Perthes Disease

Lower Limb

Overview

Perthes Disease is a childhood hip condition characterized by avascular necrosis of the femoral head epiphysis, typically affecting children aged 4-8 years. The condition results from temporary disruption of blood supply to the femoral head, causing bone necrosis, fragmentation, and potential long-term deformity if inadequately managed. Early diagnosis and appropriate management are crucial to minimize residual disability and prevent premature osteoarthritis.

Pathophysiology

Perthes Disease occurs when the blood supply to the femoral head epiphysis is interrupted, leading to avascular necrosis. The exact etiology remains unclear but involves transient vascular disruption, possibly related to increased intracapsular pressure, inflammation, or thrombosis of the lateral epiphyseal vessels. The disease progresses through four stages: initial (necrosis), fragmentation (revascularization with bone resorption), reossification (new bone formation), and remodeling (reshaping of the femoral head). The extent of femoral head deformity depends on the child's age at onset, the percentage of epiphysis involved, and the quality of containment during the healing phase. Poor outcomes are associated with loss of femoral head sphericity, increased lateral pillar involvement, and inadequate coverage.

Typical Presentation

Site

Anterolateral hip, often unilateral; pain may radiate to medial thigh, knee, or groin

Quality

Dull, aching pain; may be activity-related; sometimes sharp pain with certain movements or muscle spasm

Intensity

Mild to moderate; often intermittent initially, becoming more constant as disease progresses

Aggravating

Weight-bearing activities, running, jumping, prolonged standing, internal rotation and adduction of the hip, fatigue toward end of day

Relieving

Rest, recumbency, heat application, activity modification, anti-inflammatory medication

Associated

Antalgic gait, limping, hip stiffness (especially morning stiffness), limitation of hip abduction and internal rotation, relative leg length discrepancy, Trendelenburg gait, thigh or knee pain (referred), audible clicking or catching, pain with spinal flexion (psoas irritation), muscle wasting of hip flexors and abductors

Orthopaedic Tests

Trendelenburg Test

Procedure

Patient stands on one leg (affected side) while examiner observes for pelvic drop on the contralateral (non-weight-bearing) side. The test is positive if the pelvis drops on the non-affected side.

Positive Finding

Pelvic drop on the non-weight-bearing side, indicating hip abductor weakness or pain inhibition

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Suggests weakness or pain in hip abductors (gluteus medius/minimus), common in Perthes disease due to pain or muscle inhibition. Helps assess functional hip stability.

Thomas Test

Procedure

Patient supine on examination table; examiner flexes the non-tested hip fully to eliminate lumbar lordosis, then observes whether the tested hip flexor tightness causes hip extension loss or knee extension loss. A pillow under the pelvis helps stabilize.

Positive Finding

Hip flexor contracture demonstrated by inability to fully extend the hip or elevation of the knee when the contralateral hip is flexed

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Detects hip flexor tightness, which frequently occurs in Perthes disease due to pain-related guarding and altered biomechanics. Restricted hip extension limits gait quality.

Internal Rotation Range of Motion (ROM) Assessment

Procedure

Patient supine with hip flexed to 90 degrees and knee flexed to 90 degrees. Examiner internally rotates the hip and measures the arc of motion using visual estimation or goniometry.

Positive Finding

Loss of internal rotation (typically <20–30 degrees) or pain with internal rotation movement

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Loss of internal rotation is a characteristic finding in Perthes disease, reflecting femoral head deformity, capsular restriction, or pain inhibition. This restriction contributes to altered gait and may increase risk of secondary osteoarthritis.

Abduction ROM Assessment

Procedure

Patient supine or standing; examiner passively or actively abducts the hip and measures the arc of motion. Pain or restriction during movement is noted.

Positive Finding

Reduced hip abduction (typically <30–40 degrees) or pain at end-range

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Reduced abduction may indicate capsular tightness, femoral head deformity, or pain-guarding. This restriction affects single-leg stance stability and contributes to compensatory gait patterns.

Antalgic Gait Observation

Procedure

Examiner observes patient walking at a comfortable pace, noting stride length, single-leg stance duration, weight distribution, trunk lean, and presence of limp or pain avoidance patterns.

Positive Finding

Shortened stride length on affected side, reduced single-leg stance time on affected limb, ipsilateral trunk lean (Trendelenburg gait), or pain-related limp

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Gait analysis reveals pain-avoidance strategies and functional motor impairment. Antalgic patterns reflect pain, weakness, or loss of hip ROM. Long-term compensatory gait may lead to secondary mechanical changes.

Faber Test (Patrick Test)

Procedure

Patient supine; examiner flexes, abducts, and externally rotates the affected hip, placing the ankle across the opposite knee in a figure-4 position. Examiner then gently applies downward pressure on the flexed knee to assess ROM and pain.

Positive Finding

Pain in the hip (anterior or lateral), reduced range of motion into flexion/abduction/external rotation, or clicking/apprehension

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Tests hip capsular mobility and can reproduce pain if capsular inflammation or femoral head incongruence is present. Helps differentiate hip pathology from lumbar or sacroiliac sources.

⚠ Red Flags

  • •Systemic symptoms: fever, unexplained weight loss, night sweats suggesting infection or malignancy
  • •Acute severe pain with hip effusion on ultrasound raising suspicion of transient synovitis or septic arthritis
  • •Bilateral involvement suggesting metabolic or systemic disorder rather than idiopathic Perthes
  • •Onset before age 4 or after age 8 in typical presentation
  • •Signs of neurological involvement: lower limb weakness, sensory disturbance, or bowel/bladder dysfunction
  • •Acute increase in pain, swelling, or inability to bear weight requiring urgent imaging to rule out acute complications
  • •History of significant trauma preceding symptom onset

⚡ Yellow Flags

  • •Parental anxiety about prognosis and long-term outcome affecting compliance with treatment
  • •Overprotective parenting limiting child's normal activity and social participation
  • •Delayed psychosocial development due to activity restriction and peer comparison concerns
  • •School absences or educational disruption due to frequent medical appointments
  • •Pain catastrophization or excessive focus on symptoms by child or caregiver
  • •Low socioeconomic status affecting access to specialist care or compliance with treatment protocols
  • •Family history of hip dysplasia or connective tissue disorders
  • •Psychological impact of limping or visible gait abnormality on self-esteem

Osteopathic Techniques

Region

Hip joint and femoral head

Technique

Articulation

Rationale

Gentle articulation within pain-free range promotes synovial fluid circulation, reduces intra-articular pressure, and maintains hip mobility without compromising the healing femoral head. This supports the goals of containment and prevents compensatory stiffness.

Region

Hip flexors (psoas, iliopsoas)

Technique

MET

Rationale

Muscle energy techniques to the psoas and iliopsoas reduce hip flexor tension and spasm, which increases intra-articular pressure and exacerbates pain. Normalized hip flexor length improves hip extension and reduces anterior hip impingement.

Region

Hip abductors and external rotators

Technique

Soft Tissue

Rationale

Soft tissue mobilization to gluteus medius, minimus, and deep external rotators addresses muscle inhibition and promotes neuromuscular re-education. Strong abductors are essential for pelvic stability and reduce Trendelenburg gait pattern.

Region

Lumbar spine and sacroiliac joints

Technique

HVLA

Rationale

Lumbar restriction contributes to compensatory hip mechanics; careful HVLA to the lumbar spine and sacroiliac joints restores spinal mobility and reduces abnormal stress distribution to the affected hip during weight-bearing and movement.

Region

Thoracic spine and rib cage

Technique

Articulation

Rationale

Thoracic restriction alters postural alignment and breathing mechanics, increasing intra-abdominal and intrathoracic pressure; restoring thoracic mobility normalizes postural control and reduces compensatory hip stress.

Region

Lymphatic system and hip region

Technique

Lymphatic

Rationale

Gentle lymphatic techniques promote fluid drainage from the hip joint and surrounding tissues, reducing effusion and inflammation, thereby decreasing intra-articular pressure and supporting the body's natural healing response.

Add-On Approaches

Chinese Medicine

TCM approaches focus on tonifying Kidney and Spleen qi to support bone healing and addressing Blood stasis in the hip region. Acupuncture points such as GB34 (Yanglingquan), LV3 (Taichong), and local points around the hip may reduce pain and inflammation; herbal remedies containing bone-nourishing herbs (e.g., eucommia, dipsacus) support skeletal recovery. Moxibustion may enhance circulation and warmth to the affected joint.

Chiropractic

Chiropractic care focuses on hip joint manipulation and mobilization to maintain capsular mobility and reduce pain; sacroiliac joint adjustments address pelvic imbalance contributing to abnormal gait mechanics. Diversified or Gonstead techniques can target lumbar and hip restrictions, though caution is warranted during fragmentation phase to avoid excessive hip stress.

Physiotherapy

Physiotherapy emphasizes hip abductor strengthening (clamshells, sidelying leg lifts, standing hip abduction), internal/external rotator training, core stability exercises, and gait re-education to normalize Trendelenburg pattern. Hydrotherapy offers reduced weight-bearing strengthening, proprioceptive training, and pain management. Stretching programs address hip flexor and adductor tightness. Progressive weight-bearing exercises are titrated according to radiographic stage and clinical response.

Remedial Massage

Remedial massage techniques address muscle tension and trigger points in hip flexors, adductors, and rotators; myofascial release to the tensor fasciae latae and iliotibial band reduces lateral hip tension. Deep tissue techniques to gluteal muscles improve contractility and neural drive. Soft tissue mobilization supports circulation and reduces muscle guarding around the affected hip joint.

Rehabilitation Exercises

Supine Hip Flexion and Extension (Pendulum Movement)

Range of MotionBeginner

Supine Figure-Four Stretch (Hip External Rotator Stretch)

StretchingBeginner

Supine Hip Flexor Stretch (Modified Thomas Stretch Position)

StretchingBeginner

Sidelying Hip Abduction (Clamshell Modification)

StrengtheningBeginner

Sidelying Glute Medius Lift with Hip Flexion

StrengtheningBeginner

Quadruped Hip Extension (Donkey Kick Modified)

StrengtheningIntermediate

Supine Glute Bridge (Bilateral, Progressing to Unilateral)

StrengtheningIntermediate

Standing Hip Abduction with Pelvic Stability (Wall Support)

PosturalIntermediate

Single-Leg Standing with Core Engagement (Supported Progression)

BalanceIntermediate

Aquatic Walking or Swimming (Non-Weight-Bearing)

CardiovascularBeginner

Tandem Standing with Upper Limb Reaching

BalanceAdvanced

Standing Hip Internal and External Rotation (Resistance Band, Progressive Load)

StrengtheningAdvanced

Referral Criteria

  • •Initial diagnosis or confirmation of Perthes Disease: refer to pediatric orthopedic specialist for imaging (X-ray, MRI) and staging
  • •Signs of acute hip pain with effusion: refer to pediatrician or orthopedic surgeon to rule out transient synovitis or septic arthritis
  • •Rapid progression of pain or loss of motion: return to orthopedic specialist for reassessment and consideration of containment therapy (bracing, surgery)
  • •Significant Trendelenburg gait or pelvic instability unresponsive to conservative care: refer to physiotherapy for advanced gait training or consider orthopedic reassessment
  • •Psychological distress or behavioral changes secondary to activity restriction: refer to pediatric psychologist or counselor
  • •Evidence of systemic disease (fever, weight loss, lymphadenopathy): refer to pediatrician for investigation of alternative diagnoses
  • •Bilateral hip involvement: refer to metabolic bone disease specialist or endocrinologist to exclude systemic metabolic disorder
  • •Lack of progress after 3-4 months of appropriate conservative management: refer back to orthopedic specialist for reassessment of containment strategy
  • •Complications such as limb length discrepancy affecting gait: refer to orthopedic surgeon for assessment of need for epiphysiodesis or shoe modification
  • •Age at presentation unusual (before age 4 or after age 8): refer for specialist evaluation to confirm diagnosis and exclude other pathology