you're looking for a physical therapist (or any other health care provider):

    • Get recommendations from family and friends or from other health care providers.
    • When you contact a physical therapy clinic or home health agency for an appointment, ask about the physical therapists' experience in helping children with neuromuscular disorders, developmental disorders, or orthopedic impairments.
    • During your first visit with the physical therapist, be prepared to describe your child's symptoms and motor skills in as much detail as possible, and discuss your goals.
     

    Further Reading

    The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for a visit with their health care provider.

    APTA has determined that the following articles provide some of the best scientific evidence on SCFE. The article titles are linked either to a PubMed* abstract of the article or to free access of the full article, so that you can read it or print out a copy to bring with you to your health care provider.

    Thawrani DP, Feldman DS, Sala DA. Current practice in the management of slipped capital femoral epiphysis. J Pediatr Orthop. 2015 April 15 [Epub ahead of print]. Article Summary on PubMed.

    Georgiadis AG, Zaltz I. Slipped capital femoral epiphysis: how to evaluate with a review and update of treatment. Pediatr Clin North Am. 2014;61:1119-1135. Article Summary on PubMed.

    Peck K, Herrera-Soto J. Slipped capital femoral epiphysis: what’s new? Orthop Clin North Am. 2014;45:77-86. Article Summary on PubMed.

    Podeszwa DA, Gurd D, Riccio A, et al. Increased acetabular depth may influence physeal stability in slipped capital femoral epiphysis. Clin Orthop Relat Res. 2013; 471:2151-2155. Free Article. Article Summary on PubMed.

    Wabitsch M, Horn M, Esch U, et al. Silent slipped capital femoral epiphysis in overweight and obese children and adolescents. Eur J Pediatr. 2012;171:1461-1465. Article Summary on PubMed.

    Fabry G. Clinical practice: the hip from birth to adolescence. Eur J Pediatr. 2010;169:143-148. Article Summary on PubMed.

    Kleposki RW, Abel K, Sehgal K. Common pediatric hip diseases in primary care. Clinical Advisor. 2010;21-26. PubMed Article Summary Not Available.

    Johanns J, Knopp W. What’s causing your young patient’s hip pain? J Fam Pract. 2010;59:555-561. Free Article. │ Article Summary on PubMed.

    Sawyer JR, Kapoor M. The limping child: a systematic approach to diagnosis. Am Fam Physician. 2009;79:215-224. Free Article. │Article Summary on PubMed.

    Hart ES, Grottkau BE, Albright MB. Slipped capital femoral epiphysis: don’t miss this pediatric hip disorder. Nurse Pract. 2007;32:14-21. Article Summary on PubMed.

    Aronsson DD, Loder RT, Breur GJ, Weinstein SL. Slipped capital femoral epiphysis: current concepts. J Am Acad Orthop Surg. 2006;14:666-679. Article Summary on PubMed.

    Wills M. Orthopedic complications of childhood obesity. Pediatr Phys Ther. 2004;16:230-235. Article Summary on PubMed.

    Slipped capital femoral epiphysis (SCFE). Kidshealth website. Accessed September 19, 2015.

    Slipped capital femoral epiphysis. American Academy of Orthopaedic Surgeons website.  Accessed September 20, 2015.

    *PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

    Authored by Mary Meyer, PT, MPT, C/NDT and Venita Lovelace-Chandler, PT, PhD, PCS. Reviewed by APTA’s Move Forward editorial board.