Perthes disease 

Perthes disease pleads that you as a parent should never ignore groin and upper thigh pain in your growing child.

These are the signs to look out for. Boys around five years old who start to walk in an odd manner and begin complaining of discomfort in the upper leg; but girls get it too. 

Because, undetected, it often leads to the first full hip replacement in the third decade; it's imperative that both parents and doctors take children who develop an odd gait seriously. 

It's a serious condition in the growing child characterised by an insidious

  1. limp
  2. pain in the groin
  3. sometimes pain around the hip, buttock, upper leg and knee
  4. pain when walking, and certainly during sport
  5. pain when moving the thigh, even perhaps while lying in bed
  6. mild pain in the early stages.

This is not growing pains, which in my opinion doesn't exist, in any case.

Please, do not neglect your child with a limp. This is a very serious condition which, if not caught and managed in its early stages, leads to multiple total hip replacements, the first often around aged thirty; and a ruined life, no exaggeration.

Early detection is absolutely essential for the treatment to be successful. And because it starts insidiously, in its early stages Perthe's disease is often neglected. By the time everyone has woken up, it's too late.

If your child is limping, don't just say: "It'll get better, Mummy will rub it."

"I have had Perthes' disease and now have a cyst in the hip joint. I am in severe pain and on loads of analgesics; at only twenty-seven what options do I have?"

Who gets it? In one sense the growing pains diagnosis is correct. This condition occurs in the growing child, usually around 5 years old, but it can occur earlier and much later. I have seen boys around 12 developing Perthes.

It is more common in boys, but oddly the prognosis is worse for girls.

Neglected, the first hip replacement may occur before your child turns 30 years old, and a wheelchair in the fifties is definitely on the cards. I have two patients in exactly this scenario. A ruined life, I can assure you. And needlessly so.

A prophet of doom? Not so, because carefully and correctly managed, this is a very treatable condition. But it must be detected early. The alternative is severe, premature hip arthritis.

Perthes Disease?

What is Perthes' disease? It's a serious childhood condition characterised by pain in the groin and a limp. Never let someone tell you that it is growing pains before a proper assessment has been made.

It was named after Georg Perthes. So it's Perthes' disease, not Perthe's disease.

All tissue requires a nerve and blood supply. In Perthes' Disease, a loss of the blood supply to the growing ball of the femur (the hip) occurs. No one is quite sure why this happens. It could be due to trauma, a fall for example; we're just not sure.

Without its blood supply the growing 'epiphysis' dies, with fragmentation and resorption of the bone. Compare the right and leg hips in this growing child. Notice how it's also affected the roof of the hip joint, the "acetabulum". Compare right and left sockets.

The limping child

The limping child should always be professionally assessed unless he has stubbed his toe, or something equally obvious.

The first symptoms are groin and thigh pain and the first "sign" is a distinct limp.

Often the pain is written off as growing pains; medically this is thought to be neuralgic but in my humble opinion, so I call it growing pains chiropractic they are caused by hypermobile joints.

Transient synovitis

The first signs are pain in the hip, anterior thigh, groin or knee, reluctance to place weight on that leg, and a marked limp. Usually there was a history of minor trauma, the sort that every sporting child would experience regularly. Occasionally there is a history of cold, gastric upset or bladder infection, and a mild fever, but not necessarily so.

Ranges of motion may be slightly or severely affected.

X-rays are negative, or the changes are so subtle that they are usually only recognised on review.

  • Subchondral lucency in the lateral part of the growing femoral epiphysis.
  • Increased joint space superiorally and medially.
  • A smaller bony epiphysis when compared to the normal leg.

There is a 3% chance that your child will experience transient synovitis in his/ her first fourteen years, boys/ girls: 2 to 1. There is a 20 times risk of a second episode after the first has healed.

Treatment: Bed rest alone, until pain free and a full range of motion of the hip. In some cases, traction. Three days to two weeks.

Initially, the hip was kept in extension, however the Malmo study suggests this aggravates the course of the condition and is more likely to cause a loss of blood supply, avascular necrosis and true Perthes' disease. The best position appears to be that favoured by the child: usually about 45 degrees of flexion and slight external rotation.

In a study done in Malmo, 3.4 percent of these cases progressed to full blown Perthes' disease, many of them those kept in extension with traction.

In short, only a small proportion of children with acute hip pain will progress to a Perthes' disease, but all cases should be immobilised with bed rest in the most comfortable position, and non weight bearing until pain and range of motion have returned to normal.

The diagnosis is made from an xray, but in the early stages of the disease, the radiographs may be normal. If the age and symptoms fit, I assume that it's Perthes' Disease until confidently proven otherwise. It's such a serious problem, that it's better to assume the worst, and be wrong, than vice versa.

The most important part of the treatment of Perthes' disease is getting the weight off the leg. Crutches should be rigidly enforced. You don't mess with this condition.

Then gentle exercises of the hip are important. Movement of the joint brings fresh nutrients and oxygen into the capsular fluid, and removes waste products. This is always important for every joint, but even more so when the blood supply to the hip has been temporarily interrupted.

Your chiropractor will check the sacroiliac joint, which is probably best adjusted using an activator, and use various soft tissue techniques on the muscles of the hip, and the capsule.

Personally I recommend an orthopaedic consultation as well. Two heads are always better than one. Usually bed rest, a splint and even traction are recommended.

Good nutrition is vital at this stage. No junk food, and plenty of salads and fruit. Omega 3 from fish oil or flax seed and chicken bones bouillon.

Perthes disease? No, of course, Perthes' Disease, but search engines are illiterate and don't like the apostrophe.

For more about vegetarian omega 3 oil see our Flaxseed oil article at obesity in the chiropractic clinic newsletter, number 16. Flaxseed and obesity in the chiropractic clinic.

After ranges of motion have returned to normal, and the child is no longer reluctant to weight-bear, a full rehab programme is recommended, including these hip exercises.

Hip arthritis

Hip arthritis, and severe degenerative joint disease, often before thirty is the result of a missed diagnosis.

Pain and disability is an increasing problem in our society; it's complex but, detected early, there is much to be done to prevent the serious and very costly affects of hip arthritis.

Perthes' disease is but one cause of this nasty condition; a short leg is another as are hip dysplasia and impingement syndromes.

Groin and thigh pain

Groin and thigh pain are a limp are the hallmarks of Perthe's disease.

There are in short many causes of groin, hip and thigh pain; it's in the limping child where immediate action is vital.

In the adult it's less important that treatment be promptly initiated as it's often has a slow and chronic nature. Acute pain like this hip and thigh pain case should not be allowed to become chronic; early care is often miraculously successful.

Deal with a small problem before it becomes a major debilitating disease.


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Perthes hip 
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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I have left alone. After seven treatments his pain and stiffness is 50 percent better, and he is happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti-inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He is doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost pain-free. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he is well pleased; sixty-five percent better after three treatments.

5. Mr T is a wise man; he has taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily stroll has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift; he has a short leg.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. X-rays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65-year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88-year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done. 

10. Mr X is a 71-year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a few months ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It is a non-complicated upper cervical facet syndrome, and she is doing well.

12. Mr D is a 38-year old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he could not sleep on that shoulder.

13. Mr D, a 71-year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors should not be treating the elderly most medical sites state but that is so much bunkum.

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