Slipped capital femoral epiphysis

Slipped captial femoral epiphysis and gait.

Yesterday in the clinic a young teenager was brought into the office with a gait problem. Or so it seemed. The patient was walking with a "peg legged" locked knee gait on the right side. It was as if she was wearing a straight leg knee immobilizer. There was no knee bend during gait, she was not in much pain. A month prior, when the problem started, she recalls "straining" the right thigh during tennis. There was a sudden sharp jabbing pain in the mid thigh, and over the next 2 days , much thigh and lateral hip pain. Radiographs of the femur were unremarkable by another doctor. Physical therapy exercises by another facility have been fruitless.
On the exam table there was a terrible pelvis distortion pattern and the affected leg looked, no kidding, 1 inch longer on the table. The knee and quad during exam were splinted, she did not want the knee bent. or so I thought.
As the exam went on, it became clear that it was not the knee that did not want bent, it was hip flexion that she did not want, she was just unaware it was the hip, because the pain would only come on into the thigh during the exam.
I proceeded to gently press over the anterior femoral head, and she screamed.

This is a SCFE until proven otherwise. This was a 13 year old, with sudden onset of thigh pain after an abrupt load. I have seen this a few times in practice, and they have often presented in just this manner. Growth plates have to be high on the list in teenagers, especially when pain remains ongoing, and there are extraordinary joint splinting and compensations such as in her gait. She was clearly splinting through the quads, in an attempt to completely unload the gluteal generated hip joint compression. She could not activate or contract her quadriceps, at all ! She wanted no part of compression or load across this hip joint. The locked knee gait was her attempt to depend on more quad generated hip/limb stability during loading.

If you are training or treating teens, the growth plate always has to be on the differential diagnosis list.
* this is not her radiograph above, i am still waiting to hear from someone.

Gait Posture. 2017 Oct;58:358-362. doi: 10.1016/j.gaitpost.2017.08.026. Epub 2017 Aug 26.
Gait deviations in transverse plane after SCFE in dependence on the femoral offset. Hummel S1, Rosenthal D2, Zilkens C2, Hefter H2, Krauspe R2, Westhoff B2.

A Case of Hip pain in a Young Runner: Perthes Disease

here is a nice little short video of a young girl with a healed Perthe’s Disease (full name, Legg-Calve-Perthes Disease) that came to see us a few years ago with right hip pain.  After an examination and a very brief treatment stint films were obtained and found an early stage Perthe’s Hip.  Early diagnosis is always important in this disorder that affects the vascularity of the head of the femur. Failure to make an early diagnosis is a disaster which leads to deformity and permanent disability for the patient.  Perthe’s affects mostly male boys under the age of 10. There is really no clear etiology but many studies point to a period of increased pressure within the joint from an inflammatory process. A term “Transient Synovitis” has been labeled by some.  In this case, the disorder was caught in its first stage and the hip revascularized, did not collapse and it is doing well.  Collapse is the most devastating outcome of this disease process, it is why you do not mess around with children with unresolving hip pain, obtain imaging early.  The main problem, as is seen here, is that she cannot get to her gluteal muscles to stablize the hip in the frontal plane.  Here you see a classic Trendelenberg Sign when she steps onto the right leg. 

When she steps onto the left hip the hip,knee and foot are well aligned in the frontal plane and the right hemipelvis rises above the left hip joint line.  Comparatively, when she steps on the right, there is a significant lateral pelvic and body mass shift beyond a line drawn up from the foot-knee line.  Consequently the left hip drops and she looks like she has a short right leg.  Measurements (as unreliable as they are)  do not show a leg length discrepancy.  However, this type of mechanical behavior can put undue stress on a healing femoral head.  Using a sole lift to help regain pelvic leveling during gait help maintain balanced femoral head pressures and cartilage coverage during the last stages of joint formation in this adolescent.  The problem is that there will be dependency on the lift so regular daily exercises with guaranteed compliance is imperative.  She must regain use of the glute in gait and stance or this hip will be a problem in later years, guaranteed.  So, this is a difficult case.  It is not for the faint of heart.  Bottom line, do not mess with kids with hip pain for long without imaging to rule out terrible problems like this.  There are so many gait problems that will ensue if the gluteal stability is not regained.  To name just a few, the right foot will always be supinated and this means risk for bunions (see last weeks Dr. Ivo video on bunions and the adductor hallucis muscle) and other disorders that are caused by an unanchored first metatarsal.  Additionally, the knee can degenerate the lateral compartment quickly not to mention the plethora of muscular problems (low back pain, knee pain etc) and strategies (ie. pelvic distortion patterns) that will ensue from such a gait.  There is so much more to Perthes Disease than we have mentioned here, but this is not the venue for such complicated topics.  The important thing is to beware of systemic problems that can compromise the integrity of the neuromusculoskeletal system that can have short and long term effects on one’s gait. Here is a link to some more info on Perthes Disease …… but even this is scant info (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002244/)….. make sure you do your reading if you are in the clinical world and see young patients. 

It is not always just about muscles and shoes and orthotics. You have to always be on your toes (no pun intended).

we are…….. so much more…….. than just Gait Guys.