12-year-old male with slipped capital femoral epiphysis_ curran

RUNNING HEAD: 12-year-old Male with Slipped Capital Femoral Epiphysis: a Case Report

12-year-old Male with Slipped Capital Femoral Epiphysis: a Case Report

Cara Curran, Maura Harrington, Nicole Hentnick, Allyson Zeberlein

Grand Rounds II PT 744

Sacred Heart University

Doctorate of Physical Therapy Program

12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report

1

Abstract

Case description and purpose. The purpose of this case report is to outline examination

and treatment strategies for a patient status post in-situ pinning secondary to stable slipped

capital femoral epiphysis (SCFE). This case focuses on a 12-year-old male presenting to

outpatient physical therapy ten weeks after surgery on the right hip. Patient presented with

primary hypothyroidism controlled by hormone replacement therapy for one year with no noted

complications and obesity. Patient had a history of previous in-situ pinning on the left hip exactly

one-year prior with no noted complications. He presented to the clinic with pain, mobility

deficits, strength deficits, and movement coordination impairments in the right hip and

associated lower extremity. He had difficulty standing, walking, and running safely without pain

secondary to his impairments. He reported he is unable to participate in training for football and

high intensity activity during recess at school. This case report outlines anatomy and physiology

of the hip and bone growth, pathology of SCFE and hypothyroidism, as well as the physical

therapy examination and treatment associated with this patient’s diagnosis.

Outcomes. A multimodal approach involving patient education, manual therapy,

therapeutic exercises, therapeutic activities, and neuromuscular re-education was implemented in

order to return the patient to functional and sport-specific activities. Outcomes were measured

using the Modified Harris Hip Score (mHHS) and the Star Excursion Balance Test (SEBT). A

72% increase was seen on the mHHS and scores achieved on the SEBT were less than a 94%

difference placing the patient at a decreased risk for injury by the end of physical therapy

treatment.

Discussion. The plan for examination and treatment of this unique patient will provide

insight into the approach necessary to return similar patients to their highest attainable level of


2

functioning. Additional research needs to be done in the area of pediatric orthopedics in order to

improve physical therapy care to adolescents with orthopedic injuries.

Background and Pathology

Anatomy and Physiology of the Hip

The coxofemoral joint or the hip complex, is made up of the acetabulum of the pelvis

joining with the head of the femur. The acetabulum is a deep, hemisphere shape that faces

laterally and slightly anterioinferiorly. The acetabulum faces about 30 degrees from vertical and

has a lunate surface covered with hyaline cartilage located only around the periphery. The

femoral head is a large hemispheric shape that is covered with hyaline cartilage except for a

small portion of it called the fovea capitis

(Figure 1). The angle of inclination of the

head and neck is 125 degrees, which is the

frontal plane orientation of the femur. In

children, the angle of inclination is usually

150 degrees, which increases the risk of

subluxation. The femur also has an angle of

torsion, which is normally 10-15 degrees of lateral rotation.

This angle is the head and neck position as it relates to the

femoral condyles in the transverse plane. The inner portion of the acetabulum is non-articular, so

when the head of the femur engages with it, it forms a vacuum, which increases joint stability

(Levangie, P. & Norkin, C., 2011).

The hip is a ball and socket joint that allows for three degrees of freedom. The primary

motions at the hip joint occur in the sagittal plane, flexion and extension. During hip flexion the

Figure 1. Structures of the hip. http://healthfavo.com/hip-joint-

anatomy.html


3

head of the femur spins posteriorly and glides inferiorly within the acetabulum and allows for

125 degrees of motion. During hip extension the femoral head spins and glides anteriorly and

allows for about 15 degrees of osteokinematic motion. During hip abduction the femoral head

glides inferiorly and adduction glides superiorly; normal values for hip abduction is around 45

degrees and adduction is 25 degrees. Medial rotation causes the head of the femur to spin

medially and lateral rotation causes the head of the femur to spin laterally which allows for 45

degrees of motion in each direction. The joint capsule of the joint provides stability and checks

to these motions (Levangie, P. & Norkin, C., 2011).

The hip complex has a strong and large joint capsule. It is reinforced by two ligaments

anteriorly and one posteriorly. Anteriorly, the iliofemoral “Y” ligament and pubofemoral

ligament create a “z” shape (Figure 2). These bands check extension, lateral rotation, adduction,

and abduction. Posteriorly, the ischiofemoral ligament is a

large ligament that has fibers that wrap around the femoral

neck and check extension. These ligaments are strong enough

to even check upward migration of a congenitally dislocated

hip. The ligamentum teres is a ligament at the head of the

femur that arises from the acetabular notch and inferior

transverse acetabular ligament. It passes to the fovea capitis

of the femur and does not help contribute to joint stability.

However, this ligament serves as the pathway for the branch

of the obturator artery to supply blood to the femoral head.

The disruption of this ligament can cut off supply of blood from this artery and lead to avascular

necrosis (AVN) of the femoral head. This is important in cases of SCFE because AVN can occur

Figure 2. Anterior ligaments of the hip joint.

Drake, Richard. Gray's Anatomy for Students, 2nd

Edition. Churchill Livingstone, 2009.


4

if the slip is not stabilized in an appropriate amount of time. Other blood supply to the hip occurs

through the circumflex arteries (Levangie, P. & Norkin, C., 2011).

The open packed position and maximum congruency of the hip complex is flexion,

abduction and slight lateral rotation. The closed packed position of the joint is full hip extension.

The hip is the only joint where the closed packed position and position of maximum congruency

are different. Hip joint congruency and stability are also influenced by different hip deformities

such as coxa valga and coxa vara. Coxa valga decreases joint stability because it turns the head

of the femur up toward the acetabulum and also decreases the moment arm of the gluteus medius

muscle causing a decrease in total muscle torque. The gluteus medius muscle is an important

muscle during gait and single limb stance because it contributes to hip joint stability. Coxa vara

decreases joint stability because it causes the femoral head to face inferiorly in the acetabulum

and there is no bony block for inferior translation. However, coxa vara increases the moment arm

for the gluteus medius thus allowing it to produce less force with the same total torque produced.

In children, coxa valga is common and with increased weight bearing the hip moves into optimal

position (Levangie, P. & Norkin, C., 2011).

Hip musculature also contributes to the stability of the hip joint as well as mobility in all

directions: flexion, extension, adduction, abduction, lateral rotation, and medial rotation. The

lateral rotators of the hip are all very strong stability muscles due to their ability to create

compression at the joint with their line of pull perpendicular to the shaft of the femur. The

abductors, including the gluteus medius, also provide joint compression at the hip joint for

stability during unilateral stance because of their rotary and translatory components of pull. The

hip extensors, including the gluteus maximus, are stability muscles because they counteract the

effect of gravity when flexion forces are acting on the hip joint (Levangie, P. & Norkin, C.,


5

2011). See Table 1 for a complete list of hip musculature that includes origin, insertion, action,

and innervation.

Table 1. Hip musculature (Moore, Dalley, & Agur, 2013). Muscle Origin Insertion Action Innervation Illiopsoas Upper 2/3 of the

iliac fossa, anterior sacroiliac and iliolumbar ligaments and upper lateral surface of the sacrum

Lesser trochanter of the femur

Flexes thigh at the hip joint

Anterior rami of L1-L4

Gluteus Maximus Posterior gluteal line of the illium, the dorsal surfaces of the sacrum and coccyx, and sacrotuberous ligament

Iliotibial tract and gluteal tuberosity of the femur

Extension of the hip and lateral rotator of the thigh at the hip joint. Its upper fibers may assist in abduction of the thigh and lower fibers adduct

Inferior gluteal nerve

Gluteus Medius Gluteal surface of the illium under the gluteus maximus

Greater trochanter of the femur

Abduction of the thigh at the hip joint. Anterior fibers medially rotate the thigh and posterior fibers laterally rotate the thigh

Superior gluteal nerve

Rectus Femoris Anterior inferior iliac spine and illium above the acetabulum

Quadriceps tendon to base of patella and onto the tibial tuberosity via the patella ligament

Flexes the thigh at the hip

Femoral nerve L2-L4


6

Vastus Medialis Intertrochanteric line and the medial lip of the linea aspera of the femur

Quadriceps tendon to base of patella and onto tibial tuberosity via the patellar ligament

Extends leg at knee

Femoral nerve L2-L4

Biceps Femoris Inferiormedial part of the upper area of the ischial tuberosity, lateral lip of the linea aspera

Head of the fibula

Flexes the leg at the knee joint; extends and laterally rotates the thigh at the hip joint; medially rotates the leg at the knee joint

Tibial nerve and common fibular nerve

Semimembranosis Ischial tuberosity

Medial condyle of the tibia

Flexes leg at the knee joint

Sciatic nerve L5-S2

Semitendinosis Tuberosity of the ischium

Pes anserinus on the tibia

Flexes leg at the knee joint

Sciatic nerve L5-S2

Tensor Fascia Latae

Anterior iliac crest

Lateral condyle of the tibia via the iliotibial tract

Abducts and flexes thigh at the hip

Superior gluteal nerve L4-S1

Adductor Magnus Inferior ramus of pubis and ischial ramus for oblique head and ischial tuberosity for vertical head

Gluteal tuberosity, linea aspera and proximal supracondylar line of femur. Adductor tubercle of femur

Adducts and flexes thigh at hip. Extends thigh at hip

Obturator nerve L2-L4, Sciatic nerve L2-L4

Gemellus Superior and Inferior

Superior: ischial spine Inferior: ischial tuberosity

Medial surface of greater trochanter 9trochanteric fossa) of femur

Laterally rotate and extend the thigh and abduct flexed thigh; steady femoral head in acetabulum

Superior: nerve to obturator internus (L5-S1) Inferior: nerve to quadratus femoris (L5-S1)

Transverse Abdominus

Thoracolumbar fascia, medial lip of the iliac

Pubic crest and pectineal line

Compress abdominal contents

Thoracoabdominal nerve (T6-T11), Subcostal nerve


7

crest, lateral 1/3 of inguinal ligament, and costal cartilages of the lower six ribs

(T12), iliohypogastric nerve (L1), and ilioinguinal nerve (L1)

Multifidis Mammillary processes of lumbar vertebrae and transverse processes of the thoracic vertebrae, articular processes of the lower four cervical vertebrae

Base of spinous processes of all vertebrae from C2-L5

Extend vertebral column, lateral flexion to the same side, and rotate the vertebral column to the contralateral side

Dorsal rami of spinal nerves

Anatomy and Physiology of Bone

Embryonic development. The embryonic skeleton is initially composed of mesenchyme

in the general shape of bones. Cartilage formation occurs in the sixth week of embryonic

development. Bone formation follows one of two patterns. The methods of formation both

involve the replacement of connective tissue with bone. The two methods are intramembranous

development and endochondral ossification. Intramembranous ossification occurs as bone forms

within the mesenchyme, arranged in sheet-like layers. Endochondral ossification is the process

by which bone forms within hyaline cartilage that develops from the mesenchyme (Tortora, G. &

Derrickson, B., 2012).

Endochondral ossification is the way by which most bones of the body are formed. This

process is best observed in long bones, like the femur. The process begins as mesenchymal cells

crowd together in the general shape of the future bone. These cells develop into chondroblasts,

which secrete cartilage ECM. This cartilage ECM produces a cartilage model consisting of


8

hyaline cartilage. Then, a covering develops around the cartilage model. This covering is called

the perichondrium. As chondroblasts become buried in the cartilage ECM, they become

chondrocytes. The cartilage model grows in length by continuous cell division of chondrocytes.

Secretion of the ECM continues as the bone continues to grow in length. This growth in length is

referred to as interstitial or endogenous growth. Appositional growth, however is the growth in

width that occurs because of the deposition of ECM on the cartilage surface of the model by new

chondroblasts developing from the perichondrium. Surrounding cartilage ECM calcifies around

the periphery of the bond as the bone continues to hypertrophy (Tortora, G. & Derrickson, B.,

2012).

Bone growth. Throughout a person’s

lifespan, bones continue to grow and remodel.

Growth in length involves two major events

including interstitial growth of cartilage on the

epiphyseal side of the epiphyseal plate. The

epiphyseal plate is referred to as the growth

plate. It is a layer of hyaline cartilage in the

metaphyisis of a growing bone that consists of 4

zones (Figure 3). These four zones are from

distal to proximal include the zone of resting

cartilage, the zone of proliferating cartilage, the

zone of hypertrophic cartilage, and the zone of

calcified cartilage. The zone of resting cartilage is

nearest the epiphysis and consists of small, scattered chondrocytes. The cells here do not

Figure 3. Epiphyseal bone growth. (http://classes.midlandstech.edu/carterp/Courses/bio210/chap06/lecture1.html)


9

function in bone growth. The resting zone functions to anchor the epiphyseal plate to the

epiphyseal end of the bone. The zone of proliferating cartilage contains slightly larger

chondrocytes arranged in stacks. These chondrocytes undergo interstitial growth as they divide

and secrete more ECM. The division of these chondrocytes functions to replace those cells that

die on the diaphyseal side of the epiphyseal plate. The zone of hypertrophic cartilage contains

maturing chondrocytes arranged in columns. The zone of calcified cartilage is the final zone of

the epiphyseal plate. It is only a few cells thick and consists mostly of dead chondrocytes

because the ECM around them has calcified. Osteoclasts then break down dead cartilage as

osteoblasts replace calcified cartilage by laying down new ECM. This process is called

endochondral ossification. Endochondral ossification continues and cells mature, turning the

zone of calcified cartilage into the newest section of the diaphysis. The epiphyseal plate is able to

stay relatively consistent in size because as the zone of calcified cartilage becomes the newest

section of the diaphysis, more cells proliferate on the epiphyseal end of the bone (Tortora, G. &

Derrickson, B., 2012).

Activity at the epiphyseal plate is the only way that the diaphysis can increase in length.

If a bone fracture damages the epiphyseal plate, the fractured bone may be shorter than the

unaffected bone once adult structure is reached. This is because damage to the avascular

cartilage accelerates closure of the epiphyseal plate due to cessation of cell proliferation, thus

inhibiting growth of the length of the bone (Tortora, G. & Derrickson, B., 2012).

Epiphyseal plates typically close at the end of adolescence as the epiphyseal cartilage

cells stop proliferating. At this time, bone replaces all cartilage. The epiphyseal plate fades,

leaving the epiphyseal line. Closure of the epiphyseal plate occurs 1-2 years earlier in females

than in males (Tortora, G. & Derrickson, B., 2012).


10

Slipped Capital Femoral Epiphysis

SCFE is a pediatric and adolescent disorder of the hip that is characterized by the

displacement of the capital femoral epiphysis from the femoral neck through the physeal plate

(Kienstra et al., 2016). It affects one in every 5,000 to 10,000 children, with substantial

variability among ethnic groups. The disorder affects males more commonly than females. It is

most prevalent in Black and Hispanic populations. In the United States, SCFE rates are higher in

the Northeast followed by the West and Midwest regions. SCFE commonly presents in children

ages 10-17 years old, but there is a downward trend occurring in age most likely due to children

reaching puberty at younger ages (“Slipped Capital Femoral Epiphysis: Background,

Epidemiology, Functional Anatomy,” n.d.).

The term SCFE is misleading, as it is actually the portion of the proximal femur distal to

the physis that is displaced anterolaterally and superiorly. This displacement gives the

appearance of posterior and inferior displacement of the epiphysis, which in fact remains in a

normal position in the acetabulum (Kienstra, K. J., & Marcias, C. G., 2016). In patients with

SCFE it is not uncommon to find that the proximal epiphyseal growth plate is unusually widened

at the zone of hypertrophic cartilage. This zone normally makes up about 15-30% of the physis,

but can take up as much as 80% of the physis in patients with SCFE. Widening of the zone of

hypertrophy occurs due to a quick and abnormal cartilage build-up of less organized, but dense,

cartilage. Increased hormone levels, during puberty or with an endocrine disorder, have an effect

on cartilage development at the epiphyseal growth plate. This leads to weakening of the growth

plate, which can lead to slippage (“Slipped Capital Femoral Epiphysis: Background,

Epidemiology, Functional Anatomy,” n.d). As children age the femoral neck angle becomes

more acute exposing the epiphyseal growth plate to more shear forces. Shear forces can become


11

greater when adolescents are obese or have structural deformities like femoral neck retroversion.

The pathogenesis of SCFE is not complete understood; however, the discussed risk factors have

been correlated with the condition (Novais & Millis, 2012).

Obesity is a common risk factor in patients with SCFE, as well as children who have

comorbidities involving the endocrine system such as: hypothyroidism, low growth hormone

levels, pituitary tumors, and craniopharyngioma. Metabolic endocrine disorders have been

associated in patients who develop SCFE before the age of ten (“Slipped Capital Femoral

Epiphysis: Background, Epidemiology, Functional Anatomy,” n.d). Patients commonly

presenting with hypothyroidism will have decreased levels of thyroid hormone leading to an

overall slowing of the basal metabolic rate. Slowing of the basal metabolic rate may occur in

conjunction with other secondary effects if hypothyroidism goes undetected or is not treated

properly, such as SCFE (Peltek Kendi̇rci̇, H. N., et al, 2015).

Diagnosis of SCFE occurs through physical examination and a radiograph (“Slipped

Capital Femoral Epiphysis: Background, Epidemiology, Functional Anatomy,” n.d). On an

anteroposterior radiograph a Klein line is drawn from the superior portion of the femoral neck

and should intersect with the femoral head (Figure 4). In cases of SCFE, the femoral head is

situated below this line. On a frog-

leg lateral view radiograph, a

straight line is drawn through the

center of the femoral neck

proximally, the line should be at the

center of the epiphysis (Figure 5). A

line anterior to the epiphysis is

Figure 4. Klein line. http://www.aafp.org/afp/2010/0801/p258.html


12

suggestive of SCFE. The severity of slippage is

important data to collect from imaging. There are

three grades based on the percent of femoral

head displacement from the neck. Grade I is less

than 33%, Grade II is between 33-50%, and

grade III is greater than 50% slippage. Greater

slippage is associated with less stability as well

as increased risk of complications in the

future (Kienstra, K. J., & Marcias, C. G.,

2016).

SCFE can be classified as chronic or acute depending on duration of symptoms. Acute

SCFE is defined as symptoms presenting for less than three weeks. Symptom onset is sudden.

Severe pain is the chief complaint for patients with acute SCFE. Limping or inability to bear

weight on the affected leg without a history of trauma is a common presenting symptom. Range

of motion for patients with acute SCFE will be limited and guarded. Chronic SCFE often

presents as a slow onset of symptoms that have occurred for greater than three weeks. Chronic

SCFE frequently refers pain into the thigh or the knee of the affected leg via the obturator nerve.

Range of motion limitations for chronic SCFE will present with loss of abduction and internal

rotation of the affected hip (Kienstra, K. J., & Marcias, C. G., 2016). SCFE is more commonly

found in the left hip than the right. Bilateral hip involvement is rare and ordinarily both hips do

not present at the same time. The second hip will usually become symptomatic a year later.

Bilateral involvement is also more common in patients who also have an endocrine disorder

Figure 5. Frog leg lateral view. https://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=146&seg_id=2940


13

(Novais & Millis, 2012). Determining the classification of SCFE is important to formulate the

surgical plan of care.

Treatment

The treatment of SCFE is emergent and has two main principles—stabilization of the slip

to prevent progression and promote closure of the upper femoral physis (Abu Amara, 2013).

There is no role for observation or attempts at closed reduction; treatment is surgical. Delays in

diagnosis or treatment could allow the slip to progress potentially leading to early degenerative

arthritis and AVN (Larson, 2012). Evidence suggests that if surgical intervention occurs within

24 hours of SCFE onset, significantly fewer complication occur (7% rate of AVN); however,

when surgical intervention occurs between 24 to 48 hours, AVN rates dramatically increase to

87.5% (Loder, R. & Deitz, F. et al, 2012). When selecting an appropriate surgery, the

classification of SCFE is considered. As discussed previously, SCFE can be classified by

chronicity or stability. Prognosis regarding subsequent AVN is dependent upon a new and more

clinically useful classification of SCFE based on physeal stability. Unstable SCFE’s have a much

higher rate of AVN (Loder, R. & Deitz, F. et al, 2012). Acute SCFE is typically classified as

unstable whereas chronic SCFE

is typically classified as unstable.

Refer to Figure 6 for

classifications of SCFE.

Each surgical approach

has advantages and

disadvantages depending on how

the slip is classified. Possible Figure 6. Classifications of SCFE.

(Sharma, V. & Oddy, M., 2014)


14

treatment options include: hip-spica cast immobilization, in-situ stabilization with a single screw,

open epiphysiodesis with autograft or allograft bone, open reduction with corrective osteotomy

through physis and internal fixation, compensatory basilar neck osteotomy, intertrochanteric

osteotomy. See Table 2 with list of procedures and rate associated complications.

Table 2. Surgical procedures and rates of associated complications.

Hip-spica cast immobilization is not a surgical procedure itself, but can be used if

surgical intervention is not an option. Immobilization typically lasts twelve weeks, avoids the

complications of anesthesia and surgery, and can provide prophylactic treatment for the opposite

hip when introduced bilaterally. However, the spica cast may not stabilize the SCFE effectively

causing a progression of the slip, despite immobilization in the cast. The frequency of

chondrolysis appears to be higher than with surgical treatment and the casts can become

cumbersome and cause cast sores, especially if the patient is obese. Overall, hip-spica casting is

not recommended to treat patients with SCFE (Sharma, V. & Oddy, M., 2014).

As for the surgical interventions, there are several options, but in-situ stabilization with a

single screw is the method of choice for patients with stable slips due to low risk of

complications, see Figure 7 (Loder, R. & Deitz, F., 2012). The case being discussed had a stable


15

slip and underwent in-situ stabilization

with a single screw, and will be the

procedure focused on in this paper. As

for surgical interventions more

appropriate for unstable and more severe

slips, there are several; however, the best

treatment is not yet known. Open

epiphysiodesis with autograft or allograft is

used most commonly and allows a rapid

reliable closure of the physis. The hip is exposed via the iliofemoral approach and a rectangular

window of bone is removed from the anterior aspect of the femoral neck. A cylindrical tunnel is

created across the physis, and multiple corticocancellous strips of iliac crest bone graft are driven

into the tunnel as bone pegs across the proximal femoral physis in attempt to promote early

closure of the physis. A cortical strut allograft could also be used in this procedure. The risk of

damaging the vascularity of the femoral head is reduced in this procedure because the graft is

inserted at the proper angle and the risk of the graft being inserted too deeply and causing joint

penetration is also reduced. This approach also avoids the complications of internal fixation,

including unrecognized pin penetration and hardware failure. Curettage (during creation of the

tunnel) may make the slip even more unstable. Fixation afforded by bone graft is not as solid as

that provided by pins; there is still a risk of additional slippage. Surgery and the period that the

patient is under anesthesia is longer, blood loss is increased, the incision is larger, and a spica

cast is needed after this procedure (Thompson et al., 2013).

Figure 7. Complications associated with surgical procedures.

(Loder, R. & Deitz, F., 2012).


16

Another surgical option for unstable and severe slips is the osteotomy. There are several

approaches for the osteotomy, but each is recommended most commonly as a secondary

procedure after clinically significant deformity develops. The procedures are all aimed at altering

the arc of motion and slowing the onset of osteoarthritis. There are three locations where the

osteotomy may take place: through the physis, femoral neck, or subtrochanteric regions (Sharma,

V. & Oddy, M., 2014). As the osteotomies move from proximal to distal, the risk of AVN

decreases, but the correction moves further from the point of deformity. The osteotomy through

the physis region is performed at the site of the deformity, but it has a high risk of AVN. The

osteotomy though the femoral neck has a decreased prevalence of AVN but shortens the femoral

neck, which may result in impingement of the greater trochanter against the lateral aspect of the

acetabulum during hip abduction. The osteotomy through the subtrochanteric region is used

primarily if restricted range of motion persists even after remodeling of the slip. It improves hip

motion and is rarely associated with AVN but results in a leg-length discrepancy (Sharma, V. &

Oddy, M., 2014).

In-situ stabilization with a single screw is the preferred method for treating patients with

stable slips. During the procedure, the patient lies supine on a fracture table or radiolucent top

table and the affected limb is place in slight flexion and internal rotation. Intraoperative imaging

is essential and should be used to ensure the hip is correctly positioned. A single screw or

multiple screws are inserted percutaneously under fluoroscopic guidance. A single screw is

preferred in a stable slip and one to two screws is controversial for an unstable slip. More than

two screws is not recommended because it increases the risk of iatrogenic damage to the

vascularity of the femoral head. The screw is entered at or above the level of the lesser trochanter

to avoid subtrochanteric fracture and directed in an anterolateral to posteromedial direction. Two


17

and a half threads of the screw should engage the epiphysis for a good hold and the screw

positon should be confirmed. This procedure is short and simple with minimal blood loss. It has

a high success rate and further slippage. Complication rates are low. The procedure may be

technically difficult in patients with severe slips and is associated with a risk of pin penetration

into the joint, especially if multiple pins are used.

Ambulation after surgery begins with bilateral axillary crutches for about four to six

weeks post-surgery. Weight bearing instructions vary by surgeon preference. Some surgeons air

on the side of caution, instructing partial weight bearing until the 2 week check-up. The patient

may progress to full weight bearing status, but is still encouraged to utilize crutches, until 6

weeks post-surgery. This precaution is taken as a slip may still occur after in situ pinning during

the initial healing period (Loder, R. & Deitz, F., 2012).

The most common complications associated with surgical treatment of SCFE are AVN,

chondrolysis, and pin penetration into the joint (Arora et al., 2013). AVN is the most devastating

complication of SCFE. Responsible factors include: acute or unstable SCFE, over-reduction of

an acute SCFE, attempted reduction of the chronic component of an acute-on-chronic SCFE,

placement of pins in the superolateral quadrant of the femoral head, and femoral neck osteotomy

especially if performed before the physeal closure. Reported rates of incidence vary from 0% in

stable slips to as high as 58% in unstable slips (Arora et al., 2013). Clinical features of AVN may

include pain in the groin or knee, loss of motion of the hip (particularly internal rotation), and

irritability with passive hip motion into internal and external rotation. Post-operative treatment

includes walking with crutches non-weight bearing, range of motion exercises, traction, and anti-

inflammatory medication (Arora et al., 2013). Responsible factors associated with chondrolysis

are unknown; there is a possible role of an auto-immune phenomenon or factors interfering with


18

cartilage nutrition. Risk factors include immobilization in a cast, unrecognized permanent pin

penetration, and severe SCFE. Incidence varies from 1.5-50% and clinical features include pain

in the groin or knee and loss of hip motion (particularly internal rotation). Treatment includes

that similar to AVN, as well as early and aggressive physical therapy to help regain range of

motion, and other surgical interventions involving distraction or external fixation (Arora et al.,

2013). The prevalence of device penetration into the joint has decreased with the use of the

fluoroscopic guidance and cannulated single-screw fixation. If SCFE is mild or moderate and is

maintained between the femoral head and the acetabulum, the prognosis is good; chondolysis

and AVN will likely not develop. Hips with a severe SCFE and those with AVN or chondolysis

undergo more rapid deterioration with degenerative changes and ultimately require

reconstructive procedures. (Larson et al., 2012). In a follow-up study with a mean 16 years, they

found that one-third of patients treated for SCFE has residual pain, and 10% of patients at 10

years underwent reconstructive surgery. Five percent of patients were likely to develop arthritis

severe enough to warrant total hip arthroscopy twenty years after surgery (Larson et al., 2012).

Hypothyroidism

Hypothyroidism is a disease that involves the deficiency of the thyroid hormone.

Hypothyroidism is categorized into type I (hormone deficient) with a subdivision of congenital

hypothyroidism and type II (hormone resistant). Type I is characterized by reduced function of

thyroid tissue. Of the affected population, 95% are classified as type I (Goodman & Fuller,

2009). Type II occurs in a smaller percentage of cases. It is described as an inadequate

stimulation of the gland due to pituitary or hypothalamic disease. Overall, the disease is four

times more prevalent in women than men. The highest incidence occurs between the ages of

thirty to sixty (Lui, 2015).


19

Chad Williams presents to our clinic with a one-year history of Type I primary

hypothyroidism. This disease involves the loss of thyroid tissue which leads to the decrease in

secretion of thyroid hormone. Thyroid hormone synthesis and secretion is regulated by the

hypothalamus. Thyrotropin-releasing hormone (TRH) is

released from the hypothalamus and stimulates secretion of

TSH from the anterior pituitary gland. Normally, when thyroid

hormones rise, the pituitary gland slows TSH production. TSH

secretion is the body’s effort to stimulate thyroid hormone in

adequate amounts. Components of TSH include T3 and T4.

With hypothyroidism, the thyroid gland does not fully respond to

TSH. The components of TSH continue to elevate and when they

reach the organs, bodily functions begin to slow (Goodman, 2009).

The result is an elevated level of TSH in the blood with low thyroid function. Decreased levels of

thyroid hormone lead to an overall slowing of the basal metabolic rate Figure 8 (Peltek Kendi̇rci̇,

H. N., et al, 2015).

Primary hypothyroidism has systemic effects as a result of a slowed metabolism.

Common sequelae include cardiopulmonary bradycardia due to decreased metabolic rate. Lipid

metabolism will increase serum cholesterol and triglyceride levels thus leading to an increased

risk of coronary artery disease. Thyroid hormones also play a role in the production of red blood

cells with the potential for the development of anemia and possibly related pulmonary disorders

with lack of available oxygen molecules. Another system affected is the gastrointestinal tract as

it’s motility is decreased as well as the absence of hydrochloric acid, or achlorhydria. More

Figure 8. Pathogenesis of hypothyroidism.

http://emedicine.medscape.com/article/122393

-overview


20

prominently presenting in a physical therapy examination can include slowed neurologic

functioning and a decrease in body heat production (Peltek Kendi̇rci̇, H. N., et al, 2015).

If Chad did not present with a known history of primary hypothyroidism, it is important

to differentiate Type I from Type II due to different pathogenesis of the disease. Secondary

hypothyroidism is a result of failure of the pituitary gland to synthesize and release adequate

amounts of TSH. Common causes include pituitary dysfunction or effects from surgical removal

or damage from radiation to the thyroid. Typically, early detection for Type II is difficult since

many of the signs and symptoms are vague and ordinary. Some common symptoms include

fatigue, mild sensitivity to cold, mild weight gain resulting from fluid retention of 10-15 pounds,

forgetfulness, depression, and dry skin or hair. As the disorder progresses, increased edema

presents with an alteration in the composition of the dermis and other tissues causing connective

tissues to be separated. This differentiation is due to increased amounts of mucoplysaccharides

and proteins in the body which bind with water, thus causing non pitting edema. Decreased

mental stability is a common presentation as well, with cardiovascular involvement associated

with decreased cardiac output. Clinical signs include a slowed pulse rate with neuromuscular

manifestations. These include flexor tenosynovitis with stiffness due to my edematous tissue in

the carpal tunnel. Other common neuromuscular symptoms arise with proximal muscle weakness

and arthritis of the small joints of the hands (Peltek Kendi̇rci̇, H. N., et al, 2015).

Hypothyroidism can be diagnosed using the most sensitive indicator of an increased TSH

level for primary hypothyroidism greater than 10 mlU/L (Sawka, A. M., & Jonklaas, J., 2015).

Chad was tested when he was diagnosed with his left SCFE one year prior. In the blood marker

taken, a positive test will indicate T3 levels that are stagnant with gradually decreasing T4 levels

(Liu et al., 2015). Serum cholesterol, alkaline phosphatase, and triglyceride levels also can be


21

significantly elevated. The presence of antithyroid antibodies will show evidence for the

existence of autoimmune thyroiditis resulting in progressive destruction of thyroid tissue by

circulating antithyroid antibodies (Peltek Kendi̇rci̇, H. N., et al, 2015). Patients presenting with

atherosclerosis and subsequent hypothyroidism can have exercise induced angina (Peltek

Kendi̇rci̇, H. N., et al, 2015). Patients can find difficulty with the pharmacologic thyroid hormone

replacement since this medication increases the heart’s need for oxygen by increasing the body’s

metabolism.

Once the patient was diagnosed with SCFE by his orthopedic surgeon, he was referred to

an endocrinologist for diagnosis of hypothyroidism after an ordered blood test came back

positive for elevated TSH levels of 16 mlU/L. With this criteria, Chad was immediately placed

on medication for elevated TSH due to the fact that elevated TSH can result in pituitary

hyperplasia and lowered growth hormone (GH) levels. Since the average age of puberty in males

is 13.5 years old, Chad would be at the cusp of epiphyseal growth thus placing him at a higher

risk for long term complications from his SCFE (Liu et al., 2015).

Medical management. The goals of treatment for hypothyroidism include first, correct

thyroid hormone deficiency. This can be done through thyroid replacement therapy. Chad was

placed immediately on Levoxyl once diagnosed and has been able to regulate his thyroid

hormones since. Levothyroixine is the generic name brand that is most commonly prescribed as

a first course of treatment (Sawka, A. M., & Jonklaas, J., 2015). Levoxyl is a common

pharmacological intervention that suppresses the pituitary secretion of TSH to prevent its

cascade of hormone imbalances. By blocking the excess secretion of TSH, T3 and T4 levels will

not decrease in its inverse relationship. Ultimately, the replacement therapy is effective in raising

the decreased metabolic rate and has been shown effective in the prevention of secondary


22

goiters, from decreased iodine, and associated thyroid cancers. The medication is taken orally

and is absorbed in the gastrointestinal tract thus, timing is key to proper absorption. Ideally,

Levoxyl should be taken with water either one hour before breakfast or at bedtime or three hours

after the final meal of the day (Sawka, A. M., & Jonklaas, J., 2015). Levothyroxine interacts with

calcium and iron supplements by decreasing its absorption so patients should be educated on

taking supplements at a different time of day as a result. Patient has been instructed to take daily

in the morning as soon as he wakes up and is followed up by his endocrinologist annually.

Chad’s endocrinologist’s last evaluation before his surgery indicates normal levels of T3

and T4 with creatinine levels at 100 mL/min indicating no signs of kidney damage from long

term use (Liu et al., 2015). Clinical implications involve monitoring the patient for any changes

in dosing due to a tendency for palpitations, high blood pressure, angina, and tachycardia

associated with relatively higher metabolic rate from their normal lowered baseline. It will also

be important to monitor the patient’s weight loss and to aim for BMI to be in the 40-60th

percentile.

Side effects of any thyroid replacement therapy include atrial fibrillation or osteoporosis.

Many patients who experience symptoms of an elevated basal metabolic rate can benefit from a

medication that lowers the side effects of a normalized TSH. L-thyroxine monotherapy is an

example which has been shown to normalize the serum TSH (McAninch, E. A., & Bianco, A. C,

2016). In a study by McAninch et al. the possible role of more personalized plans of care, in

order to better normalize triiodothyronine levels using polymorphisms, was researched. In the

past, studies with rats have suggested that L-Thyroxine monotherapy continue to exhibit markers

of hypothyroidism due to the direct lower serum of T3 and relatively high T4 which inactivates

the type 2 iodothyronine deiodinace (D2). This is a premise of many new and upcoming drug


23

trials with managing secondary effects of hypothyroidism. This study relates to Chad, since it

shows a significant loss of D2 in the hypothalamus of rat trials thus a call for a need of L-

triodothruonine drug trials in humans in order to better normalize TSH for patients with primary

hypothyroidism.

Initial Examination

Subjective History and Chief Complaint

Chad Williams was a twelve-year-old African American male when he presented to the

outpatient orthopedic clinic with his mother, Mary Williams. Chad’s past medical history

included a diagnosis of hypothyroidism as well as slipped capital femoral epiphysis on the left

hip one year ago. At his twelve year physical, Chad reported pain in his left hip and reported to

have been “walking with a limp.” He was sent to an orthopedic surgeon two days later, when he

was diagnosed with SCFE. Chad was scheduled for in-situ stabilization with a single screw

surgery the next day. Chad made full recovery without any presentation of symptoms six months

post-surgery. Due to Chad’s age and other risk factors, he was also sent for blood work, which

provided his doctor with enough information to diagnose him with hypothyroidism.

Two months ago, Chad began to notice diffuse right knee, hip and groin pain. His mother

reported that he had begun “walking with a limp” again and scheduled an appointment with his

orthopedic surgeon. Chad was diagnosed with SCFE in his right hip and one day later underwent

the same in-situ stabilization procedure. Two weeks ago, Chad had an appointment with his

orthopedic surgeon who noted that Chad was not progressing the way he would like him to.

Chad had ongoing complaints of stiffness and pain in his right hip and notable scar tissue build

up. Chad was then referred to physical therapy for ROM and strengthening by his orthopedic

surgeon.


24

Chad then presented to physical therapy ten weeks status post in-situ stabilization

pinning. Chad’s mother reported that he is active and likes to play with the neighborhood kids

after school for at least 60 minutes a day. Chad enjoys playing football and hoped to be able to

return to training for contact football this Fall. He currently continues to ambulate with bilateral

axillary crutches for long distances only because he continues to have discomfort during

ambulation and expressed concern of re-injury. His goals were to decrease pain, increase range

of motion, and improve coordination and strength of his right leg in order to return to his

activities. Chad comes from a supportive family with a mother, father and two older brothers.

They were well educated in SCFE management and were eager to get him to football tryouts in

the upcoming Fall season.

24-hr pain report (NPRS)=

5/10 pain at worst (walking long distances, going up/down stairs)

0/10 best (sitting, laying on back)

0/10 current

Review of Systems

Chad Williams was born on February 14, 2004 and presented to our clinic on February

16, 2016. Blood pressure is 110/70, heart rate is 75 beats per minute, and temperature is 98.6.

Chad is 5’ 0’’, 134 lbs placing him in the 97th percentile for boys (CDC, 2016). Chad is

considered obese for his age. Chad has a past medical history of primary hypothyroidism was

diagnosed shortly after his diagnosis of SCFE in the left hip. His hypothyrodism is medically

managed with Leyoxyl. His last lab reports his TSH targets are within the normal limits at 3.50

mlU/L with about 0.45-4.50 mlU/L being the norm (Sawka, A. M., & Jonklaas, J., 2015). His


25

mother also reported that he receives a well-balanced diet, is allergic to dairy products, and takes

a Vitamin D supplement. At that time, there were no other health concerns reported.

Initial Hypothesis and Plan for Examination

Based upon information gathered in the chart review and history, a thorough plan for

examination was established. Chad appears to be experiencing muscle stiffness and weakness

causing pain, secondary to in-situ stabilization pinning procedure performed to manage his

SCFE.

Observation

Skin inspection: There is equivocal build-up of scar tissue at the surgical incision site on

the right hip. He has one other skin lesion noted on the left hip from surgical repair of SCFE one

year prior to this surgery; he has no notable scar tissue formation on the left hip.

Gait: Chad walked into the clinic with mild increased weight bearing on the left lower

extremity leading to increased stance time on the left compared to the right. He had a significant

right Trendelenburg. He had mild pronation in bilateral feet.

Posture: Chad had mild pronation in bilateral feet and notable moderate valgus in

bilateral knees with medial tilt in bilateral patellae. He had increased weight bearing over the

right leg due to pain.

Tests and Measures

Range of motion. An initial active and passive range of motion (ROM) was conducted

with the following findings summarized in Table 3 and Table 4. Chad demonstrates a decrease in

overall ROM in his right hip. Significant decreases are noted in flexion, extension, internal

rotation, and abduction. Lumbar ROM was measured and was WNL in all directions. All tests


26

were conducted using procedures described in Dutton’s Orthopedics Examination, Evaluation,

and Intervention.

Table 3. Initial active range of motion assessment. Hip AROM Right Left

Flexion 100 * 128 Extension 10 18 Internal Rotation 15 * 30 External Rotation 25 25 Adduction 30 32 Abduction 30 48

*pain

Table 4. Initial passive range of motion assessment. Hip PROM Right Left

Flexion 105 (limited by tissue stretch and pain)

134

Extension 15 (limited by tissue stretch) 22 Internal Rotation 25 (limited by tissue stretch) 34 External Rotation 25 25 Adduction 35 35 Abduction 36 (limited by tissue stretch

and pain) 48

Strength. An initial MMT strength assessment was conducted with the following finding

summarized in Table 5. Chad had decreased strength in the right lower extremity overall with

significant decreases in the gluteus medius muscle and internal rotators. He had some areas of

decreased strength in his left lower extremity musculature, most importantly, his left gluteus

medius. All tests were conducted using procedures described in Dutton’s Orthopedics

Examination, Evaluation, and Intervention.

Table 5. Initial strength assessment. Muscle Right Left

Illiopsoas 4/5* 4+/5 Gluteus Medius 3+/5* 4/5* Gluteus Maximus 4/5 5/5 Hip Adductors 4/5 5/5 Hip Internal Rotators 3+/5* 5/5 Hip External Rotators 4/5 4+/5


27

Hamstrings 5/5 5/5 Quadriceps 4/5 5/5 Gastrocnemius 4/5 5/5

*pain

Muscle length testing. All tests were performed using protocols described in Dutton’s

Orthopedics Examination, Evaluation, and Intervention.

Ely’s test: + R (116 degrees)

Thomas test: + R (iliopsoas)

Ober test: + R (6-)

Straight leg raise: 75 degrees R, 80 degrees L

Joint mobility assessment. Not assessed at this time.

Functional testing. Functional mobility was assessed using the following tests:

Transfers:

Sit to stand: Chad used appropriate upper extremity push off from chair as he

stood up, decreased forward flexion noted with a shift in weight toward his left

side.

Supine to side-lying: no abnormalities noted bilaterally

Supine to sit: no abnormalities noted bilaterally

Single limb stance: Test was performed on stable surface with the patient’s eyes open

using a stop watch to time.

R= 5s Test was stopped due to pt stepping forward with left leg to catch balance.

Pt demonstrated decreased anterior/posterior sway and increased medial/lateral

sway. Observable Trendelenburg stance on the R.

L= 30s – observable Trendelenburg stance on the L.

Single limb squat: Assessed on a stable surface.


28

R: increased medial/lateral sway during decent into squat, notable R lateral lean

throughout motion and decreased trunk forward flexion. Reached 50% of hip and

knee flexion compared to the L.

L= notable L lateral lean throughout motion. Able to reach full squat position

with otherwise good form.

Step-up: Assessed on a 4” and 8” firm step

R: able to perform step-up onto a 4” step. Knee ascended over toes as motion was

performed. Decreased trunk flexion.

L= 8” step performed with good form. Knee did not ascend over toes and full

upright posture was achieved.

Star Excursion Balance Test

The Star Excursion Balance Test (SEBT) is a widely used examination tool for return to

sport. It has been tested in many different populations ranging from high-level professional

athletes to recreational athletes as young as 12-13 years old (Reiman & Thorborg, 2014). The

test assesses dynamic postural control through unilateral weight-bearing requiring proximal

stability at the trunk and pelvis while coordinating movement of the lower extremity. Dynamic

postural control is essential for athlete’s returning to sport, especially after lower extremity

injuries. After an injury, athletes must re-build up lower extremity strength in order to maintain

stability throughout play and prevent re-injury. The gluteus medius muscle was activated in all

anterior and medial directions and exceeded threshold of activation for strength gains in the

medial directions. The gluteus maximus was activated in all directions as well as the vastus

medialis muscle. The vastus medialis exceeded threshold of activation for strength gains in all

directions (Norris & Trudelle-Jackson, 2011).


29

The SEBT has been found to have good reliability, moderate strength construct validity,

and excellent criterion validity (Hegedus, McDonough, Bleakley, Baxter, & Cook, 2015). A

study by Hyong et al. concluded that the SEBT has strong intrarater reliability (0.88-0.96)

following standardized National Strength and Conditioning Association (Miller, Association, &

others, 2012) protocol for SEBT that was also used in this study. Due to the test’s clinometric

properties, studies have been conducted to assess its effectiveness in return to sport. There is

evidence that the SEBT can provide information to predict injury risk. A composite reach score

difference of less than 94% predicted a 3-fold increase in injury risk. An anterior reach

difference of 4cm or greater is associated with a 2.7 fold greater injury risk for athlete’s upon

returning to sport (Hegedus, McDonough, Bleakley, Baxter, & Cook, 2015).

The SEBT is performed with the subject standing on one leg in the middle of the “star-

shaped” circle on level-ground. Four pieces of athletic tape are cut into six to eight foot strips.

Two strips are put on the ground in and X-shape; the other two strips are put over the first X-

shape so that there are eight lines that make 45 degree angles. There should be eight directions:

anterior, anterior medial, medial, posterior medial, posterior, posterior lateral, lateral, and

anterior lateral. The subject was instructed to put his hands on his waist. Before testing begins

the subject was allowed four practice trials in order to understand how to perform the test

correctly. To examine the right lower extremity, the subject stood with his right foot in the center

of the tape and the left foot was lifted off of the ground. The subject was then instructed to

stretch his left leg forward as far and tap the tape with his big toe while maintaining balance and

then return to the starting position. The same protocol was followed for each direction (Miller,

Association, & others, 2012).


30

The test was performed three times on each leg with allowed two-minute rest breaks

between trials. The examiner marked the tape at the point of big toe contact with a marker; the

average of the three trials for each direction on each leg was recorded in centimeters.

Measurements were taken from the center of the star to the mark recorded by the examiner with

a tape measure. The measurements were then averaged and compared to the subject’s leg length

to get the percentage of leg length that the subject was able to reach. The test was terminated if

the subject made any heavy contact with the ground to catch balance, could not return to the start

position under control, or if there were any shifts in the stance limb (Gribble, Hertel, & Plisky,

2012; Miller, Association, & others, 2012). Chad’s results are listed in Table 6.

Table 6. Chad’s initial evaluation results on the SEBT. Right Left

Anterior 50% 75% Posterior 60% 90% Medial 62% 94% Lateral 56% 80% Anterior Lateral 68% 75% Anterior Medial 70% 85% Posterior Lateral 75% 92% Posterior Medial 80% 97%

*All values are expressed in the percentage of leg length.

Chad was able to perform the SEBT with ease on the left lower extremity without any

trials being terminated. There was some observable hip drop as chad returned to the starting

position bilaterally. On the right lower extremity, Chad had increased valgus when performing

the test in all directions. He had three trials terminated during testing on the right side in the

anterior, anterior medial, and medial directions due to loss of balance and inability to return to

the starting position in a controlled manner. During other trials, Chad was able to perform the

motion in those directions in a more controlled manner and those results were then recorded in


31

Table 6. Chad had composite scores that were greater than a 94% difference, placing him at an

increased risk for injury (Hegedus, McDonough, Bleakley, Baxter, & Cook, 2015).

Functional Outcome Measures

Modified Harris Hip Score. The Harris Hip Score (HHS) is an outcome measure

composed of 10 questions, 2 questions (ROM and absence of deformity) for the physician

physical examination component and 8 questions for the patient-reported outcome component.

When only the patient-reported outcomes portion of the HHS is completed, it is referred to as a

modified Harris Hip Score (mHHS) (Wamper et. al., 2010). See Appendix A. At initial

evaluation, Chad presented with a score of 69 on the mHHS.

Re-Evaluation Examination


Chad presented to outpatient physical therapy now four weeks into rehab for his right hip

status post in-situ pinning secondary to SCFE. His chief complaint was stiffness in his right hip

and increased pain when walking long distances. He wanted to return to football by the fall and

was currently unable to perform high impact activities due to ongoing weakness in his right hip

musculature. Chad’s mother expressed concern that he continued to complain of increased pain

when walking downstairs at school. Chad reported that he feels as though he is making

improvements with physical therapy and is feeling less pain than when he first started. He

expressed concern that he was not able to jump or run yet.


3/10 pain at worst (walking long distances and going down stairs)


0/10=current


32

Review of Systems

Blood pressure was 112/70, heart rate was 75 beats per minute, and temperature is 98.6.

Chad is 5’ 0’’, 128 pounds placing him in the 95th percentile for boys (CDC, 2016). Chad was

still considered obese for his age, but due to increased activity levels with walking and cycling

he was able to lose six pounds since the initial evaluation. Chad continued to manage his

hypothyroidism with Leyoxyl and is doing well. There were no other reports of health concerns

at that time.

Plan for Examination


examination was established.

Observation

Skin inspection: Chad’s surgical incision site had healed appropriately. There was no

notable scar tissue build up on the right hip.

Gait: Chad was able to walk with even stance time bilaterally. Mild pronation noted in

bilateral feet.

Posture: Chad had mild pronation in bilateral feet and notable moderate valgus in

bilateral knees with medial tilt in bilateral patellas. Even weight bearing through both lower

extremities was present.

Tests and Measures

Range of motion. Active and passive range of motion (ROM) was conducted with the

following findings summarized in Table 7 and Table 8. All tests were conducted using

procedures described in Dutton’s Orthopedics Examination, Evaluation, and Intervention.

Significant gains in ROM had been made since initial evaluation. Chad continued to have


33

decreased ROM in the right lower extremity, most notably in flexion and internal rotation due to

pain.

Table 7. Active range of motion at re-examination. Hip AROM Right Left

Flexion 112 * 128 Extension 18 18 Internal Rotation 20 * 30 External Rotation 25 25 Adduction 30 32 Abduction 45 48

*pain

Table 8. Passive range of motion at re-examination. Hip PROM Right Left

Flexion 120 (limited by tissue stretch and pain)

134

Extension 22 22 Internal Rotation 32 (limited by tissue stretch

and pain) 34

External Rotation 25 25 Adduction 35 35 Abduction 48 48

Strength. An initial MMT strength assessment was conducted with the following finding

summarized in Table 9. All tests were conducted using procedures described in Dutton’s

Orthopedics Examination, Evaluation, and Intervention. Chad continued to have overall

decreased strength in his right lower extremity. Most importantly, painful and weak iliopsoas,

gluteus medius, and hip internal rotation strength.

Table 9. Strength assessment at re-examination. Muscle Right Left

Illiopsoas 4/5* 5/5 Gluteus Medius 4/5* 4/5 Gluteus Maximus 4/5 5/5 Hip Adductors 4/5 5/5 Hip Internal Rotators 4/5* 5/5 Hip External Rotators 4/5 5/5 Hamstrings 5/5 5/5 Quadriceps 4/5 5/5


34

Gastrocnemius 5/5 5/5 *pain Muscle length testing. All tests were performed using protocols described in Dutton’s

Orthopedics Examination, Evaluation, and Intervention.

Ely’s test: + R (120 degrees)

Thomas test: + R (iliopsoas)

Ober test: + R (2-)


Joint mobility assessment. All hip joint mobility was assessed and is normal. Joint mobility was

assessed using the protocol outlined in Dutton’s Orthopedics Examination, Evaluation, and

Intervention.

Functional testing. Functional mobility was assessed in the following tests.

Transfers:

Sit to stand: Chad used appropriate upper extremity push off from chair as he

stood up, decreased forward flexion noted. He was able to maintain equal weight

bearing through both lower extremities.



R= 17s Test was stopped due to Pt stepping forward with L leg to catch balance.

Observable Trendelenburg stance on the R.



R: Increased R lateral lean throughout motion and decreased trunk forward

flexion. Reached 80% of hip and knee flexion compared to the L.


35

L= notable L lateral lean throughout motion. Able to reach full squat position

with otherwise good form.

Step-up: Assessed on an 8” firm step

R: able to perform step-up onto an 8” step. Knee ascended over toes as motion

was performed. Decreased trunk flexion and complaints of pain upon initiation of

movement were reported.

L= 8” step performed with good form. Knee did not ascend over toes and full



The test was performed using the same procedures as in the initial evaluation. Chad’s

result as re-evaluation are as follows in Table 10:

Table 10. Chad’s SEBT Score at Re-Examination. Right Left

Anterior 60% 75% Posterior 80% 90% Medial 82% 94% Lateral 65% 80% Anterior Lateral 70% 75% Anterior Medial 80% 85% Posterior Lateral 86% 92% Posterior Medial 85% 97%

All values are expressed in the percentage of leg length.


trials being terminated. There was some observable hip drop as chad returned to the starting

position on the right. Chad was able to perform all of the trials without any termination due to

faulty movement. He made improvements in all directions, but he was still at increased risk for

injury because his composite scores continue to be less than a 94% difference (Hegedus,

McDonough, Bleakley, Baxter, & Cook, 2015).


36


Modified Harris Hip Score. At re-evaluation, 14 weeks post-op and after 4 weeks of

physical therapy, Chad presented with a score of 81 with a decrease in pain and an increase in

ease of ascending/descending stairs (Edwards et. al., 2015).

Discharge Examination


Chad presented to outpatient physical therapy now eight weeks into rehab for his right

hip status post in-situ pinning secondary to SCFE. Chad reported that he feels as though he is

ready to return to football in the Fall. He has made many improvements over the eight weeks.

His chief complaint continued to be his inability to walk long distances without some discomfort.

Chad reported that he felt comfortable performing jumping and balance activities especially in

the past two weeks and is excited to return to practice after his final visit with his orthopedic

surgeon in two days.


1/10 pain at worst (walking long distances)


0/10=current

Review of Systems

Blood pressure is 110/74, heart rate is 75 beats per minute, and temperature is 98.6. Chad

is 5’ 0’’, 120 lbs placing him in the 93th percentile for boys (CDC, 2016). Chad is considered

overweight for his age, but due to increased activity levels with walking and cycling he was able

to lose fourteen pounds since the initial evaluation. Chad had lost enough weight to move from


37

the obese and into the overweight category for BMI. Chad continued to manage his

hypothyroidism with Leyoxyl. There were no other reports of health concerns at that time.

Plan for Examination


examination was established.

Observation

Gait: Chad was able to walk with even stance time bilaterally. Mild pronation noted in

bilateral feet.

Posture: Chad had mild pronation in bilateral feet, knee valgus and medial tilt of bilateral

patellae was still present upon postural examination, however, less prominent than in the initial

examination. He was able to evenly weight bear through both lower extremities.

Tests and Measures

Range of motion. Active and passive ROM was conducted with the following findings

summarized in Table 11 and Table 12. All tests were conducted using procedures described in

Dutton’s Orthopedics Examination, Evaluation, and Intervention. Significant gains in ROM had

been made since initial evaluation. Chad continued to have decreased ROM in the right lower

extremity, but no longer complained of pain during movement. His hip ROM was considered

functional and most directions were equal with the left.

Table 11. Active range of motion at discharge examination. Hip AROM Right Left

Flexion 122 128 Extension 18 18 Internal Rotation 26 30 External Rotation 25 25 Adduction 30 32 Abduction 47 48

*pain


38

Table 12. Passive Range of Motion at Discharge Examination. Hip PROM Right Left

Flexion 130 134 Extension 22 22 Internal Rotation 32 (limited due to tissue

stretch) 34

External Rotation 25 25 Adduction 35 35 Abduction 48 48

Strength. A final MMT strength assessment was conducted with the following finding

summarized in Table 13. All tests were conducted using procedures described in Dutton’s

Orthopedics Examination, Evaluation, and Intervention. Chad made good improvements in

overall lower extremity strength throughout the eight weeks of therapy. He continued to have

decreased right lower extremity strength, but all strength was functional.

Table 13. Discharge manual muscle test results. Muscle Right Left

Illiopsoas 4+/5 5/5 Gluteus Medius 4/5 5/5 Gluteus Maximus 5/5 5/5 Hip Adductors 5/5 5/5 Hip Internal Rotators 4+/5 5/5 Hip External Rotators 4+/5 5/5 Hamstrings 5/5 5/5 Quadriceps 5/5 5/5 Gastrocnemius 5/5 5/5

*pain

Muscle length testing. All tests were performed using protocols described in Dutton’s

Orthopedics Examination, Evaluation, and Intervention book.

Ely’s test: -

Thomas test: -

Ober test: -



39

Functional testing. The following tests were performed to assess functional mobility.

Transfers:

Sit to stand: Chad performed sit to stand with appropriate trunk flexion and upper

extremity push off. He had equal weight bearing through both lower extremities.

He stood to full upright posture.



R= 26s Test was stopped due to Pt stepping forward with L leg to catch balance.



R: Reached full hip and knee flexion compared to the L. Able to achieve full

squat position using good form and controlled movement without loss of balance.

L= Able to reach full squat position with good form.

Step-up: Assessed on an 8” firm step

R: able to perform step-up onto an 8” step pain-free. Step-up performed with good

form and full, upright posture was achieved.

L= 8” step performed with good form. Knee did not ascend over toes and full,



The test was performed using the same procedures as in the initial evaluation. Chad’s

result as re-evaluation are as follows in Table 14:

Table 14. Chad’s Discharge SEBT Results. Right Left

Anterior 71% 75% Posterior 85% 90%


40

Medial 92% 94% Lateral 80% 80% Anterior Lateral 76% 75% Anterior Medial 85% 85% Posterior Lateral 90% 92% Posterior Medial 95% 97%

All values are expressed in the percentage of leg length.


trials being terminated. Chad was able to perform all of the trials without any termination due to

faulty movement. He made improvements in all directions and is no longer placed in the risk for

injury category because his composite score differences are no longer less than a 94% difference

(Hegedus, McDonough, Bleakley, Baxter, & Cook, 2015).


Modified Harris Hip Score. At final evaluation, Chad presented with a score of 95.

Chad had decreased pain, no limp or antalgic gait pattern, normal ascent/descent of stairs, and

was able to don/doff socks/shoes with ease (Edwards et. al., 2015).

Evaluation

Diagnosis. After initial examination and differential diagnoses were considered, a

physical therapy diagnosis was formulated according to the International Classification of

Functioning. Chad is unable to play football and participate in after school activities secondary to

difficulty standing, walking, and running due to increased pain, mobility deficits, decreased

strength, and movement coordination impairments because of in-situ pinning with a single screw

associated with a diagnosis of SCFE.

Prognosis. Chad has a good prognosis. He will be able to stand, walk, and run without

increased pain and return to football and after school activities within 8 weeks. He will be placed

at a decreased risk for re-injury with suitable scores on the Star Excursion Balance Test.


41

Goals. Short and long term goals are displayed in Table 15.

Table 15. Short and Long Term Goals. Short-Term Goals (4 weeks) Long-Term Goals (8 weeks)

Chad will be able to return knowledge of HEP and be knowledgeable of increasing WB on his affected (right) limb.

Chad will be able to negotiate DL stance on an uneven surface for 30 seconds.

Chad will be able to ambulate with increased stance time on the right limb and with an equal step length.

Chad will be able to stop and change direction without loss of balance or pain on turf surface.

Chad will be able to don/doff shoes independently reporting 0/10 pain.

Chad will be able to participate in after school activities that involving jumping and running without pain or instability.

Chad will be able to successfully complete SEBT on affected limb without loss of balance.

Chad will be able to successfully complete SEBT on affected limb with scores within 94% of each other indicating decreased risk of re-injury.

Intervention

Chad Williams presented to physical therapy ten weeks post-op through his orthopedic

surgeon’s referral. After initial examination it was determined the patient would most benefit

from a multimodal approach involving manual therapy, therapeutic exercise, therapeutic

activities, and neuromuscular re-education. An evidence based approach was taken in developing

appropriate interventions for this patient including an adapted protocol from Yazbek et al.

Interventions are summarized in Table 17.

Patient education. Patients should be provided with education in regards to joint

protection strategies and avoidance of symptom-provoking activities. Education should be

individually tailored to meet the patient’s functional demands and include activity modifications

if particular activities provoke pain (Enseki et al., 2014). Chad reported his worst pain when

walking long-distances and when ascending/descending stairs during his initial examination. He

was educated promptly on avoiding walking long distances and how to modify his movement so

ascending/descending the stairs no longer provoked his pain. Patient education continued


42

throughout Chad’s physical therapy treatment; he was educated on correct movement strategies

when Chad started to return to more sport-specific activities. Due to the complications associated

with Chad’s surgical procedure, he and his mother were educated on the signs of avascular

necrosis (pain in the groin or knee, loss of motion of the hip, particularly internal rotation, and

irritability with passive hip motion into internal and external rotation).

A home exercise program was implemented for Chad in order to further the progression

of his rehabilitation. A summary of his home exercise program during each phase and after

discharge can be found in Table 16.

Table 16. Home Exercise Program. Exercises were performed 2x/day, 5days/week. Phase 1 Phase 2 Phase 3 Discharge - Hip flexor, rectus

femoris, hamstrings, and TFL/ITB 30”x2

- Transversus abdominis contractions 5”x10

- Double limb bridge with TA contraction 2x10

- Hip flexor, rectus femoris, hamstrings, and TFL/ITB 30”x2

- Clams 2x10 - Lunges 2x10

- Single leg bridging 2x10

- Side-lying hip abduction against wall 2x10

- Prone heel squeezes 2x10

- Sprinting with quick starts/stops

- Box jumps - Cone drills with

quick changes in direction

Manual therapy. Utilization of manual therapy can be used in attempt to improve rate of

nutrient imbibition for the articular cartilage. Techniques may include soft tissue mobilization

and joint mobilization/manipulation, and are beneficial in pain reduction and restoration of

motion. Indications for joint mobilization/manipulation of the hip joint include hip pain and

decreased passive range of motion with a capsular end-feel (Enseki et al., 2014). During his

initial examination, Chad had pain with active hip flexion and abduction. Maitland grade one

and two posterior and inferior caudal glides were performed to decrease pain within the hip joint

during phase one of Chad’s rehabilitation process. Mobilizations were performed during sessions

in the first two weeks of physical therapy, and were performed for 30 seconds, for two sets. Soft


43

tissue mobilization was also performed in phase one in order to reduce tissue irritability and

begin restoration of motion. Longitudinal strokes were applied to muscle to decrease tissue

irritability followed by transverse strokes to breakdown adhesive muscle tissue. It was performed

during the first two weeks of physical therapy, and was performed for eight total minutes to the

iliopsoas, rectus femoris, hamstrings, and tensor fasciae latae-iliotibial band.

Therapeutic exercises and activities. Soft tissue restrictions of the lower extremity can

be addressed through soft tissue mobilization, contract/relax stretching, and prolonged stretching

that does not increase the patient’s symptoms. Two-joint muscles around the hip (iliopsoas,

rectus femoris, hamstrings, and tensor fascia latae-iliotibial band) are the most commonly

shortened muscles around the hip; as was true in Chad’s initial examination (Enseki et al. 2014).

Soft tissue mobilization was performed as previously described. Contract/relax stretching was

performed on the iliopsoas, rectus femoris, and hamstrings according to the procedures detailed

in Dutton's Orthopaedic Examination, Evaluation, and Intervention. Contract/relax techniques

were performed during the early phase sessions; contractions were held for seven seconds at 50%

contraction and relaxation was maintained for 14 seconds with a progressively deeper stretch

after each contraction for three repetitions. Prolonged static, manual and active, stretching was

also implemented for the iliopsoas, rectus femoris, hamstrings, and tensor fascia latae-iliotibial

band during the early phase. Stretches were maintained for 30 seconds and repeated two times

per session both manually and actively. Contract/relax stretching as well as manual and active

stretching was carried over into phase two of rehabilitation in order to address further muscle

flexibility and range of motion deficits.

Stabilization during movement requires normal muscle activation patterns for proper

movement coordination. It is debated whether joint instability or impaired coordinated


44

movement is a source of dysfunction. Adequate joint stability

depends on contractile and noncontractile elements; so,

improper coordination of movement patterns may play a role in

whether or not patients experience symptoms related to

instability. Studies have determined that, in healthy people,

pelvic postural control during lower extremity exercises occur

through simultaneous contraction of local and global muscles. It

has also been found that multifidus and transversus abdominis

activation was impaired in individuals with pelvic injuries

(Yazbek et al., 2011). Activities to improve recruitment,

activation, and timing of deep lumbopelvic musculature,

transverse abdominis, and multifidus were implemented in the

early phase of Chad’s rehabilitation in order to improve

movement coordination. The goal of this was to activate

these deep muscles before and during the activation of

muscles that produce hip motion.

During Chad’s initial examination, he

was found to have impaired movement

coordination during the SEBT and

other balance assessments.

Stabilization exercises were performed

isolating the transversus abdominis

and multifidus as well as contractions

Figure 9. Stabilization exercises implemented in phase one.

(Philippon et al., 2011).

Figure 10. Stabilization exercises implemented in phase three.

(Yazbek et al., 2011).


45

with light exercises like resisted terminal knee extension, resisted knee flexion, and

progressively, double limb bridging (Figure 9). These exercises were performed during sessions

in the early phase of intervention for 10 repetitions and 2 sets each. During phase two of

intervention, stabilization exercises were incorporated into moderate exercises like double limb

squat, single limb balance, and lateral bridging. Exercises were performed for 10 repetitions and

2 sets each. During phase three, tranversus abdominis and multifidus contractions were

incorporated into functional tasks like ascending and descending stairs and sport-specific tasks.

Stabilization exercises were also performed on a Swiss ball to incorporate stabilization in more

functional planes of movement (Figure 10). Swiss ball exercises were performed until fatigue or

breakdown in form.

Asymmetrical muscle weakness should be addressed in patients found to have muscle

imbalances. A hip strengthening program for the specific weakened muscles is recommended

(Enseki et al., 2014). During Chad’s initial examination, he was found to have muscle

imbalances in the majority of right hip musculature; including, iliopsoas, gluteus medius, gluteus

maximus, internal and external rotators, and adductors. Gluteus medius, gluteus maximus, and

iliopsoas weakness can contribute to increased anterior hip shear forces. This weakness may

contribute to hip instability as well as abnormal lower extremity positioning associated with

excessive lower extremity dynamic valgus (i.e. femoral adduction and internal rotation) (Yazbek

et al., 2011). This position may be an aggravating one for patients with hip pain and could lead to

further injury in the long term. (Philippon et al., 2011). A hip strengthening program began in

phase two for Chad, because he had diminished pain with improved control of trunk stabilization

and dynamic valgus, allowing him to progress from phase one, according to a protocol adapted

by Yazbek et al.


46

In phase one, strengthening began indirectly

to the hip musculature through the stabilization

exercises described above. In phase two, a more

vigorous strengthening program began with

exercises targeted directly to hip musculature,

specifically the gluteus medius and hip internal

rotators. Exercises included resisted hip extension,

traditional hip clam, clam with hip in neutral, and

stool hip rotation; exercises are depicted in Figure 11

(Philippon et al., 2011). All exercises were

performed in a slow and controlled manner for 10

repetitions and two sets each. Other

exercises included standing hip flexion,

extension, abduction, and adduction

with elastic resistance; lunges; and side-

stepping gait with an elastic band over

midfeet; all performed for 10 repetitions

with three sets each (Yazbek et al.

2011). In phase three, additional

exercises were added to the program that

were more rigorous toward

strengthening the gluteus medius as well

as surrounding hip musculature. Exercises

Figure 11. Strengthening exercises implemented in phase two.


Figure 12. Strengthening exercises implemented in phase three.



47

included single-leg bridging, prone heel squeeze, side-lying hip abduction with external rotation,

side-lying hip abduction with internal rotation, and side-lying hip abduction against a wall;

exercises are depicted in Figure 12 (Philippon et al., 2011). All exercises were performed in a

slow and controlled manner for 10 repetitions and two sets each. Other exercises included in

phase three were more sport-specific exercises. One of Chad’s goals was to return to football as a

running back. Sport-specific drills included the agility ladder, box jumps, cone drills with quick

changes in direction, and sprinting with quick starts/stops.

Individuals with hip joint pain may be deconditioned secondary to decreased activity

levels due to pain. Cardiorespiratory/aerobic conditioning is necessary to promote optimal health

or remediate metabolic disorders such as obesity and diabetes. Activities that minimize hip

shearing forces are optimal (Enseki et al., 2014). Activities that enable aerobic conditioning with

limited stress to the hip include stationary cycling, swimming, and use of elliptical exercise

equipment. At the beginning of phase two, after a decrease in hip pain, Chad started an aerobic

conditioning program on the stationary cycle. Chad was instructed to cycle for ten minutes with a

three-minute warm up and a three-minute cool down. During the ten minutes, Chad was

instructed to achieve 60-80% of his age predicted maximal heart rate (120-160bpm). The aerobic

conditioning program was carried out through the continuation of his rehabilitation program.

Each week, steady-state time increased by two minutes, with the finial steady-state time equal to

20 minutes.

Neuromuscular re-education. Neuromuscular re-education can be defined as

“movement training progressions that facilitate the development of multi-joint neuromuscular

engrams that combine joint stabilization, acceleration, deceleration, and kinesthesia through

intermittent protocols that progress from low-intensity movement focused in a single plane to


48

multiplanar power training” (Enseki et al., 2014). During Chad’s initial examination he was

found to have movement coordination deficits that needed to be addressed. Movement

coordination impairments were previously addressed in Chad’s rehabilitation program with

stabilization exercises that also targeted neuromuscular re-education. Further neuromuscular re-

education began in phase two for Chad with exercises involving a balance board, a DynaDisc,

and a jumping board.

Gait interventions. After his initial examination, it was determined that the patient

would benefit from specific gait interventions due to strength and movement coordination

deficits. Gait training began immediately, day one, as Chad presented without use of bilateral

axillary crutches after being weaned two weeks prior from a four-point gait pattern to full weight

bearing ambulation. Prior to physical therapy, the patient was instructed on proper four-point

gait; right crutch advancement, right foot, left crutch advancement, left foot, all in a separated

sequence. The rationale behind four-point crutch gait is to gradually increase weight bearing

through both coxafemoral joints in order to prepare for independent ambulation (Kienstra, 2016).

After eight weeks of crutch ambulation, Chad was cleared by his orthopedic surgeon to begin full

weight bearing. The importance of gait training at that stage is due to Chad's age, placing him in

the early phases of puberty. A non-antalgic gait pattern must be adopted in order to stress the

long shaft of the femur and distal joints optimally for ambulation (Kienstra, 2016).

During his first session of gait training, Chad was placed in the parallel bars and tolerated

modified independent standing with hands on the parallel bars for balance. Chad was able to

complete a full gait cycle to the end of the parallel bars with a notable Trendelenburg on the right

hip. Chad was able to complete single limb stance on the right side with manual and tactile

cueing with an inferior and medially directed compression force from behind the patient on the


49

right iliac crest. The noted abductor weakness along with decreased stance time on the affected

limb was addressed with strengthening exercises discussed previously. Stance time was

improved with pain reduction strategies and neuromuscular reeducation to address movement

coordination.

The rehabilitation protocol from Yazbek et. al. discussed previously was also adapted to

incorporate the mutual goal of proprioceptive feedback in gait training. Phase one included the

interventions discussed above. At two weeks, Chad began phase two of the protocol which is

shown in Table 17. At four weeks, Chad was able to complete an independent ambulation of 10

feet without notable Trendelenburg. During this week of therapy, functional gait training was

progressed without manual cueing and verbal cueing was implemented. As a qualitative analysis

moving forward in his therapeutic interventions, energy conservation was addressed. During

limb advancement the sacrum should move in a transverse plane motion to adduct the femur and

accept the force of the trunk. An efficient gait cycle was adapted by Chad by the end of phase

two in order for him to progress further in phase three of the protocol.

Table 17. Summary of Interventions. Phase 1 Phase 2 Phase 3 Progression Criterion

Identification of impairments Decreased pain and improved movement coordination

Good balance and proprioception with normal muscle strength and range of motion

Pain - Soft tissue mobilization - Maitland grade 1 & 2

mobilizations

AROM - Soft tissue mobilization - Contract/relax stretching - Manual and active

stretching

- Contract/relax stretching

- Manual and active stretching

Stabilization - Isolated contraction of the transversus abdominis and multifidus

- Transversus abdominis and multifidus contraction with

- Transversus abdominis and multifidus


50

- Transversus abdominis and multifidus contraction with light exercise (resisted terminal knee extension and knee flexion, and double limb bridging)

moderate exercise (double limb squat, single leg stance, lateral bridging)

contraction with functional tasks

- Swiss ball exercises

Muscle Strength

- Resisted hip extension

- Traditional hip clam

- Clam with hip in neutral

- Stool hip rotation - Standing hip

flexion, extension, abduction, and adduction with elastic resistance

- Lunges - Side-stepping gait

with an elastic band over midfeet

- Single-leg bridging

- Prone heel squeeze

- Side-lying hip abduction with external rotation

- Side-lying hip abduction with internal rotation

- Side-lying hip abduction against a wall

- Sport specific drills

Aerobic conditioning

- Stationary cycling - Stationary cycling with gradual increase in time

Neuromuscular re-education

- Balance board - DynaDisc - Jumping board

Gait - Compression to increase weight bearing through right lower extremity

- Single limb stance

- Ambulation with equal step length without manual and verbal cueing

Discussion

Patient Reported Outcome Measures (PROs) are important tools in determining the

success of interventions. Ideally, they should be tested for validity in each population. However,

many scores are applied to new populations (such as pediatric populations) without validation. A

2015 systematic review was conducted to discover which hip-specific PROs are used in pediatric


51

populations with impingement and similar diagnoses. The systematic review also aimed to

determine what clinometric evidence exists for the use of these specific PROs in this population.

Two separate literature searches were performed. The first search attempted to identify any

PROs used in a pediatric population with hip impingement disorders, and the second search was

intended to identify studies that assessed the clinometric properties of the PROs in a pediatric

population with the same disorders. The first search combined both subject headings and

keywords for pediatric patients, for impingement and associated disorders (such as Legg-Calvé-

Perthes disease and SCFE), and for PROs (such as “score” or “index”). The second search

combined keywords for the specific PROs found in the first search with subject headings and

keywords for clinimetric evaluation (“validity”, “repeatability”, etc) and the same subject

headings and keywords for pediatric patients and impingement and associated disorders used in

the original search. The search was limited to patients ages 0-18. Studies with fewer than five

subjects and mixed populations of adults and children and/or adolescents were excluded from the

search. The following six hip-specific PROs were found to have been used in studies of pediatric

impingement populations: (1) Harris Hip Score (HHS); (2) modified Harris Hip Score (mHHS);

(3) Iowa Hip Score; (4) Merle d’Aubigné Hip Score; (5) Hip Outcome Score (HOS) (Activities

of Daily Living and Sports subscores); and (6) Non-arthritic Hip Score (NAHS). There were no

papers validating any of the aforementioned PROs in a pediatric population. The modified Harris

Hip score was used as a PRO in the case of Chad Williams. It was utilized as a test-retest

measure for this specific patient. Its benefits are that it is easy to administer and inexpensive. It

has clinometric properties supported in literature, however, none of this is specific to a pediatric

population. This makes it difficult to determine the extent of clinically important change that

occurs throughout treatment with a patient (d’Entremont et. al., 2015). It has been reported that


52

the MCID for the modified Harris Hip Score at three, six, and twelve months are 13.0, 9.0, and

20.0, respectively. The study supporting this data was a prospective cohort study at a single

center in a consecutive series of patients with femoroacetabular impingement who were treated

with arthroscopic labral repair/re-fixation and femoral osteoplasty. There were 130 patients with

a mean age of 35.6 (sd 11.7) years and 42.3% were male (Chahal et. al., 2014) In addition to the

lack of literature specifying clinometric properties for the mHHS in the pediatric population,

there is limited research for the clinical importance in the short-term. The posed MCIDs for the

mHHS are over an extended period of time. Therefore, there is limited literature to compare to

when a patient is undergoing less than 12 weeks of therapy. In Chad’s case, we were unable to

establish clinical significance in this outcome measure in the re-evaluation after four weeks as

well as in the final examination after eight weeks of therapy.

Common patterns arose in the research and gathering of information on the rehabilitation

of pediatric orthopedic cases. It is apparent that no straight SCFE case reports have been

completed with a statistically significant improvement in functional limitations. Thus, the

clinical significance for physical therapy following a SCFE is not always recommended due to

the variability of cases. Even more important is the lack of pediatric orthopedic physical

therapists that physicians have to refer to. These two facts alone are the reasoning behind the

major gaps in the literature that are found when searching for physical therapy and SCFE.

Other gaps in the literature result from a lack of literature supporting post-operative

SCFE rehabilitation. There are no set protocols for goals and objectives of rehabilitation after

pinning. Only weight bearing precautions are outlined which results in a possible reason why

many SCFE cases are not referred to physical therapy if weight bearing tolerance can be given

on follow-up physician appointments.


53

According to the American Academy of Pediatrics, there is a 2020 vision for increased

advocating for pre-operative and post-operative care on orthopedics. This is within the scope of

the American Board of Pediatric Specialists. Specifically, for Chad Williams’ case, obesity is

one of the top visions for advocating since childhood obesity is on the rise. There needs to be

more research on how pre- and post-operative strengthening and movement coordination training

is within a specialty of a certified pediatric specialist (CPS) and the need for increased physician

referral is vital in the return to functional activity. Certified pediatric specialists can help

decrease the risk and achieve the goal of childhood obesity recognition and treatment in order to

prevent secondary complications. There is a call for an increased number of orthopedic physical

therapists who specialize in pre-pubescent cases such as Chad Williams. An increased number of

sub-specialty PCS will help to advocate a need for post-operative therapy for individuals, like

Chad, who need functional intervention as well as surgical.


54

References

AAP. (2016). 2020 Vision. Retrieved April 1, 2016, from

http://www2.aap.org/visionofpeds/docs/member_survey_summary.pdf

Abu Amara, S., Leroux, J., & Lechevallier, J. (2014). Surgery for slipped capital femoral

epiphysis in adolescents. Orthopaedics & Traumatology, Surgery & Research: OTSR,

100(1 Suppl), S157-S167. doi:10.1016/j.otsr.2013.04.015

Arora, S., Dutt, V., Palocaren, T., & Madhuri, V. (2013). Slipped upper femoral epiphysis:

Outcome after in situ fixation and capital realignment technique. Indian Journal Of

Orthopaedics, 47(3), 264-271. doi:10.4103/0019-5413.111492

Bock, C., & Orr, R. M. (2015). Use of the Functional Movement Screen in a Tactical

Population: A Review. Journal of Military & Veterans’ Health, 23(2), 33–42.

Chahal, J., Van Thiel, G. S., Mather, R. C., Lee, S., Salata, M. J., & Nho, S. J. (2014). The

minimal clinical important difference (MCID) and patient acceptable symptomatic state

(PASS) for the modified Harris Hip Score and Hip Outcome Score among patients

undergoing surgical treatment for femoroacetabular impingement. Orthopaedic Journal of

Sports Medicine, 2(2 suppl), 2325967114S00105.

Cummings, J. N., Butler, B., & Kraut, R. (2002). The quality of online social relationships.

Communications of the ACM, 45(7), 103-108. Hu, Y., Wood, J. F., Smith, V., &

Westbrook, N. (2004). Friendships through IM: Examining the relationship between

instant messaging and intimacy. Journal of Computer-Mediated Communication, 10, 38-

48


55

d’Entremont, A. G., Cooper, A. P., Johari, A., & Mulpuri, K. (2015). What Clinimetric Evidence

Exists for Using Hip-specific Patient-reported Outcome Measures in Pediatric Hip

Impingement?. Clinical Orthopaedics and Related Research®, 473(4), 1361-1367.

Dutton, M. (2004). Orthopaedic examination, evaluation & intervention. McGraw Hill

Professional.

Edwards, P. K., Queen, R. M., Butler, R. J., Bolognesi, M. P., & Barnes, C. L. (2015). Are

Range of Motion Measurements Needed When Calculating the Harris Hip Score?. The

Journal of arthroplasty.

Emder, P. J., & Jack, M. M. (2011). Iodine-induced neonatal hypothyroidism secondary to

maternal seaweed consumption: A common practice in some Asian cultures to promote

breast milk supply. Journal of Paediatrics & Child Health, 47(10), 750–752.

http://doi.org/10.1111/j.1440-1754.2010.01972.x

Enseki, K., Harris-Hayes, M., White, D. M., Cibulka, M. T., Woehrle, J., Fagerson, T. L., &

Clohisy, J. C. (2014). Nonarthritic hip joint pain. The Journal Of Orthopaedic And Sports

Physical Therapy, 44(6), A1-A32. doi:10.2519/jospt.2014.0302

Goodman, C. C., & Fuller, K. S. (2009). Pathology: Implications for the Physical Therapist.

Gribble, P. A., Hertel, J., & Plisky, P. (2012). Using the Star Excursion Balance Test to assess

dynamic postural-control deficits and outcomes in lower extremity injury: a literature and

systematic review. Journal of Athletic Training, 47(3), 339–357.

Hegedus, E. J., McDonough, S. M., Bleakley, C., Baxter, D., & Cook, C. E. (2015). Clinician-

friendly lower extremity physical performance tests in athletes: a systematic review of

measurement properties and correlation with injury. Part 2—the tests for the hip, thigh,


56

foot and ankle including the star excursion balance test. British Journal of Sports

Medicine, 49(10), 649–656.

Hyong, I. H., & Kim, J. H. (2014). Test of intrarater and interrater reliability for the star

excursion balance test. Journal of Physical Therapy Science, 26(8), 1139–1141.

Kienstra, K. J., & Marcias, C. G. (2016). Evaluation and management of slipped capital femoral

epiphysis (SCFE). 1-26.

Kiesel, K. B., Butler, R. J., & Plisky, P. J. (2014). Prediction of Injury by Limited and

Asymmetrical Fundamental Movement Patterns in American Football Players. Journal of

Sport Rehabilitation, 23(2), 88–94. http://doi.org/10.1123/JSR.2012-0130.

Larson, A. N., Sierra, R. J., Yu, E. M., Trousdale, R. T., & Stans, A. A. (2012). Outcomes of

slipped capital femoral epiphysis treated with in situ pinning. Journal Of Pediatric

Orthopedics, 32(2), 125-130. doi:10.1097/BPO.0b013e318246efcb

Levangie, P. K., & Norkin, C. C. (2011). Joint structure and function: a comprehensive analysis.

FA Davis.

Liu, M., Hu, Y., Li, G., & Hu, W. (2015). Low Growth Hormone Levels in Short-Stature

Children with Pituitary Hyperplasia Secondary to Primary Hypothyroidism. International

Journal of Endocrinology, 2015, 1–6. http://doi.org/10.1155/2015/283492.

Loder, R. T., & Dietz, F. R. (2012). What is the best evidence for the treatment of slipped capital

femoral epiphysis?. Journal Of Pediatric Orthopedics, 32 Suppl 2S158-S165.

doi:10.1097/BPO.0b013e318259f2d1

McAninch, E. A., & Bianco, A. C. (2016). The History and Future of Treatment of

Hypothyroidism. Annals of Internal Medicine, 164(1), 50–56.

http://doi.org/10.7326/M15-1799.


57

Miller, T., Association, C., & others. (2012). NSCA’s Guide to Tests and Assessments. Human

Kinetics.

Minthorn, L. M., Fayson, S. D., Stobierski, L. M., Welch, C. E., & Anderson, B. E. (2015). The

Functional Movement Screen’s Ability to Detect Changes in Movement Patterns After a

Training Intervention. Journal of Sport Rehabilitation, 24(3), 322–326.

http://doi.org/10.1123/jsr.2013-0140.

Moore, K. L., Dalley, A. F., & Agur, A. M. (2013). Clinically oriented anatomy. Lippincott

Williams & Wilkins.

Norris, B., & Trudelle-Jackson, E. (2011). Hip-and thigh-muscle activation during the star

excursion balance test. Journal of Sport Rehabilitation, 20(4), 428.

Novais, E. N., & Millis, M. B. (2012). Slipped capital femoral epiphysis: prevalence,

pathogenesis, and natural history. Clinical Orthopaedics and Related Research®,

470(12), 3432–3438.

Peltek Kendi̇rci̇, H. N., Aycan, Z., Sağsak, E., Keski̇n, M., & Çeti̇nkaya, S. (2015). The

evaluation of transient hypothyroidism in patients diagnosed with congenital

hypothyroidism. Turkish Journal of Medical Sciences, 45(4), 745–750.

http://doi.org/10.3906/sag-1404-109.

Philippon, M. J., Decker, M. J., Giphart, J. E., Torry, M. R., Wahoff, M. S., & LaPrade, R. F.

(2011). Rehabilitation exercise progression for the gluteus medius muscle with

consideration for iliopsoas tendinitis: an in vivo electromyography study. The American

Journal Of Sports Medicine, 39(8), 1777-1785. doi:10.1177/0363546511406848

Reiman, M. P., & Thorborg, K. (2014). CLINICAL EXAMINATION AND PHYSICAL

ASSESSMENT OF HIP JOINT‐RELATED PAIN IN ATHLETES. International

Journal of Sports Physical Therapy, 9(6), 737–755.


58

Sawka, A. M., & Jonklaas, J. (2015). Hypothyroidism. Canadian Medical Association Journal,

187(3), 205–205. http://doi.org/10.1503/cmaj.141596.

Sharma, V., & Oddy, M. J. (2014). Slipped capital femoral epiphysis: a review. British Journal

Of Hospital Medicine (London, England: 2005), 75(3), 155-161.

Slipped Capital Femoral Epiphysis: Background, Epidemiology, Functional Anatomy. (n.d.).

Retrieved April 4, 2016, from http://emedicine.medscape.com/article/91596-overview#a6

Stobierski, L. M., Fayson, S. D., Minthorn, L. M., Valovich McLeod, T. C., & Welch, C. E.

(2015). Reliability of Clinician Scoring of the Functional Movement Screen to Assess

Movement Patterns. Journal of Sport Rehabilitation, 24(2), 219–222.

http://doi.org/10.1123/jsr.2013-0139.

Thompson, G. H., Lea, E. S., Chin, K., Liu, R. W., Son-Hing, J. P., & Gilmore, A. (2013).

Closed bone graft epiphysiodesis for avascular necrosis of the capital femoral epiphysis.

Clinical Orthopaedics And Related Research, 471(7), 2199-2205. doi:10.1007/s11999-

013-2819-8

Tortora, G. J., & Derrickson, B. H. (2008). Principles of anatomy and physiology. John Wiley

& Sons.

Wamper, K. E., Sierevelt, I. N., Poolman, R. W., Bhandari, M., & Haverkamp, D. (2010). The

Harris hip score: Do ceiling effects limit its usefulness in orthopedics? A systematic

review. Acta orthopaedica, 81(6), 703-707.

Yazbek, P. M., Ovanessian, V., Martin, R. L., & Fukuda, T. Y. (2011). Nonsurgical treatment of

acetabular labrum tears: a case series. The Journal Of Orthopaedic And Sports Physical

Therapy, 41(5), 346-353. doi:10.2519/jospt.2011.3225


59

Appendix A

Modified Harris Hip Score Please mark one choice for each topic: Pain: ___None/ignores (44points) ___Slight, occasional, no compromise in activity (40 points) ___Mild, no effect on ordinary activity, pain after activity, uses aspirin (30 points) ___Moderate, tolerable, makes concessions, occasional codeine (20 points) ___Marked, serious limitations (10 points) ___Totally disabled (0 points) Function: Gait Limp ___None (11 points) ___Slight (8 points) ___Moderate (5 points) ___Severe (0 points) ___Unable to walk (0 points) Support ___None (11 points) ___Cane, long walks (7 points) ___Cane, full time (5 points) ___Crutch (4 points) ___2 canes (2 points) ___2 crutches (1 points) ___Unable to walk (0 points) Distance Walked ___Unlimited (11 points) ___6 blocks (8 points) ___2-3 blocks (5 points) ___Indoors only (2 points) ___Bed and chair (0 points) Functional Activities: Stairs ___Normally (4 points) ___Normally with banister (2 points) ___Any method (1 points) ___Not able (0 points)


60

Socks/Shoes ___With ease (4 points) ___With difficulty (2 points) ___Unable (0 points) Sitting ___Any chair, 1 hour (5 points) ___High chair, ½ hour (3 points) ___Unable to sit, ½ hour, any chair (0 points) Public Transportation ___Able to enter public transportation (1 points) ___Unable to use public transportation (0 points)

12-year-old male with slipped capital femoral epiphysis_ curran

Documents