Slipped Capital Femoral Epiphysis
Lower LimbOverview
Slipped Capital Femoral Epiphysis is a hip disorder occurring in adolescents where the femoral head displaces posteriorly and medially relative to the femoral neck due to weakness of the growth plate. This condition is most common in overweight adolescents aged 10-16 years and can lead to significant complications including avascular necrosis and osteoarthritis if not appropriately managed. Early recognition and appropriate referral for surgical stabilization are critical for optimal outcomes.
Pathophysiology
SCFE occurs when shear forces exceed the load-bearing capacity of the proximal femoral growth plate (physis), resulting in posterior slippage of the epiphysis relative to the metaphysis. Risk factors include rapid growth, obesity, endocrine disorders (hypothyroidism, growth hormone deficiency, hypogonadism), male gender, and increased femoral anteversion. The slippage compromises the blood supply to the femoral head, increases intra-articular pressure, and alters hip biomechanics, leading to progressive degeneration and potential avascular necrosis if left untreated.
Patient Education
Early weight management, activity modification to avoid high-impact activities, and prompt medical evaluation of persistent groin or knee pain in adolescents are essential to prevent progression and complications.
Typical Presentation
Site
Ipsilateral groin, inner thigh, or referred anterior knee pain; may present unilaterally or bilaterally (bilateral involvement is common). Note: SCFE frequently presents as isolated knee or thigh pain with no hip complaint — examine the hip in any adolescent presenting with knee pain.
Quality
Dull ache, sharp pain with movement, clicking or catching sensation in the hip
Intensity
Mild to moderate pain; typically progressive in chronic presentations; acute slips may present with severe pain and inability to bear weight
Aggravating
Weight-bearing activities, internal rotation of the hip, climbing stairs, sitting cross-legged, running or jumping, rapid increase in physical activity
Relieving
Rest, hip flexion with external rotation (Frog-leg position), reduced weight-bearing, activity modification
Associated
Antalgic gait, external rotation contracture, positive Drehmann sign (external rotation occurs passively with hip flexion), limited hip abduction and internal rotation, limb length discrepancy, obesity in most cases
Orthopaedic Tests
Frog-Leg Position (Abduction External Rotation Test)
Procedure
Patient supine; examiner passively abducts and externally rotates the affected hip. Observe for loss of external rotation or guarding compared to the unaffected side.
Positive Finding
Inability to achieve full external rotation (typically <40–50°) or pain with the maneuver, particularly loss of external rotation that is disproportionate to abduction loss
Interpretation
High sensitivity for SCFE; loss of external rotation is a hallmark finding due to the posterior slip of the femoral head. Guides need for imaging confirmation. No confirmed diagnostic-accuracy study supports the figures previously shown for this test in SCFE; the ranges were unsourced. SCFE remains a clinical suspicion confirmed by radiographs (AP and frog-leg lateral views).
Internal Rotation Test (Hip Flexion Internal Rotation)
Procedure
Patient supine with affected hip flexed to 90°. Examiner internally rotates the hip passively and observes for restriction or pain.
Positive Finding
Loss of internal rotation (typically <20–30° compared to normal 40–50°) or reproduction of groin/thigh pain
Interpretation
Indicates mechanical restriction consistent with SCFE; loss of internal rotation in flexion is characteristic and warrants advanced imaging. No confirmed diagnostic-accuracy study supports the figures previously shown for this test in SCFE; the ranges were unsourced. SCFE remains a clinical suspicion confirmed by radiographs (AP and frog-leg lateral views).
Drehmann Sign (Hip External Rotation in Flexion)
Procedure
Patient supine; examiner passively flexes the affected hip to 90° and allows gravity to cause external rotation. Note the position and any obligatory external rotation.
Positive Finding
Hip assumes externally rotated position (20–40° external rotation) when passively flexed, appearing to 'roll out'
Interpretation
Obligatory external rotation as the hip is flexed is a classic sign of SCFE and relatively specific, and is most evident in acute or progressive slips. No confirmed diagnostic-accuracy study supports a sensitivity/specificity pair, so treat it as corroborating a clinical suspicion that is confirmed on AP and frog-leg lateral radiographs.
Antalgic Gait Observation
Procedure
Observe patient walking; note limp, weight-bearing preference, stride length asymmetry, and hip position during stance and swing phases.
Positive Finding
Antalgic gait with reduced stance phase on affected side, shortened stride, and possible trendelenburg sign or pelvic hike
Interpretation
Non-specific but common finding indicating hip pain or dysfunction; may be the presenting complaint in mild or chronic SCFE. Supports need for further investigation. No confirmed diagnostic-accuracy study supports the figures previously shown for this test in SCFE; the ranges were unsourced. SCFE remains a clinical suspicion confirmed by radiographs (AP and frog-leg lateral views).
Supine Hip Flexion–Abduction Test (Patrick's Test Modified)
Procedure
Patient supine; examiner flexes, abducts, and externally rotates the affected hip (figure-4 position). Gently press downward on the medial knee to end-range abduction.
Positive Finding
Pain in groin, anterior hip, or inability to achieve full abduction/external rotation; asymmetry compared to contralateral side
Interpretation
Tests combined hip motions; pain or restriction is non-specific but consistent with intra-articular pathology including SCFE. Often uncomfortable in acute or progressive slip. No confirmed diagnostic-accuracy study supports the figures previously shown for this test in SCFE; the ranges were unsourced. SCFE remains a clinical suspicion confirmed by radiographs (AP and frog-leg lateral views).
Trendelenburg Sign / Hip Abductor Strength Test
Procedure
Patient stands on affected leg; observe for pelvic drop on the contralateral side or ask patient to stand on one leg. Alternatively, test hip abduction strength supine or sidelying.
Positive Finding
Positive Trendelenburg sign (pelvis drops on contralateral side during single-leg stance) or weakness in hip abduction (graded <5/5)
Interpretation
Indicates hip abductor insufficiency or pain inhibition; common in SCFE but non-specific. Helps assess functional impairment and guides rehabilitation. No confirmed diagnostic-accuracy study supports the figures previously shown for this test in SCFE; the ranges were unsourced. SCFE remains a clinical suspicion confirmed by radiographs (AP and frog-leg lateral views).
⚠ Red Flags
- •Acute severe hip pain with sudden inability to bear weight (acute slip may indicate necrosis risk)
- •Severe restriction of hip internal rotation and abduction
- •Persistent groin pain in adolescent that does not resolve with conservative care
- •Bilateral symptoms (requires assessment for endocrine dysfunction)
- •Signs of avascular necrosis (late-stage pain, significant functional loss)
- •Age <9 years (suggests metabolic or endocrine disorder requiring investigation)
- •Recent rapid weight gain coinciding with symptom onset
⚡ Yellow Flags
- •Low health literacy or limited understanding of activity restrictions
- •Difficulty with weight management and lifestyle modification
- •Parental anxiety regarding surgical intervention delaying appropriate referral
- •Adolescent non-compliance with activity modification recommendations
- •Fear-avoidance behavior leading to excessive deconditioning
- •Psychosocial stressors affecting engagement in rehabilitation
- •Poor access to orthopedic surgical services in rural or remote settings
Osteopathic Techniques
Region
Proximal femur and hip capsule
Technique
Rationale
Gentle soft tissue mobilization to hip flexors, adductors, and external rotators can reduce muscle guarding and pain without exacerbating the slip. This improves tissue extensibility and circulation.
Region
Lumbar spine and pelvis
Technique
Rationale
Gentle articulation of the lumbar spine and sacroiliac joints addresses compensatory restrictions and optimizes pelvic mechanics, reducing abnormal stress distribution to the hip joint.
Region
Hip joint and surrounding musculature
Technique
Rationale
Functional osteopathic techniques in hip flexion and external rotation positions support healing without inducing shear forces across the compromised growth plate.
Region
Abdominal and pelvic fascia
Technique
Rationale
Gentle lymphatic drainage techniques to the hip region improve drainage of inflammatory exudate and support tissue recovery post-injury or post-surgical intervention.
Region
Thoracic spine and rib cage
Technique
Rationale
Restoring thoracic mobility and rib mechanics optimizes postural alignment and reduces compensatory hip stress during rehabilitation, particularly important for weight management activities.
Region
Hip external rotators and piriformis
Technique
Rationale
Gentle Muscle Energy Techniques to improve hip external rotation without aggressive stretching protects the growth plate while restoring functional range of motion.
Add-On Approaches
Chinese Medicine
Acupuncture and moxibustion at points such as GB29 (Juliao), GB30 (Huantiao), and LV3 (Taichong) may support pain management and circulation; however, priority is medical/surgical management.
Chiropractic
Pelvic adjustments and spinal manipulations should be avoided given growth plate vulnerability; conservative mobilization of lumbar and pelvic segments may be appropriate as adjunct after medical clearance.
Physiotherapy
Structured progressive hip strengthening (gluteal sets, clamshells, side-lying hip abduction), gait retraining, weight management programs, and proprioceptive training are essential; avoid aggressive stretching or internal rotation movements.
Remedial Massage
Gentle remedial massage to hip musculature, gluteal region, and lumbar paraspinals can reduce myofascial tension and compensatory guarding; avoid aggressive deep tissue work directly over the hip joint.
Rehabilitation Exercises
Gluteal Sets (Glute Activation)
Supine Hip Abduction (Frog-Leg Position)
Side-Lying Hip Abduction
Clamshells (Side-Lying Hip External Rotation)
Supine Hip Flexion and External Rotation Stretch (Frog Pose)
Supine Hip External Rotation with Knee Bent
Posture Awareness and Hip Positioning in Sitting
Single-Leg Stance Support (Non-Affected Side)
Prone Hip Extension (Glute Strengthening)
Swimming or Water-Based Therapy (Low Impact)
Standing Hip Abduction with Support
Core Stability - Transverse Abdominis Activation
Referral Criteria
- •Suspected SCFE is an urgent referral, not a watch-and-wait: an adolescent with groin, hip, or referred knee pain plus restricted internal rotation should be made non-weight-bearing and referred for same-day imaging and paediatric orthopaedic assessment. Do not defer referral to observe the response to conservative care — delay increases the risk of slip progression and avascular necrosis.
- •Clinical suspicion of SCFE based on positive Drehmann sign or external rotation contracture
- •Positive imaging findings (X-ray showing epiphyseal slippage) requiring orthopedic surgical assessment
- •Acute presentation with severe pain and inability to bear weight (potential acute slip requiring emergency orthopedic evaluation)
- •Bilateral symptoms (requires endocrinology referral to assess for metabolic or hormonal dysfunction)
- •Complications including avascular necrosis or early osteoarthritic changes (advanced management required)
- •Inadequate response to conservative management after 4-6 weeks suggesting need for surgical stabilization
- •Presence of endocrine risk factors (hypothyroidism, growth hormone deficiency) requiring specialist coordination