Hip Abductor Weakness and Ipsilateral Achilles Tendon Pain in a 10 Year-Old Male
with Prior History of Same-Side Legg-Calves-Perthes Disease: A Case Report
Manual Therapy Fellowship 1
Dyess AFB, TX., 2Regis University Manual Therapy Fellowship Program, Denver, CO.
ABSTRACT
Purpose: Physical therapists must frequently
investigate beyond the area of the patient’s
primary complaint to determine the underlying
impairment contributing to their patient’s
disability. The purpose of this case report is to
describe the biomechanical evaluation and
treatment rationale for a 10-year-old male, with a
prior history of right Legg-Calves-Perthes Disease.
Case Description: The patient complained of
right Achilles insertional pain with running and
playing soccer. His pediatrician’s two-week
treatment regimen of rest, ice and stretching
alleviated all symptoms at rest but they returned
as soon as he returned to soccer play. A physical
therapy evaluation was performed 4 weeks after
initial symptom onset.
• Examination of the foot and ankle revealed no
deficits in strength, passive motion, and no
tenderness to palpation. Gait analysis
demonstrated deficits (Table 1). Hip
assessment (Table 2) was normal except right
hip abduction MMT graded at 3+/5 with noted
pelvic and trunk compensatory movement
patterns.
• A treadmill running assessment showed normal
dorsiflexion through mid and late-stance with
onset of symptoms after 34 seconds and
continuation for the next minute. When
questioned further the patient reported he had
recently been experiencing “some” intermittent
pain in the area of the right hip, primarily with
weight-bearing activities. The patient could not
localize the pain, instead reporting that the pain
occurred “inside” the hip. Radiographs of the
right hip were ordered and were read as
unremarkable by the radiologist.
Treatment: It was hypothesized that the
weakness identified in the right hip abductors
altered the biomechanical loading and function
during running of the right Achilles, leading to
the presenting symptoms. The patient began a
16-week strengthening program requiring he
walk while carrying 5% to 15% of his
bodyweight (4-12 pounds) in his left hand to
functionally strengthen his right hip abductors
(Figure 1). Results: 15 week reassessment
Eric Wilson, PT, DSc, OCS, SCS, CSCS , 1 2
Hypothesis Table 1: Gait Assessment
• Weakened right hip abductors caused instability at •Lack of right ankle DF beyond neutral during mid & late-stance
right leg during walking – caused decreased step- •Early heel rise right compared to left
length on the left. •Contralateral (left) pelvic drop during right lower extremity
• Right leg prevented from attaining late-stance phase
weight-bearing
•Decreased step-length on the left when compared to the right
& minimal dorsiflexion past neutral – result was (31cm vs. 18 cm)
functional shortening of right Achilles w/ walking
• During running, step length and DF was normal thus Table 2: Hip Assessment
produced stretch at right Achilles resulting in irritation •A/PROM WNL
• Negative Flexion-Adduction, FABER, Scour tests
Intervention: • No palpable bony landmark asymmetry
• Clinic exercise prescription: walked 1.6mph on TM • No pain with palpation
• Hip strength 5/5 (except abduction 3+/5)
with 4# left UE x3’ (left UE fatigue).
• Initial: TM walk TID, 4# left UE, minimum 2’
Figure 1: Biomechanical Rationale of Exercise
• Progression Criteria: 10’ TID w/o fatigue x 3 days
then increase to 8#, decrease time (until fatigue)
• Progression Criteria: 7.5’ TID w/o fatigue x 3 days
M M1
then increase to 12# TID for maximum of 20’ each M2
Discussion:
• Pt met goals, disability (inability to play soccer) was
overcome as were his functional limitations (inability
to run, improper gait mechanics)
• Differential loading between un/involved hips
observed with unilateral LCPD1
• Strengthening hip abductors would produce increase
in step length2 by walking with weight comprised of 5- Diagram depicting frontal plane mechanics of the gluteus
15% of bodyweight in contralateral UE3,4 (Fig 1) medius/minimus (GMM)at the pelvis with a contralaterally carried
load. M=moment arm from center of acetabulum to line of pull of
Conclusions: GMM; M1=moment arm from center of acetabulum to center of body;
• After 16 wks of exercise the patient was able to run M2=increased moment arm from center of body to contralateral
on treadmill w/o symptoms weight. (Adapted from Wilson 2005)
• 6 month telephone follow-up revealed pt was
participating in spring soccer league x 2 months
without symptoms
• The patient’s symptoms may have resolved due to
the removal of the exacerbating activities (running &
soccer) although an initial 2 week period of rest by
his pediatrician did not relieve symptoms prior to PT.
• Additional research could investigate Achilles pain
and hip abductor strength in children with a history of REFERENCES:
1. Bailey et al. Med Sci Sports Exerc. 1997
LCPD. 2. Petrofsky JS. Med Biol Eng Comput. 2001
3. Neumann DA. Phys Ther. 1996
4. Neumann & Hase. J Ortho Sports Phys Ther 1994
5. Wilson E. J Strength Cond. 2005
The opinions and assertions contained herein are the private views of the author and are
not to be construed as official or as reflecting the views of the Departments of the Air
Force or Defense.