Legg Calve Perthes

Disease
Synonyms
Perthes Disease
Osteochondritis Deformans Juvenilis
Childhood Aseptic Necrosis of Femoral Head

Dr. P. Ratan khuman (PT)

M.P.T., (Ortho & Sports)
 Definition
• Perthes’ disease is a self-limiting form of
osteochondrosis of the capital femoral epiphysis
of unknown aetiology that develops in children
commonly between the ages of 5 – 12 years.
• It is a condition of immature hip caused by
necrosis of the femoral epiphysis; the femoral
head subsequently deforms as necrotic bone is
replaced by living bone.
• It is Hip disease occurring during early childhood
and caused by impaired circulation in the
femoral head.
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 Historical background
• The disease was described almost simultaneously, in
1910, by –
– G. C. Perthes in Germany,
– J. Calve in France
– A.T. Legg in America.
– Hence name – “Legg Calve Perthes Disease”

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 Grade – I
• Only anterolateral quadrant affected

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 Grade - II
• Anterior third or half of the femoral head

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 Grade – III
• Up to 3/4 of the femoral head affected,
• only the most dorsal section is intact

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 Grade – IV
• Whole femoral head affected

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 Physical Therapy
Assessment & Diagnosis

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 Clinical Assessment
• A thorough history and examination be completed to
establish an impairment based physical therapy diagnosis and
individualized plan of care (APTA).
• It is recommended initial evaluation, on a monthly basis or
sooner if the pt demonstrates a change in status, and at
discharge:
– Pain and symptoms
– Lower extremity PROM & AROM
– Lower extremity strength
– Gait
– Balance
– Outcome measures

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 Classification of Phases of Rehab
• It is recommended that the Classification Instrument in
Perthes (CLIPer) be used to place the patient into a
rehabilitation classification phase upon examination.
• The patient should be re-examined using the CLIPer on
a monthly basis to determine the appropriate
progression through the rehab classification stages
• It is recommended the patient is referred back to the
orthopaedic surgeon if the patient’s status worsens
over two consecutive PT sessions

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Rehabilitation Classification Phase
• Score total 14 to 24: Severe Involvement
• Score total 6 to 13: Moderate Involvement
• Score total 0 to 5: Mild Involvement

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 Goals for Management
CLIPer score 14 to 24 CLIPer score 6 to 13 CLIPer score 0 to 5
• Reduce pain to < 7/10 • Reduce pain to < 4/10 • Reduce pain to 1/10 or
• Increase ROM to >50% • Increase ROM to > 75% of the less
of the uninvolved side uninvolved side • Increase ROM to >90%
• Increase strength to • Increase strength to > 75% of of the uninvolved side
>50% of the uninvolved the uninvolved side • Increase strength to >
side • Progress from use of an 90% of the uninvolved
• Patient to be assistive device if approved by side
independent with the physician and without adverse • Improve balance to
appropriate assistive effects >90% of the maximum
device and weight • Independence with a step to Pediatric Balance Scale
bearing precautions pattern on stairs without UE score or single limb
• Improve balance to support stance of the
>50% of the maximum • Improved efficiency in walking uninvolved side
Pediatric Balance Scale • Improved balance to > 75% of • Ambulation with a non-
score or single limb the maximum Pediatric painful limp with
stance of the Balance Scale score or single normal efficiency
uninvolved side. limb stance of the uninvolved
side

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 Pain Management

CLIPer • Hot pack with stretching

score • Cryotherapy
14 to 24 • Medications as prescribed by the referring physician for
pain

CLIPer • Hot pack with stretching

score • Cryotherapy
6 to 13 • Medications as prescribed by the referring physician for
pain

CLIPer • Hot pack with stretching

score • Cryotherapy
0 to 5 • Medications as prescribed by the referring physician for
pain

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 ROM Management
• Static stretch for LE musculature with or without hot pack
• Dynamic ROM & AAROM if muscle guarding due to pain and
is unable to achieve end ROM with static stretch.
CLIPer • Perform AROM and AAROM following passive stretching to
score maintain newly gained ROM .
14 to 24 • Stretching for hip – IR, ER, Abd, Extensor, & any other lower
extremity motion that is significantly limited

CLIPer
score • Same as above
6 to 13 • Dosage of may differ based on patient preference &
comfort.
CLIPer
score • Same as above
0 to 5 • Dosage of may differ based on patient preference &
comfort.

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 ROM cont…
• Static Stretching Parameters –
– 2 minutes of stretching/day/muscle group
– 30 second hold time
– 4 repetitions per muscle group
– If not tolerated, may do 10 to 30 second hold time
with repetitions adjusted to meet 2 minute
requirement
• e.g. if holding 15 seconds, would do 8 stretches

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 ROM cont…
• Dynamic Stretch Parameters –
– 5 second hold
– 24 repetitions per muscle group per day to meet 2
minute stretching time required

• Done if patient does not tolerate static stretch

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 Strengthening Ex (CLIPer score 14 to 24)
• Isometric Ex -> Isotonic Ex in gravity lessened
-> Isotonic Ex against gravity.
• It is appropriate to include concentric and
eccentric contractions.

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 Strengthening Ex (CLIPer score 14 to 24)
• Focus on strengthening of HIP (Abd + Flexors + ER
+ IR + Extensors + or any other LE muscle group
that displays significant strength deficits).
• Special attention to gluteus medius to min intra-
articular pain & for pelvic control during single leg
activities and ambulation .
• Weight bearing Vs Non-weight bearing ex is
based on patient’s tolerance to weight bearing
positions, and safety.

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 Strengthening Ex (CLIPer score 14 to 24)
• Closed chain double limb exercises with light
resistance (less than full body weight)
• It is not recommended to perform single limb
closed chain ex on the involved side due to
increased intra-articular pressure in the hip
joint.

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 Strengthening Ex (CLIPer score 6 to 13)
• Isotonic Ex in gravity lessened -> Isotonic Ex
against gravity.
• Include concentric & eccentric contractions.
• Weight bearing and non-weight bearing
activities can be used in combination based on
the patient’s ability and goals of the treatment
session.

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 Strengthening Ex (CLIPer score 6 to 13)
• Upper extremity supported functional
dynamic single limb activities may be
performed.
– e.g. step ups, side steps
• Double limb closed chain ex may be used with
light resistance if weight bearing allows.
– e.g. mini-squats

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Strengthening Ex (CLIPer score 0 to 5)
• Isotonic Ex in gravity lessened -> Isotonic Ex
against gravity.
• Include concentric & eccentric contractions.
• Functional dynamic single limb activities with
UE support as needed for patient safety may
be performed.
– e.g. step ups, sidesteps
• Closed kinetic chain single limb exercises with
light resistance may be performed.
– E.g. leg press
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 Strengthening Ex Prescription
• Special attention should be given to:
– Hip abductors (especially gluteus medius)
– Hip internal rotators
– Hip external rotators
– Hip flexors
– Hip extensors

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 Isometric Strengthening
• Parameters –
– 10 sec hold + 10 rep/muscle gr, total = 100 sec.
– Can adjust hold time to 5 sec + 20 rep to meet 100
sec requirement
• Intensity –
– Performed at approx. 75% maximal contraction
• Performed with hip in neutral position

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 Isotonic Strengthening
• Parameters –
– High repetitions (10 to 15 reps) and 2 to 3 sets
– Perform both concentric & eccentric contraction
– Low resistance
• Rest 1 to 3 minutes between sets
• Rest can include exercise of a different muscle group or
cessation of activity
• If pt is unable to perform 2 sets of 10 rep, exercise
intensity should be decreased either through weight or
type of exercise
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 Balance training (CLIPer score 14 – 24)
• If weight bearing status & symptoms allow –
– Activities that include double limb stance and a
narrowed base of support on stable surfaces may
be performed.
• It is not recommended to perform single limb
activities due to increased intra-articular
pressure in the hip joint.

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 Balance training
(CLIPer score 6 – 13 & 0 – 5)

• Same as previous stage

• Limit prolonged single limb activities due to
excessive joint compressive forces

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 Gait training (CLIPer Score 14 – 24)
• Follow the referring physician’s guidelines for
weight bearing status.
• Begin gait training with –
– Appropriate assistive device
– Weight bearing status as determined by the
referring physician or
– Based on the patient’s tolerance to full weight
bearing due to pain or safety

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 Gait training (CLIPer Score 6 – 13)
• Continue to follow the referring physician’s
guidelines for weight bearing status.
• Progress to gait training without use of an
assistive device as appropriate, focusing on
minimizing deficits and improving efficiency of
walking.

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 Gait training (CLIPer Score 0 – 5)
• Continue to follow the referring physician’s
guidelines for weight bearing status
• Progress to gait training without the use of
an assistive device as appropriate, focusing
on minimizing deficits and improving the
efficiency of walking.
• Stair negotiation & other functional mobility.
• Progress to walking on uneven surfaces with
an emphasis on safety.
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 Weight Relief
• The load on the hip can basically be relieved
by the following methods:
– Bed rest
– Wheelchair
– Walking with crutches,
– Bracing devices (Thomas splint , Mainz orthosis,
etc.).

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Petrie Cast

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Broomstick Cast

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 Classification Instrument in Perthes (CLIPer)
Domains Description Score
7 to10/10 4
Pain with
4 to 6/10 2
ADL
0 to 3/10 0
Less than 50% of uninvolved side for the majority of directions 6
Hip ROM 50 to 75% of uninvolved side for the majority of directions 3
76 to 100% of uninvolved side for the majority of directions 0
Less than 50% of uninvolved side for the majority of muscle groups 6
Hip
50 to 75% of uninvolved side for the majority of muscle groups 3
Strength
76 to 100% of uninvolved side for the majority of muscle groups 0
Pediatric balance score less than 50% of best score (best score=56)
4
OR SLS with eyes open less than 50% of time on uninvolved side
Balance Pediatric balance score 50 to 75% of best score (best score=56) 2
OR SLS with EO of uninvolved side 50 to 75% length of time
Pediatric balance score 76 to 100% of best score (best score=56)
0
OR SLS with EO 76 to 100% of uninvolved side
NWB and uses an assistive device and without AD, displays excessive
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gait deficits with decreased efficiency
Gait No assistive device & displays excessive deficits without a decrease in 2
efficiency. Uses step to pattern on stairs
Non-painful limp Able to perform reciprocal pattern on stairs 0
Total:

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 References:
• Lee J, Allen M, Hugentobler K, Kovacs C, Monfreda J,
Nolte B, Woeste E; Evidence-Based Care Guideline
Conservative Management of Legg-Calve-Perthes
Disease In children aged 3 to 12 years, Cincinnati
children’s hospital medical center, 2011
• Benjamin Joseph, Paediatric Orthopaedics, A System
Of Decision-making, 2009
• Fritz Hefti, Pediatric Orthopedics in Practice, 2007
• David Wilson (Ed.), Paediatric Musculoskeletal
Disease With an Emphasis on Ultrasound, 2005
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