This week (2nd-8th March 2020) is Hip Health Week and we thought what better time to talk about babies and childrens’ hips as well as discuss the signs and symptoms to look out for that may indicate an underlying problem.  We are also supporting https://www.steps-charity.org.uk in their campaign to help raise awareness of hip health in babies and children.

In the UK up to 15% of children are born with some type of hip instability.  About 1 or 2 in every 1,000 babies has a hip problem needing treatment.  In fact, many more babies (about 6%) will have immature hips that will get better without treatment.

A hip problem can be hard to deal with, both for the child who has the problem and to the parent or caregiver.  A child who has a hip problem may feel pain in the hip, groin, thigh, or knee.  A child in pain may limp or be unable or unwilling to stand, walk, or move the affected leg.  A baby in pain may cry, be fussy, and have other signs of pain.

When a child is in pain his or her parents usually know it.  But pain can be hard for a child to describe.  An older child may be able to describe the pain as sharp or cramping or tell whether the pain comes and goes (intermittent).  A child between the ages of 18 months and 3 years may complain of pain or tell you he or she is not feeling well.  But the signs of pain in a very young child can sometimes be hard to recognize.  Watch for changes in how your child acts.

The signs listed below may help you decide whether your child’s pain is mild, moderate, or severe.  A child with severe pain will have more of these behaviours, the behaviours will be more constant, and you will be less able to comfort the child.  Look for:

• Changes in usual behaviour. Your child may eat less or become fussy or restless.
• Crying, grunting, or breath-holding.
• Crying that can’t be comforted.
• Facial expressions, such as a furrowed brow, a wrinkled forehead, closed eyes, or an angry appearance.
• Sleep changes, such as waking often or sleeping more or less than usual. Even children in severe pain may take short naps because they are so tired.
• Body movements, such as making fists, guarding a part of the body (especially while walking), kicking, clinging to whoever holds him or her, or not moving.

Hip problems may be present at birth (congenital) or may develop from injury, overuse, inflammation, infection, or tumour growth.  To better understand hip problems, it may be helpful to know how the hip works.  It is the largest ball-and-socket joint in the body.  The thigh bone (femur) has a ball (head) at the top that fits tightly into a cup-shaped socket (acetabulum) in the pelvis. The hip joint is tighter and more stable than the shoulder joint but it does not move as freely.  The hip joint is held together by muscles in the buttock, groin, and spine, tendons, ligaments, and a joint capsule. Several fluid-filled sacs (bursae) cushion and lubricate the hip joint and let the tendons and muscles glide and move smoothly.  The largest nerve in the body (sciatic nerve) passes through the pelvis into the leg.

Hip problems that affect children include:

• Developmental dysplasia of the hip (DDH). This condition is caused by a problem in the development of the hip joint. The top of the thigh bone (femoral head) does not fit correctly into the hip socket (acetabulum) so the femur can partially (sublux) or completely slip (dislocate) out of the socket. Babies born in the breech (bottom first) position are more likely to have hip instability than babies in a normal womb position and have an increased risk of DDH (up to 23%).
• An inward twisting of the thigh bone (Femoral Anteversion). This condition causes the knees and feet to turn inward. The child will have a “pigeon-toed” appearance and may have a clumsy walk. It’s important to note that a degree of femoral anteversion is part of normal development.  It is most evident between 2-4 years and will usually resolve spontaneously by the age of 10.
• Juvenile Idiopathic Arthritis (JIA). This condition causes one or more inflamed, swollen joints that are often stiff and painful. It first occurs before age 16.  JIA is slightly more common in girls.  It most commonly occurs in preschool age children or teenagers. There are different types of JIA and symptoms vary between the different types.
• An inflammatory reaction, such as Transient or Toxic Synovitis (Irritable Hip) commonly peaks at 3-8 years and more so in boys. This generally occurs after the child has had a cold or other upper respiratory infection.  This is the most common cause of hip pain in children.  Toxic synovitis has a scary name, but it’s not a scary condition.  This temporary inflammation of the hip can cause limping and pain in the hip and leg.  This can be unpleasant for a child and unsettling for a parent especially when symptoms start suddenly but toxic synovitis usually goes away within a week or two, and causes no long-term problems.
• Infection in the joint (Septic Arthritis), the bursa (Septic Bursitis), or the hip or pelvic bone (Osteomyelitis). Occurring at any age but most commonly from 0-6 years. Septic arthritis is an infection in the joint fluid (synovial fluid) and joint tissues.  Symptoms include fever, joint pain, swelling, redness, and warmth.  Quick treatment with antibiotics is needed to stop the risk of joint damage.
• A Slipped Upper Femoral Epiphysis (SUFE) or Slipped Capital Femoral Epiphysis (SCFE). This occurs when the upper end of the thigh bone (head of the femur) slips at the growth plate (epiphysis) and does not fit in the hip socket correctly. It has been linked to childhood obesity and is more common in boys than girls, usually between the ages of 8 and 17 years.
• Legg-Calve-Perthes Disease. This condition is caused by decreased blood flow to the head of the femur which affects the bone as seen on the X-ray and an MRI of a child with this problem. Perthes is approximately 4 times more common in boys than girls and generally occurs between 4 and 8 years of age.  Active children tend to be more affected.  The first symptom is usually a painless limp, but symptoms can be very subtle, with a mild ache in the thigh or knee not being uncommon.
• Proximal Focal Femoral Deficiency (PFFD). In other words, the end of the thigh bone closest to the hip is too short or not completely developed. In most cases, the hip joint is also not well developed.  The typical appearance is an unusually short thigh bone that is pulled upwards and turned toward the outside. The foot of the affected leg is often at the level of the opposite knee.  The knee often has varying degrees of instability as well.
• In rare cases, cancer of the bone, such as Osteosarcoma. This is a type of cancer that produces immature bone. It is the most common type of cancer that arises in bones, and it is usually found at the end of long bones, often around the hip or knee.

Treatment for a hip problem depends on the location, type, and severity of the problem as well as the child’s age, general health, and activity level. Treatment may include first aid measures; application of a brace, cast, harness, or traction; physiotherapy; medicines; or surgery.

How will I know if my child has a problem with their hips?

Here are some things to look out for with your baby or child:

• One leg shorter than the other. The leg may appear to twist in or outwards, hips/pelvis may appear to be unlevel in standing.
• Clicking or clunking hips (with or without pain). Often felt or heard when changing your baby’s nappy.
• Obvious pain when moving their leg or hip.
• If your child complains of pain in their hip, thigh or knee.
• Reluctant to weight bear on one or both legs.
• Delay in motor skills (crawling or pulling to stand)
• Abnormal gait (walking pattern); walking with a limp, dragging one leg (when walking or crawling), walking on tiptoes (often on one side), excessive intoeing.

If you are worried about your child’s hips and they present with one or more of the above then it is important to get them checked by a health professional such as your GP or a physiotherapist.  This doesn’t necessarily mean that your child is suffering from one of the conditions we have mentioned but it’s always best to get them checked.

How can physiotherapy help my child?

Here at The Children’s Physio we are highly specialised in assessing and treating children with hip conditions.  We can assess your child and provide treatment and exercises to help to keep them strong and supple.  If your child requires surgery for their hip condition we can play an important role in the rehabilitation in order for your child to get back to their pre-op functional level and help to prevent further complications in the future.

Things we may look at when we see your child are:

• Look for any signs of pain, asymmetry, leg length discrepancy , heat or swelling (rarely seen in hips as the joint is so deep).
• Assess their active and passive joint range of movement and muscle tone/strength.
• Palpate (feel) the soft tissues and joints.
• Examine their gross motor movements; crawling or walking pattern (gait) as well as look at manoeuvres such as squatting, single leg balance or hopping.
• We may refer onto specialist centres for further tests or investigations.
• We can provide advice and exercises to help your child to remain active and strong as well as techniques to aid their development before, during and after any surgical intervention.

Remember, if you have any questions or concerns relating to your childs’ hips or their general development The Children’s Physio will be able to advise.