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Description

Description

Prognosis

Etiology

Relative Anatomy

Signs/Symptoms

Treatments & PT

Legg-Calve-Perthes Disease (LCPD) is an osteonecrosis disease where the blood supply is cut off to
the femoral head of the femur and leads to the
death, fracturing, and remodeling of the femoral
head and acetabulum. LCPD affects children between 3 and 12 years old. The disease progresses
through four stages
Stage 1: Blood flow to the capital epiphysis of the
femoral head ceases. Due to the ischemia,
the bone stops growing, becomes denser,
develops cysts, and begins fracturing. Waldentroms sign, a fracture in the subchondral area of the femoral head, can be seen on
x-rays during this stage. Stage 1 may last
approximately 6 months.
Stage 2: The femoral head fragments into sections: medial, central, and lateral portions.
Under stress, the acetabulum reshapes irregularly. Reabsorption begins in the subchondral area of the femoral head at the end of
stage 2.which lasts approximately 8 months.
Stage 3: The femoral head begins to heal. Generally, the healing begins at the interior of the
head and moves outward. Once healing is
complete, the femoral
head remodels into trabecular bone. Stage 3
occurs over approximately 54 months (4.5
years).

Home Program

Legg-Calve-Perthes

Rebecca Stevens
PTA 103: Hip Disorders

Home

Program

References

4-6

Stage 4: During the final stage, the femoral


head and acetabulum reshape normally.
Stage 4 generally completes once skeletal growth is complete.
LCPD may be classified by several systems.
Catterall System: Classification is divided into
4 groups by the involvement of the femoral head.
Salter-Thompson System: Classification is
divided into 2 groups by the extent of
fractures and the lateral margins.
Herring System: Classification is based upon the involvement of the lateral
pillar.
By using various classifications, the doctor and physical therapist can determine
the best course of treatment, home program, and
prognosis.

Etiology
LCPD is a rare disease primarily affecting children between 3 and 12 years old. It is most
common in boys between 5 and 7 years old.
Bilateral LCPD is present in 5%-20% of all cases.
Children affected tend to be small for their age
and most likely are first-born children.

LCPD is a form of osteonecrosis with idiopathic


origins. One theory suggests that the disease
occurs following transient synovitis of the hip.
The blood supply disruption may occur from the
medial femoral circumflex artery or the lateral
femoral circumflex artery. As a result of the blood
flow interruption, the femoral head ceases
growth, fractures, and deforms.
Treatment should be focused around maintaining
structural integrity of the joint and applying stress
to the remodeling tissues.
Legg-Calve-Perthes Disease may also be referenced as ischemic necrosis of the hip, coxa plana,
osteochondritis, avascular necrosis of the hip, or
Perthes Disease.

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Legg-Calve-Perthes Disease

Relative Anatomy
Several areas of the hip are affected by
LCPD.

joint, including the labrum, can deform due to the flattening or


elongation occurring at the femoral head.

The femoral head and the acetabulum


are directly affected by the ischemia.
While no other anatomic structures
are directly affected, several structures
may be secondarily affected by LCPD .

Fracturing and deformation may also affect the Femoral nerve,


causing nerve pain and referred pain from the groin to the
knee.

Fracturing may proceed from the femoral head into the anatomical neck and surgical neck of the
femur. The articular cartilage surround the femoroacetabular

Muscle weakness is common on the affected leg, with particular weakness in the Gluteus medius. This weakness may lead to
a combination antalgic and Trendelenburg type gait pattern.
Without treatment, this gait pattern may in turn affect other
hip and leg muscles, bone and joint development, and the
childs psyche.

Prognosis
Prognosis is determined based upon disease onset, extent of
femoral head involvement, and hip deformation. Prognosis
may range from poor to favorable.
Although treatments will not cure LCPD, they may increase
the chance of a good prognosis, especially for older children
or those with sever femoral head involvement or severe hip
deformation. Because LCPD generally runs its course until
the growth plates close, the use of physical therapy and modalities will allow for good pain managements and correct
exercise stress application

Signs, Symptoms, and Risk Factors


Early symptoms include limping referred pain in the hip,
groin, or knee. Children can often have trouble describing
referred pain, especially as the pain is referred towards the
knee. Some children do not experience pain with LCPD and
may only be diagnosed based upon an x-ray from a separate
event, such as a fall or trauma which twists the hip. Pain
may be worse after activity, later in the day, or during the
night.
If a limp is present, it is generally due to weakness in the Psoas
muscle. Because
many of the children with LCPD
are very active,

the limp will appear pronounced.


A child with LCPD is prone to gait deviations such as the
Trendelenburg gait pattern on the affected side due to
weakness in the Gluteus medius. A Duchenne gait pattern
may also be present; the child will lean towards the stance
limb. The pelvis will either remain level or elevate on the
unloaded limb.
Because LCPD has no specific cause, it can be difficult to
establish specific risk factors. Generally, the disease is
found more often in Caucasians, Asians, and Inuit children. Children affect are often extremely active and may
have ADHD and other hyperactivity disorders.
Secondhand smoke exposure is correlated with LCPD.
The most common ages for development of LCPD is between 5-8 years, and is 4 times more likely to occur in
boys.

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Legg-Calve-Perthes Disease

Diagnosis, Treatment, and Physical Therapy Intervention


LCPD can be diagnosed by eliminating other conditions,
such as septic arthritis and spondyloepiphyseal dysplasia
tarda, and through several diagnostic procedures. X-rays,
bone scans, MRIs, arthrograms, and blood tests may all aid
in diagnosis.
The overall goal of any treatment intervention is to preserve
the natural shape of the femoral head and to prevent undue
deformation of the surrounding structures while the disease

progresses. Treatments may include observation, casts, braces,


and surgery. Generally, specific physical therapy treatments are
focused to children in stage 1-3, without hip co-morbidities, and
who have not undergone LCPD surgeries.
While bed rest, immobilization, activity restrictions, casting, and
surgery are all option to be considered, physical stress will increase the odds of correct bone remodeling. Therefore, the treatment options which include a physical therapy component are
highly effective and should be considered. In addition, since
many of the children affected with LCPD were previously physically active, the use of PT will increase their positive outlook on
the disease.
Physical Therapy will focus on evaluations, pain management,
ROM, balance, strength, and correcting gait deviations. A Physical Therapist will also be able to help teach the child how to use
assistive devices such as crutches.
In addition to working with the physical therapist, children are
advised to continue a home program to continue their rehabilitation. Most exercises can be done at home with the help of a parent of guardian.

Home Program

Warm Up

It is important to follow the Home Program as prescribed. Several exercises can be done by your child by themselves. Many are
designed to incorporate a parent, adult, or therapist to keep the
exercises fun yet therapeutic. The following is an example of
some exercises which may be part of your home program.
It is worth breaking up the home program into several sessions
throughout the day. Your child will tire both physically and
mentally if you try to do 45 minutes of exercises all at once. 10-15
minute sessions 3 times a day may be more manageable for both
you and your child.
The following is a list of suggested equipment to have ready at the
start of the exercise program. Ask you Physical Therapist where
you can purchase these items or if there is a suitable substitution.
Your insurance company MAY cover
certain items, so it is worthwhile to
call for a listing of what items and
brands they will cover.

It is important to
start your routine
with a good warm
up. A good warm
up should be about
5-10 minutes and
should increase the
heart rate. If you
cant get outside or
on a treadmill, all
of these can be
done in place.

Walking

Skipping

Jumping Rope

Jogging

Jumping Jacks

Dancing

Swiss Ball

Theraband

Bath Towel

Bicycle

Wobble Board or Bosu Ball

Wii Sports and Fitness

Ankle Weights

Basketball

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Legg-Calve-Perthes Disease
Example Home Program

The Big Four


PURPOSE:
The Big Four is a stretch for the internal and lateral rotators of your hip
and for the hamstring in the back of the leg. This will help increase the
range of motion in the hip.
WHAT TO DO:
Lay on the floor with your legs bend on a chair, bench, or Swiss ball.
Place the left foot on the right knee. Pull your right leg closer to your
body. When you feel the stretch in your left leg, stop and straighten
your right leg, making an upside-down 4 with your legs. Switch legs
and repeat.
Hold each 4 for 30 seconds, 3 times on each leg.
Do 2 times a day

The Butterfly Stretch


PURPOSE:
The Butterfly Stretch is intended to stretch the hip adductors, which
are used to close the legs together. Children with LCPD tend to have
tight hip adductors so stretching them out will allow for a greater range
of motion in the hip.
WHAT TO DO:
Sit on the floor and make sure to sit up very tall. Press the soles of
your feet together and drop your knees toward the floor. As your knees
go closer to the floor, you will feel a stretch on the inside of your leg.
TO INCREASE THE CHALLENGE
You can place your hands on your knees, which will help to lower your
knees closer to the floor. You should not push on your knees!
You can also slide your feet closer to your body to increase the stretch.
Hold for 30 seconds, repeat 3 times
Do 2 times a day

Legg-Calve-Perthes Disease

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Example Home Program

Three Legged Dog


PURPOSE:
The Three Legged Dog is meant to strengthen the hip extensors, and abdominals. In addition, it works on balance,
WHAT TO DO:
Get on all fours, like a dog. Your hands should be under your shoulders and you
knees should be under your hips. Your back should be nice and straight. Lift the
right leg straight off the ground behind you. Hold the position for 10 seconds and
return the leg to starting position. Repeat with the left leg.
TO INCREASE THE CHALLENGE
Intermediate: Place an ankle weight around the knee or ankle to increase difficulty strength difficulty.
Difficult: Lift the right leg and left arm or left leg and right arm to increase balance
difficulty.
Do 10 three legged dogs (repetitions) 3 times on each leg.
Do 2 times a day

The Dirty Dog


PURPOSE:
The dirty dog targets your Gluteus medius when you lift your leg. It is a
simple exercise which will help increase strength and stability on the
outer thigh during walking and standing.
WHAT TO DO:
Get on all fours, like a dog. Your hands should be under your shoulders
and you knees should be under your hips. Your back should be nice
and straight. Lift your right knee out to the side, keeping your knee
bent. Hold the position for 10 seconds hen return the knee to the floor.
Repeat with the left leg.
TO INCREASE THE CHALLENGE
Place an ankle weight around the knee or ankle to increase difficulty.
Do 10 dirty dogs (repetitions) 3 times on each leg.
Do 2 times a day

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Legg-Calve-Perthes Disease
Example Home Program

Bridging
PURPOSE:
Bridging is used to work on both Gluteal contractions and the muscles in your back, abdominals, and legs.
WHAT TO DO:
Lay on the floor and bend your knees. Squeeze your behind muscles together and lift your hips up. At the top position, only your head, shoulders, and feet will be on the floor. Hold the position for 20 seconds then slowly lower
yourself back to the floor
TO INCREASE THE CHALLENGE
Intermediate: Place a ball or towel between your knees. Once you are in the bridge position, squeeze your knees
together while holding.
Advanced: Once you are in the bridge position, straighten out one leg and return it to the floor then lift the other
leg and return it to the floor. Then lower yourself slowly to
the floor.
Do 10 bridges (repetitions) 3 times.
Do 2 times a day

The Clam
PURPOSE:
The clam is an exercise for your hip abductors (gluteus medius). This
exercise is a good way to strengthen the muscles to prevent limping and
outer thigh pain.
WHAT TO DO:
Lay on your right side and bend your knees a little bit (30). Place you
left hand on the outside of your hip (gluteus medius). Keeping your feet
together, lift your top knee up in the air about 12 inches. After completing the exercise on the right, flip over so you are laying on your left
side and repeat.
TO INCREASE THE CHALLENGE
Tie a Theraband or place an ankle weight at the knees.
Do 12 clams (repetitions) 3 times on each leg.
Do 2 times a day

Legg-Calve-Perthes Disease

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Example Home Program

Wobbly Ball

PURPOSE:
The Wobbly Ball exercise is a fun and challenging way to increase good
balance and isometrically strengthen the leg and back muscles.
WHAT TO DO:
Stand with both feet on the wobble board or bosu ball.
Beginners: Hold on to your parent or a chair to help you balance
Intermediate: Try balancing without using a chair
Advanced: Play catch with your parent!
Hold for 60 seconds, repeat 3 times
Do 2 times a day

Wall Ball Slides


PURPOSE:
The wall ball is a great exercise to help strengthen your gluteus muscle
and quadriceps.
WHAT TO DO:
Place the Swiss ball at the small of your back against the wall. Place
your feet a little bit in front of you and about shoulder width apart.
Slide down the wall like you are going to sit in a chair. Do no bend you
knees further than halfway (90 ). Hold for 5 seconds and return to
standing.
TO INCREASE THE CHALLENGE
Once you are in the lowered position, hold the pose for 30 seconds before standing back up.
Do 12 Wall Ball Slides (repetitions) 3 times .
Do 2 times a day

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Legg-Calve-Perthes Disease
Example Home Program

Monster Walk

PURPOSE:
The monster walk is a fun way to strengthen all the muscles of the hip. It can easily be made more challenging by adding weights or therabands.
WHAT TO DO:
Stand with your feet wider than shoulder width apart and in a slightly squat position. When you take a step, keep your feet very wide. Walk approximately 20 feet.
TO INCREASE THE CHALLENGE
Beginner: Once you reach the end of your 20 feet, try going back to the starting
pointbackwards! Have your parent guide you in a straight line!
Intermediate: Tie a Theraband around the ankles, increasing the force needed to
open the legs. Go forward and backwards.
Advanced: Continue using the Theraband, but move it to the knees or add ankle weights to increase the challenge. Go forward and backwards.
Walk 20 feet repeat 3 times
Do 2 times a day

References
Colby, L., and Kinsner, C. Therapeutic Exercise: Foundations and Techniques. 6th Ed. F.A. Davis Company, Philadelphia, PA. pages 709-763.
Evelyne, B. and Gonzalez,P. Physiopedia: Legg-Calve-Perthes Disease, http://physio-pedia.com/Legg-CalcePerthes_Disease.com. (accessed: 3/25/13)
Lee J, Allen M, Hugentobler K, Kovacs C, Monfreda J, Nolte B, Woeste E; Cincinnati Children's Hospital Medical
Center:Evidence-based clinical care guideline for Conservative Management of Legg-Calve-Perthes Disease,
Occupational Therapy and Physical Therapy Evidence-Based Care Guidelines, Cincinnati Children's Hospital
Medical Center , Guideline 39, pages 1-17, August 1, 2011.
Kembitz, C., Jenkins, G., and Tortora, G. Anatomy and Physiology: From Science to Life. 2nd Ed. John Wiley &
Sonds, Inc. USA. 2010.
Terjesen T, Wiig O, Svenningsen S. The natural history of Perthes' disease. Acta Orthopaedica [serial online]. December 2010;81(6):708-714. Available from: CINAHL with Full Text, Ipswich, MA. Accessed March 27, 2013.

The National Osteonecrosis Foundation. Legg-Calve-Perthes Disease. www,nonf.org/perthesbrochure/perthesbrochure.htm