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Transcript of 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
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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.
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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.,
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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)
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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).
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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(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)
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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).
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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).
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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.
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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.
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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).
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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).
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
Subjective History and Chief Complaint
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.
24-hr pain report (NPRS)=
3/10 pain at worst (walking long distances and going down stairs)
0/10 best (sitting, laying on back)
0/10=current
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
Based upon information gathered in the chart review and history, a thorough plan for
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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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-)
Straight leg raise: 80 degrees R, 80 degrees L
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.
Single limb stance: Test was performed on stable surface with the patient’s eyes open
using a stop watch to time.
R= 17s Test was stopped due to Pt stepping forward with L leg to catch balance.
Observable Trendelenburg stance on the R.
L= 30s – observable Trendelenburg stance on the L.
Single limb squat: Assessed on a stable surface.
R: Increased R lateral lean throughout motion and decreased trunk forward
flexion. Reached 80% of hip and knee flexion compared to the L.
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
upright posture was achieved.
Star Excursion Balance Test
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.
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 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).
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
36
Functional Outcome Measures
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
Subjective History and Chief Complaint
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.
24-hr pain report (NPRS)=
1/10 pain at worst (walking long distances)
0/10 best (sitting, laying on back)
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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
Based upon information gathered in the chart review and history, a thorough plan for
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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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: -
Straight leg raise: 85 degrees R, 85 degrees L
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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.
Single limb stance: Test was performed on stable surface with the patient’s eyes open
using a stop watch to time.
R= 26s Test was stopped due to Pt stepping forward with L leg to catch balance.
L= 30s – observable Trendelenburg stance on the L.
Single limb squat: Assessed on a stable surface.
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,
upright posture was achieved.
Star Excursion Balance Test
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%
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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.
Chad was able to perform the SEBT with ease on the left lower extremity without any
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).
Functional Outcome Measures
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.
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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).
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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.
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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.
(Philippon et al., 2011).
Figure 12. Strengthening exercises implemented in phase three.
(Philippon et al., 2011).
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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- 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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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.
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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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.
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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
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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,
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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.
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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.
12-year-old Male with Slipped Capital Femoral Epiphysis: A Case Report
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
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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)
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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)