01 Jan Hip Problems in Children and Adolescents
Although hip problems in children are relatively rare, there are a number of conditions which are potentially serious which need to be recognised and treated early.
Children presenting with hip problems are often misdiagnosed because of the sometimes vague description of the symptoms. Whilst very young children may simply go off their feet and have non-specific limp, older children often have intermittent symptoms frequently involving the knee.
Hip pain, in children and adolescents can have a number of causes and differential diagnosis is important for correct management. A consult with an orthopod for an accurate diagnosis and possible surgical intervention may be required.
Your HNA Physio will be able to provide an appropriate management plan to enable the best possible result.
Irritable Hip (Transient Synovitis)
An irritable hip, or transient synovitis, is associated with restricted movement in a healthy child. It is the most common form of hip pain and limp in pre-school aged children (3-8 yrs).
- Symptoms maybe intermittent and occur after activity.
- It is twice as common in boys.
- Typically, pain is felt in the groin, anterior thigh or knee.
- The patient has limited extremes of hip movement, particularly abduction with the flexed hips and internal rotation.
- There may be a history of recent viral URTI (2weeks).
- X Ray will be normal.
An irritable hip in itself is a self-limiting, benign condition, which usually settles in one to two weeks and requires joint rest until the symptoms have settled.
Symptoms of irritable hip can overlap with those of septic arthritis; severe limitation of hip movement would suggest septic arthritis. A consultation with an orthopaedic surgeon may be required.
Perthes disease is avascular necrosis of the capital femoral epiphysis due to a transient disruption of the blood supply to the femoral head, which can result in long-term problems.
- Perthes usually presents in children aged 4-8yrs but can be present between 2-11 years.
- It is far more common in boys than girls (4:1) with 20% affected bilaterally.
- In the early stages of Perthes disease, the child will have an intermittent limp that may get worse as the disease progresses.
- The child will present with pain and restricted hip motion, and possible atrophy of thigh musculature.
- The disease process lasts two to five years with initial ischemia to the femoral head, leading to collapse and remodelling of the femoral head.
- XRay – Density of femoral head, patchy osteolysis with variable degree of femoral head deformity.
If the femoral head is not seriously deformed, normal hip function will return.
When the collapse occurs in older children, with less remodelling potential, or if the collapse is extensive, the hip may be malformed and produce abnormal joint mechanics leading to early degenerative changes.
A surgical consult is necessary.
Slipped Upper Femoral Epiphysis (SUFE)
SUFE refers to a fracture through the physis (the growth plate), which results in slippage of the overlying epiphysis which can occur in older children during the active growth phase of hip development.
- Slight male predominance, presenting age 10-17, average age of 12 in females and 13.5 in males.
- Commonly obese children > 90th percentile in weight.
- Typically insidious onset of thigh or knee pain with a painful limp and limitation of hip movement particularly internal rotation. Period of symptoms 3 weeks to years.
- With increasing severity, limb-length discrepancy and a fixed-flexion externalrotation contracture may develop.
- An acute slip (10-15% of cases) is a traumatic episode presenting an acute physeal fracture. Symptoms are less than three weeks in duration and are associated with a marked limitation of motion secondary to pain and the patient cannot usually weight bear. There may be an external rotation deformity and shortening.
- Diagnosis can be made Radiologically, “Frog Lateral” x-rays of the affected hip will reveal slipped capital femoral epiphysis.
- Chronic slips (85% of cases) present with symptoms over a period of 3 weeks to years. Thigh and knee pain is usually the initial complaint in 46% of patients. There are frequent exacerbations and remissions of pain and limp. Examination demonstrates and antalgic (painful) gait, loss of internal rotation, loss of abduction and flexion of the hip. With increasing severity, limb-length discrepancy and a fixed-flexion external rotation contracture develops.
- Specialist referral is required as surgical intervention may be necessary to prevent progression of the slip and achieve closure of the growth plate, usually by internal fixation
of the slip.
The prognosis depends of the severity and stability of the hip and good results can be expected in 95 percent of cases.
The prognosis and rate of complications are far more favourable in stable hips and early diagnosis is very important.
If untreated, there is a risk of progression of the slip (44%) and/or degenerative joint disease (5-40%), and other complications such as avascular necrosis and rapid arthritis.
Apophysitis is caused by repetitive microtrauma at the bone- cartilage interface during periods of rapid growth.
- Sufferers are generally teenagers who present with activity-related groin pain.
- There are several apophyses around the hip and pelvis that are prone to developing traction apophysitis in active adolescents:
- Anterior superior iliac spine (ASIS) — origin of Sartorius
- Anterior inferior iliac spine (AIIS) — origin of the rectus femoris
- Iliac crest — abdominal musculature attachment
Apophysitis of the hip and pelvis usually affects runners, dancers, sprinters and soccer players, aged between 14 and 18yrs.
How can Physiotherapy Help?
- Accurate assessment & diagnosis of hip/knee pain
- Appropriate referral when indicated
- Optimise hip function by reduction of joint pain & stiffness
- Specific muscle retraining
- Restore ROM
- Modified activities specifically reduction in high impact exercise
- Promote regular appropriate physical activity ie swimming, cycling
- Prescribe & fit orthotics if required
- Prevent secondary complications including back & knee pain
- Post surgical Rehabilitaion
Important points to remember
- Classical hip pain felt in the groin or anterior thigh may not be present in children
- Hip problems in children can refer pain to the knee
- A child with knee pain should also have their hip assessed
- Hip problems in children can be quite age specific
- Xray of the hip is relevant diagnostically
- Physio intervention is important in management of hip pain
- Modification of activities – reduce high impact activities
Information compiled by HNA Physiotherapists Julie Godfrey and Kelly J Woosnam.
References available on request.
All HNA Physiotherapists have thorough training in the assessment and management of children and adolescents with hip/knee pain due to pathologies of the hip, please contact Noosa Sports & Spinal Physiotherapy Centre for further information.