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    Move Forward Guide

    Physical Therapist's Guide to Legg-Calvé-Perthes Disease

    Legg-Calvé-Perthes Disease (LCPD), a hip disorder seen only in children, results from a disruption of blood flow to the head (or “ball”) of the long bone of the leg (the femur). Without blood flow, the bone (femoral head) weakens, causes the child to limp, and causes pain. Without treatment, the femoral head may die. Approximately 1 in 1,200 children in the United States will develop LCPD. A physical therapist can help a child experiencing LCPD maintain motion of the hip joint, strengthen muscles around the hip, and use braces or devices that may be prescribed as the femoral head goes through several stages of healing.


     

    What is Legg-Calvé-Perthes Disease?

    As a child grows, the long bone of the leg (the femur), and the ball-shaped head of the femur that helps form the hip, continue to grow. In some cases and for unknown reasons, the blood supply to the head of the femur can become interrupted. Without blood flow, the femoral head begins to die and stops growing. This hip disorder occurs only in children; boys are affected 4 times more than girls. Children who develop the disease are often physically active and athletic. The average age of children diagnosed with LCPD is 6 years. Although the disease is commonly seen in children 4 to 8 years of age, anyone between the ages of 2 and 15 may develop LCPD. The condition involves both hips in 5% to 15% of affected children.

    The cause of LCPD is not known; the first signs of the disease may be limping and hip pain. Some children perceive that the pain is in the knee. The head of the femur is usually round and fits into a socket in the pelvis, forming the hip joint. The head may become flattened and deformed as the disease progresses. A fracture of the supporting bone also may occur.

    Over time and with treatment, blood vessels regrow into the femoral head and healing occurs. However, the healing process is slow, and the femoral head is weakened during the process. The bone can become permanently deformed, resulting in hip disorders in adulthood, such as osteoarthritis. Therefore, early diagnosis and treatment of LCPD are essential to ensure long-term health.

    LCPD is also known as "Perthes." LCPD comes from the names of the orthopedic surgeons (Legg, Calvé, and Perthes), who attempted to determine the causes of the disease.

     

    Signs and Symptoms

    Children with LCPD may experience:

    • Hip pain (usually only on one side).
    • Limping without a known cause (such as an injury) that lasts for several days.
    • Limited movement in the hip.
    • Pain in the knee, thigh, or groin (instead of in the hip) that may occur as “referred” pain from the hip because of nerves in the leg.
    • Muscle spasms.
    • Weakness and muscle wasting (at a later stage in the disease process).
     

    How Is It Diagnosed?

    A health professional will take the child's health history. The examination will include observing the child walking to determine if a limp is present, assessing pain in the hip or determining the possibility of referred pain to the knee or thigh, and measuring motion at the hip to see if the child has limited movement. Typically, the child will appear otherwise well, with no general illness, and the pain will not be the result of a known injury. A radiograph can usually confirm the presence of bony changes in the head of the femur (long bone of the leg), but other images, such as MRI or bone scans, may be used to ensure that no other disease is present. Physicians use the radiograph to determine the extent of the disease.

    Several classification groupings exist to describe the disease and to predict the recovery. In general, these groupings consider whether or not more than 50% of the “ball” (femoral head) is involved. If more than 50% of the femoral head has been affected, potential for regrowth without deformity is lower, and surgery may be required to help the femoral head maintain its functional shape.

    Early diagnosis is crucial to aid full recovery. LCPD has 4 distinct stages:

    1. Initial: Blood supply to the femoral head is disrupted, bone cells die, and the area becomes intensely inflamed and irritated.
    2. Fragmentation: The affected bone is weakened and the head of the femur breaks apart and collapses.
    3. Reossification: New bone grows in the affected area and begins to reshape.
    4. Healed: Bone regrowth is complete, and the femoral head has reached its final shape.

    Stage 1 takes approximately 6 weeks to 2 months; stage 2 takes 1 year or more; and stage 3 may continue for many years.

     

    How Can a Physical Therapist Help?

    The physical therapist is an important member of the team of health care professionals working with children who have LCPD. The goals of treatment for all children include:

    • Reducing hip pain.
    • Restoring and maintaining all typical hip movements.
    • Preventing the ball (femoral head) from collapsing and dislocating from the hip socket.
    • Regaining a spherical (round) femoral head.

    Nonsurgical Treatment

    Many children will recover from LCPD without difficulty and without risk of further complications as an adult. These children are treated nonsurgically with physical therapy and bracing. Some children may need bed rest during the active phase of the disease. A physical therapist can help reduce the child's pain, restore and maintain motion, and build strength in the area to help the femoral head stay within the socket. Special bracing may be used to help protect the femoral head. A physical therapist can help the child safely continue to be as active as possible while recovering.

    Surgical Treatment

    Sometimes, older children or children with more severe disease at the time of diagnosis may require surgery to keep the femoral head within the hip socket. If surgery is required, a physical therapist will help ensure postsurgical recovery by reducing the child's pain, maintaining motion in the hip, providing exercises for strengthening, and fostering participation in safe activities during all the phases of the healing process.

     

    Can this Injury or Condition be Prevented?

    The exact cause of LCPD is not known, therefore, no specific prevention has been developed. However, early identification of the symptoms of the disease is crucial to recovery. Early identification allows for treatment to reduce or eliminate the possibility of complications in adulthood. Children of small stature and immature bone age are at risk for LCPD. The disease should be suspected in these children if any symptoms develop. In a very small number of children, other members of the family may have experienced LCPD, suggesting a genetic relationship, but no specific gene is known to cause it. Research continues to try to understand the cause of LCPD and to improve treatments.

     

    Real Life Experiences

    A Child Diagnosed Early Who Does Not Require Surgery

    Jack is an 8-year-old boy who is short for his age, and very physically active. Last week, Jack started limping and complaining of pain in his groin. But his parents didn't see him trip or fall during his Friday baseball game, and he couldn't remember having had any sort of accident. This week, Jack said his pain was worse, so his parents took him to his pediatrician. His pediatrician referred him to a pediatric orthopedic surgeon for further investigation.

    After a careful examination and review of a radiograph of Jack's hip, his pediatric orthopedic surgeon diagnosed LCPD. Fortunately, Jack was in the initial phase of the disease process, and less than 50% of the femoral head was involved. The physician assured Jack's parents that he would likely have a good outcome, but the family would need to help by slowing Jack down, modifying his activity levels, and maintaining his hip motion over the next 1 to 2 years to allow the hip to heal. The surgeon then referred the family to a physical therapist.

    Jack's physical therapist evaluated his hip range of motion and strength. He also assessed his ability to use assistive devices, such as a walker or crutches, to reduce pressure on the hip. Jack's parents voiced their concerns about the difficulty of monitoring his activity and his compliance with keeping weight off the hip with an assistive device. His physical therapist worked with them and Jack on an activity modification plan, and prescribed the use of a wheelchair. He also created an individualized home-exercise program and helped the family schedule it into Jack’s daily routine.

    With the help of his physical therapist, Jack successfully healed his hip after 1 year of activity modifications and range-of-motion exercises. The pediatric orthopedic surgeon released Jack to his usual activities, but asked the family to continue with physical therapy to help with strengthening Jack’s hip muscles, prior to his return to sports.

    Jack's physical therapist again evaluated Jack’s hip motion and strength and designed a new home-exercise program for him. He made sure that he performed the exercises with proper form, intensity, and timing. He gradually added functional exercises that would help Jack return to the sports he loved and reduce his risk of reinjury. After 2 months of further treatment, Jack was discharged from physical therapy, and returned to playing shortstop on his Little League team!

    A Child Diagnosed Later Who Requires Surgery:

    Jill is a 13-year-old elite gymnast who has been battling knee and inner thigh pain for the past few weeks. She has concealed the pain from her parents and coaches for fear of losing her spot on the team. But this week, Jill began to limp, and could not hide the pain any longer. Her parents alerted the team physician, who could find nothing wrong with her knee on a radiograph image. He referred her to a pediatric orthopedic surgeon, who suspected a hip disorder because hip pain may be felt in the knee. The surgeon examined Jill's hip and noted decreased range of motion. Radiographs of her hip led to a diagnosis of LCPD. Jill was already in the fragmentation phase of the disease; more than 50% of her femoral head was involved. The surgeon stressed the severity of her condition, and recommended surgery. She had to explain to the family that Jill's gymnastics career was likely over, and the focus now was to preserve her hip so that she would not develop arthritis and need a hip replacement at a young age.

    Within a few weeks, Jill was admitted to the hospital for surgery. A physical therapist consulted with the family prior to the surgery to help them plan for how Jill would get around her house and school using assistive devices, such as crutches and a wheelchair.

    After the surgery, a hospital physical therapist was the first person to help Jill get out of bed to use the toilet. To prevent her muscles from getting weak and her joints from getting tight after surgery, the therapist instructed her in a simple home-exercise program that she could perform in her bed. Finally, she taught Jill to walk with crutches and put limited weight on her leg to help avoid pain. Jill was a natural on crutches, and was safely discharged from the hospital.

    Six weeks later, Jill returned for her postoperative follow-up visit. Radiographs showed that Jill had good healing at the surgical site, and she was allowed to put weight and walk naturally on her leg again. Her surgeon prescribed physical therapy to help her regain strength and walk without a limp.

    Jill's physical therapist evaluated her hip motion, strength, and ability to walk without an assistive device. He identified weakness in her hip muscles on the side and back of her hip and instructed her in a new home-exercise program. Jill received scheduled physical therapy treatments for 6 weeks.

    As her strength and movement improved, Jill's physical therapist helped her transition to a recreational program she could perform that was low impact on her hip, but allowed her to maintain a high degree of fitness. She joined her school's swim team, and just this week, helped win the season's first relay race!

     

    What Kind of Physical Therapist Do I Need?

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

    • A physical therapist who is experienced in pediatrics and developmental disorders. 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 neurologic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to conditions, such as LCPD.
    • An experienced pediatric physical therapist who also understands the importance of working with other health professionals who are needed to maximize outcomes for children with LCPD.
    • A physical therapist who focuses on treating infants and children with neuromusculoskeletal 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 neuromusculoskeletal disorders or other orthopaedic developmental disorders.

    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 and website resources provide some of the best scientific evidence on LCPD. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and internationally. 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.

    Smith C. Increasing awareness of Legg-Calve-Perthes disease. Br J School Nursing. 2014;9(1):21-23. Publisher Summary.

    National Organization for Rare Disorders. Legg Calvé Perthes disease: symptoms of Legg Calvé Perthes disease. Updated August 22, 2013. Accessed September 14, 2015.

    Moya-Angeler J, Abril JC, Rodriguez, IV. Legg-Calvé-Perthes disease: role of isolated adductor tenotomy? Eur J Orthop Surg Traumatol. 2013;23:921–925. Article Summary in PubMed.

    Cincinnatti Children’s Hospital Medical Center. Legg-Calvé-Perthes. Post-operative management of Legg-Calvé-Perthes disease in children aged 3 to 12 years. Published January 2013. Accessed September 14, 2015.

    Cincinnatti Children’s Hospital Medical Center. Legg-Calvé-Perthes. Conservative management of Legg-Calvé-Perthes disease in children aged 3 to 12 years.  Published October 2010. Revised August 1, 2011. Accessed September 14, 2015.

    The National Osteonecrosis Foundation. Legg-Calvé-Perthes disease.  Accessed September 14, 2015.

    US National Library of Medicine. Legg-Calvé-Perthes disease. Accessed September 13, 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 Venita Lovelace-Chandler, PT, PhD, PCS and Charter Rushing, PT, ScD, PCS. Reviewed by the MoveForwardPT.com editorial board.

     

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