Perthes Disease: Causes, Symptoms, and Treatment
Has your child started to limp without a clear injury? Is your child avoiding running or jumping, or do they complain of pain in their hip, thigh, or knee? It is completely natural to feel concerned, especially when the cause isn’t immediately clear. Although rare, one possible explanation is Perthes disease: a condition that affects the hip joint during childhood. While it can sound alarming, understanding what’s happening, and why early diagnosis and tailored treatment matter, can make a big difference to your child’s outcome.
In this blog, we’ll explain what Perthes disease is, why it happens, what signs to look out for, and how to support your child through recovery. With the right care and information, there is hope, and a high chance of a healthy, active future.
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This blog will cover the following topics on Perthes Disease:
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What is Perthes Disease?
Legg-Calvé-Perthes disease (more commonly referred to as Perthes disease), is a rare but significant paediatric hip condition that affects the femoral head (the ball part of the hip joint). Perthes occurs when the blood supply to the femoral head is temporarily interrupted, leading to avascular necrosis (the bone cells die). Due to the weakened bone, the femoral head loses its round shape and can result in pain, stiffness or reduced range of motion in the hip. Indeed, over time the body restores bloody supply to the affected bone allowing it to heal. Thus, choosing the right treatment is imperative to optimise healing time and quality.
Who is affected?
Perthes presents in children ages 3-12 years of age, with the highest rate of occurrence in those aged 5-7 years (Rodríguez-Olivas, Hernández-Zamora & Reyes-Maldonado 2022). Interestingly, boys are diagnosed five times as often as girls and the condition is found in both hips in 10-24% of patients (Rodríguez-Olivas et al., 2022).
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Stages of Perthes Disease
Perthes is a condition that has multiple stages that clinicians use to assess disease severity and progression and are important considerations when deciding what treatment method to use. Perthes is classified into four stages:
Initial Stage (Necrosis):
Disruption of blood supply to the femoral head, causing the hip joint to become stiff and painful. Areas of bone start to break down (avascular necrosis).
Fragmentation:
The femoral head begins to remodel by reabsorbing the dead bone cells and replace them with new healthy ones.
Re-ossification:
New bone continues to form and replace the damaged bone. The femoral head begins to remodel into a round shape again. This phase can last for 1-3 years.
Healing:
The dead bone cells are completely replaced by newly formed bone. This phase continues until the child stops growing
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Causes of Perthes Disease
As previously mentioned, Perthes disease occurs when blood supply to the femoral head is reduced and thus the bone weakens and changes shape. The exact cause for the reduced blood flow, remains unknown. However, several factors have been hypothesised to contribute to its development:
Genetics
The presence of certain genes found in families has been linked to the presence of Perthes. Studies have reported a correlation to inheritance of approximately 8-12% (Rodríguez-Olivas et al., 2022)
Sex
Boys are more often affected than girls
Mechanical overload
Repetitive impact to the hip joint might influence the development of Perthes. For example, sports with lots of jumping and running. Alternatively, other factors such as obesity can place higher loads on the hip joint
Vascular conditions
Blood circulatory conditions such as hypertension or prevalence to clotting may increase risk of Perthes
Environmental conditions
Such as mechanical load, structural deviations, geographic location, socio-economic status
Symptoms of Perthes Disease
The onset of Perthes disease is often gradual, with symptoms that may be subtle at first. A child with Perthes may experience one or more of the below symptoms:
Limping:
Especially after physical activity (this limp may be pain-free).
Hip or Knee Pain:
Discomfort in the hip, groin, thigh, or knee area.
Limited Range of Motion:
Difficulty moving the hip joint, particularly into internal rotation (leg turning inwards) or abduction (leg moving out to the side). Often the hip will feel stiff when trying to move it.
Muscle Weakness:
Weakness in the muscles around the hip joint.
Diagnosis of Perthes Disease
Diagnosis of Perthes disease requires thorough investigation, as other possible diagnoses need to be excluded. To do this, investigation will involve a combination of clinical examination and imaging studies. These might include:
Physiotherapy assessment:
A physiotherapist will complete a series of thorough tests to determine a child’s presentation is clinically consistent with Perthes disease.
X-Ray:
X-Rays are useful for looking at the hip joint and whether there are any changes to the shape or structure of the femoral head.
Magnetic Resonance imaging (MRI):
MRI is useful for detecting changes in blood supply to the femoral head and determine severity of the condition.
Blood tests:
Blood tests are performed to rule out infection or other conditions.
Treatment of Perthes Disease
Treatment for Perthes is decided on a case-by-case basis as the degree of femoral head deformity varies greatly between presentations. Treatment can be broken into two categories: non-surgical and surgical. Determining which treatment option is best requires careful consideration as there is no definitive gold standard treatment and therefore how to make this decision is something researchers are still investigating (Galloway, Nicolaou & Perry 2025). With this in mind, practitioners will consider the child’s age, severity of the condition and the stage of the disease when deciding on which treatment method to use.
Non-Surgical Treatment for Perthes Disease:
For less severe cases, non-surgical treatment is often preferred. This treatment consists of reducing high impact physical activity and careful monitoring of hip symptoms and range of movement.
Whilst there are no conclusive guidelines for non-surgical treatment, there are some recommendations that clinicians agree upon when treating those with Perthes. For example, in the early stages (necrosis and fragmentation of bone), a child with Perthes should avoid high impact strengthening exercises such as star jumps and squat jumps (Galloway et al., 2024). Furthermore, jumping activities such as bouncy castles and trampolines should be discouraged (Galloway et al., 2024).
Not all activities have to be ceased in the early stages. Clinicians encourage swimming, cycling and balance exercises to maintain cardiovascular fitness (Galloway et al., 2024).
Once Perthes reaches a later stage (where there is evidence of bone healing and remodelling), physios encourage activities that place slightly higher loads on the hip joint. This may include hip and trunk strengthening, stretching exercises, as well as cardiovascular activities such as cycling and swimming, and even horseriding (Galloway et al., 2024).
Surgical Treatment for Perthes Disease:
If a child’s Perthes disease presentation is severe, a surgical option might be considered. Surgical approaches typically involve either an acetabular osteotomy (where a surgeon will change the shape of the hip socket to optimise healing) or a varus femoral osteotomy (where a surgeon will change the shape of the thigh bone to optimise healing) (Galloway et al., 2024). The evidence around effectiveness of surgical treatment is unclear and therefore must be carefully decided upon by health professionals.
In summary, Perthes disease is childhood (paediatric) condition that requires careful diagnoses and management. Perthes can be broken down into four stages and thus early diagnosis is key for improving disease prognosis. There is no one way that Perthes is treated and therefore will depend on a child’s age, stage of the disease and the severity of the disease. If you start to notice your child limping, complaining of hip and or knee pain, demonstrating weakness or loss of hip range, visit a physiotherapist knowledgeable in hip conditions for an assessment. Lastly, remember that while Perthes can take considerable time to heal, it is a self-healing condition that has a high success rate in resolving with the help of health professionals.
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Author
This blog was written by Dr. Molly Connolly, one of our Sports Physiotherapists and Pilates Instructors. Molly's undergraduate degree was in Exercise and Sports science and she completed a PhD of the title: A multidisciplinary approach to understanding low back pain in elite adolescent tennis athletes. She also has a love of triathlon! Molly completed a post-graduate Masters in Physiotherapy at the University of South Australia.
You can read more about Molly here.
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References:
- Galloway, A. M., Keene, D. J., Anderson, A., Holton, C., Redmond, A. C., Siddle, H. J., ... & Perry, D. C. (2024). Clinical consensus recommendations for the non-surgical treatment of children with Perthes’ disease in the UK. The Bone & Joint Journal, 106(5), 501-507.
- Galloway, A. M., Nicolaou, N., & Perry, D. C. (2025). Surgery versus the non-surgical treatment of Perthes’ disease (Op Non-STOP): the journey to a definitive randomized controlled trial in Perthes’ disease. The Bone & Joint Journal, 107(3), 280-282.
- Rodríguez-Olivas, A. O., Hernández-Zamora, E., & Reyes-Maldonado, E. (2022). Legg–calvé–perthes disease overview. Orphanet journal of rare diseases, 17(1), 125.