Treatment of developmental hip dysplasia with manual therapy following Pavlik harness failure: a case report with long-term follow-up

ABSTRACT

Background

Developmental dysplasia of the hip (DDH) is a common musculoskeletal disorder in newborns, ranging from mild dysplasia to complete dislocation. Early detection and intervention are crucial for managing DDH. However, in some cases, standard orthopedic treatments such as the Pavlik harness fail, and alternative approaches are needed. Our study explores the possibility that manual therapy, specifically the Mézières-Bertelè Method (MBM), could be beneficial in cases of DDH that are resistant to conventional treatments.

Case Description

We present a case of a 20-month-old female who had been suffering from persistent DDH (Graf’s type IIIC on the left), pain and limping, despite previous conventional treatments, including the Pavlik harness. The patient received daily MBM sessions for six months, followed by maintenance sessions every two months.

Outcomes

After undergoing the MBM treatment, the patient showed clinical improvements, such as normal neuromotor development and restored hip joint parameters. We observed normal walking and running abilities, and X-ray parameters returned to normal levels. The patient sustained positive outcomes during long-term follow-up until the age of 7.

Conclusion

The MBM manual therapy was used to treat a challenging case of DDH resistant to conventional treatment. This case report suggests a possible correlation between manual therapy and improved outcomes in resistant DDH and highlights the potential relevance of addressing the inherent musculoskeletal components of the condition.

KEYWORDS:

• Developmental dysplasia of the hip
• manual therapy
• Mézières-bertelè method
• Pavlik harness
• case report
• neuromotor development
• alternative treatment
• resistant DDH

Background

Developmental dysplasia of the hip (DDH) is a prevalent musculoskeletal disorder that affects newborns. It includes a range of conditions, from mildly dysplastic acetabulum in a stable hip to complete hip dislocation [1]. The incidence of DDH varies due to a complex interplay of genetic factors and cultural practices, contributing to the intricate landscape of this condition [2]. The impact of DDH on a child’s quality of life, physical development, and social well-being underscores the importance of early detection and diagnosis. Regular checkups and screenings are pivotal to facilitate timely interventions for managing DDH [3]. The severity of dysplasia, assessed via ultrasound (US) within the first three months, guides subsequent treatment decisions.

The Graf method, which uses US examination, is currently the gold standard for diagnosing DDH within this critical timeframe [4]. This method, pioneered by Graf R. in 1980 [5], involves precise measurements of two angles derived from three lines (the bony roof line, the baseline, and the cartilage roof line measured at the acetabular labrum) taken from three landmarks (the lateral edge of the acetabulum, the bottom of the acetabulum, and the acetabular labrum). It provides a comprehensive classification system for hip dysplasia. The alpha angle consists in the bony roof angle, and the beta angle consists in the cartilage roof angle. According to this method, type I hips are considered mature, whereas type III hips are considered immature [6]. To treat DDH, experts recommend a noninvasive approach that focuses on timely interventions such as splints, braces, and harnesses that are tailored to the age and severity of the condition [3,7]. For infants under six months with a reducible hip, the Pavlik harness is widely used and considered the gold standard. However, the effectiveness of treatment depends on the patient and family’s compliance [8] and awareness of potential side effects such as avascular necrosis and femoral nerve palsy [9,10]. It is crucial to have collaborative efforts between healthcare professionals and parents to ensure comprehensive treatment and support the child’s growth. Early intervention can minimize potential long-term complications, fostering an improved prognosis [11].

The efficacy of the Pavlik harness in treating DDH is well-established, with a success rate often exceeding 75% [12]. However, in some cases, especially in children over six months old, early harness intervention may not be significantly beneficial. It is challenging to predict the success of harness treatment, but factors such as the alpha-angle detected during early US diagnosis can influence it [13]. When Pavlik’s method fails, closed or open reduction and casting become common alternatives for subluxated or dislocated hips. It is important to note that a failed Pavlik harness treatment attempt increases the risk of severe femoral head osteonecrosis during subsequent surgical reduction [12].

It is crucial to understand the challenges involved in managing hip dysplasia in children over six months of age. The slow rate of resolution and the limited effectiveness of bracing after this age pose difficulties for practitioners in determining suitable management options [14]. When conventional treatments fail, alternative treatments become more prominent, but there is limited data on manual therapy for DDH. A recent paper by Fludder et al. [15] reported significant improvements in two children with late-diagnosed DDH treated with manual techniques. The authors of the study found that positive changes in imaging were observed as early as three months and further normalization occurred after six months of manual therapy. They theorized that manual therapy played a role in restoring mechanotransduction, promoting hip joint growth and development, and femoral neck development. Their hypothesis revolves around the concept that appropriate mechanical forces, when applied to the surfaces of the acetabular joint, can directly influence the growth and development of the hip joint and the femoral neck. The theoretical underpinning suggests that this realignment could serve as a useful therapeutic approach for DDH [15]. Further mechanisms may include neurophysiological mechanisms such as modulation of neuromuscular activity, promotion of joint proprioception, and facilitation of proper alignment, but these aspects are currently understudied [16].

Françoise Mézières’ postural rehabilitation method, founded on the concept of ‘muscle chains,’ provides a unique perspective. The French physiotherapist developed her method of postural rehabilitation during the 20^th century, based on her observation that muscles function in groups to act together as a single muscle [17]. She called these groups, that are responsible for the body’s posture and structure [18], ‘muscle chains’. In Mézières’ morphoanalytic model, postural deformities stem from an ‘excess tone’ in these muscle chains. The approach focuses on stretching postures to address contracted muscular chains, using fundamental methods such as de-lordosation, de-rotation, and diaphragmatic liberation [19]. Other authors and disciples of Mézières, including G. Denys-Struyf, M. Nisand, and L. Bertelè, have explored this concept, albeit beyond the academic realm [19–22]. The Mézières method, recognized for its impact on the posterior muscle chain, has been associated with benefits in various fields. These include neurology, sports medicine, and postural/algological conditions. Although most of the existing literature on this method is in French and comprises small, low-quality studies, recent research efforts have introduced a more rigorous methodological analysis. For instance, a preliminary study on seven patients with migraines revealed improvements in pain and quality of life [23]. A case report has also documented that a patient suffering from thoracolumbar junction syndrome and chronic low back pain experienced relief of pain and posture improvement after 10 sessions of the Mézières’ method [24]. Postural therapy was found to aid recovery in 130 patients with tongue-tie after lingual frenectomy [25]. This exhibits an intriguing relationship between the ‘muscle chains’ described by Mézières throughout the body. A case report also demonstrated mouth-opening improvement in a patient treated for low back pain [26]. However, as of 2018 there have been no randomized clinical trials or studies conducted on the Mézières method for treating low back pain [27], despite its common application [28]. Nonetheless, a recent pilot study indicated a short-term decrease in chronic nonspecific low back pain following five-week sessions, which also facilitated body awareness learning [29]. In the field of neurology, a randomized controlled trial revealed that Parkinson’s disease patients experienced improved trunk flexibility and balance after postural rehabilitation using the Mézières method [30]. Interestingly, this method also found applications in sports medicine, demonstrating a positive effect on elite soccer athletes with nonspecific chronic low back pain, as well as providing benefits to gymnastic athletes with low back pain in two randomized controlled trials [31,32].

The concept of ‘muscle chains’ emphasizes the potential of manual therapy not only in alleviating the symptoms but also in addressing the underlying biomechanical aspects of DDH. The focus on restoring normal mechanotransduction highlights the intricate interplay between mechanical forces and the physiological development of the hip joint, providing a distinct perspective on the therapeutic mechanisms involved in DDH management.

The purpose of this case report is to describe the use of manual treatment as an alternative intervention for pediatric DDH. The manual therapy used was the Mézières-Bertelè method (MBM), a form of manual therapy and spin-off of Françoise Mézières’ original method. This was used for a case of DDH resistant to standard orthopedic procedures, including a Pavlik harness that had been used for three months.

Case description

History

The subject of this case was a female born in March 2013, with a breech presentation, and vaginal delivery facilitated with a suction cup, enjoying an otherwise healthy condition. During the neonatal screening two weeks following birth, bilateral hip immaturity was identified, leading to the diagnosis of a subluxated left hip with acetabular dysplasia (alpha angle 40°, beta angle 58.3° on the left, alpha 57.4°, beta 55.3° on the right). The physical examination indicated slight limitation of left hip abduction with Barlow maneuver. The Barlow Maneuver is a test used to determine if the hip can be dislocated, performed by gently adducting the hip while applying light pressure to the knee, pushing backwards. In this patient, it led to a definitive diagnosis of subluxated left hip with acetabular dysplasia. To address this issue, the initial treatment involved the use of a Leopardi-type divaricator diaper for a period of one month, 23/24 hours per day.

After using the divaricator diaper, further orthopedic evaluations were conducted, which revealed persistent dysplasia with subluxation of the left hip. The following measurements were obtained during the US exam in April 2013 (Figure 1): the right hip (Figure 1(a,b)) had an alpha angle of 54° and a beta angle of 59°, indicating type IIA dysplasia according to Graf’s classification. The left hip (Figure 1(c,d)) had an alpha angle of 46° and a beta angle of 107°, indicating type IIIC dysplasia. The physical examination confirmed that the left hip was subluxated and was resistant to reduction.

Figure 1. Bilateral hip ultrasound (a, b: right hip; c, d: left hip) at 1 month of age. Left hip type according to Graf: IIIc. At the physical examination, the left hip was subluxated and impossible to reduce. White arrow: acetabulum. **: femoral head.

In an attempt to address the condition, manual reduction was initially considered. This was performed using flexion and abduction with continuous traction. However, despite best efforts, it was unsuccessful. As a result, more invasive approaches were proposed to alleviate the dysplasia. These included arthrography, traction, and the application of a pelvic-podalic cast. The patient’s family declined these recommended interventions. Other hospitals also suggested a course of action involving traction followed by casting and surgical intervention. Yet, once again, the family refused to pursue these options. In the meantime, the patient was placed in a Pavlik harness while waiting for further intervention. It was understood that although the harness provided temporary support, surgery would likely be necessary in the future. In October 2013, a six-month period of traction on the left lower limb was recommended, followed by surgical intervention.

However, after using the Pavlik harness for three months, the left hip dysplasia was still present. A follow-up US exam performed in July, 2013 (when the baby was 4 months old), showed on the right, alpha angle >60°, beta angle >55° (Graf’s type IA); on the left side, evidence of dysplasia, very poor bony conformation of the acetabulum, flattened acetabular margin, acetabular cartilage compressed at the top, alpha angle between 43 and 49°, beta angle >77°. The type, according to Graf, was type IId. This finding led to the consideration of surgical intervention. The orthopedic surgeon suggested a surgical operation consisting of adductor + psoas tenotomy and plaster cast for six weeks. Yet, the family opted against this proposed surgical approach.

An X-Ray examination performed in September, 2014 (child aged 1 year and 2 months) showed: bilateral coxae valgae (144 degrees) with hypoplasic femoral cephalic nuclei on the left (Figure 2).

Figure 2. X-Ray examination at 1 year and 6 months of age, showing hypoplasic left femoral cephalic nucleus (arrow).

At 1 year and 8 months of age, the child was brought to our Clinic exhibiting a limp and complaining of slight pain in the left leg. Physical examination in the orthostatic position revealed hyperlordosis, a shorter left lower limb, externally rotated, and limitations in the range of hip movements, particularly concerning abduction. Measured range of movements (ROMs) of the hips were as follows: on the right side, external rotation: 74°, internal rotation: 30°; on the left side: external rotation: 40°, internal rotation: 50°; flexion > 90° bilaterally. After this evaluation and considering the failure of the previous treatment, we recommended daily manual therapy using the Mézières-Bertelè method (MBM) for six months. We believed that restoring the the child’s postural balance could help improve hip function and restore correct intra-articular relationships.

The family agreed to our proposal, which did not involve any surgical intervention that had previously been rejected. The family’s objective was to eliminate the child’s pain and limping, if possible, while avoiding invasive orthopedic treatment, which may be associated with its own set of post-surgical complications. It is important to acknowledge that there are both direct and indirect risks associated with this treatment option. Directly, manual therapy, such as the MBM, is generally considered safe when performed by properly by adequately trained professionals. However, potential risks do exist, ranging from minor discomfort during or post-therapy to, in rare occasions, injury due to improper technique. In this case, these risks were minimized by the professional supervision under which the therapy was administered. Indirectly, opting against the conventionally preferred surgical procedure in DDH cases was a significant decision. While surgery often results in a more immediate correction of the hip joint, it also carries its own risks, such as those related to anesthesia, infection, and the inherent uncertainties of the surgical outcome. Long-term complications can include residual dysplasia, redislocation, osteonecrosis, and even the potential requirement for joint replacement surgery [33].

To ensure the effectiveness of our approach, we arranged with the family to schedule the first clinical follow-up five to six months later. During this time, the physiotherapist supervised the patient to ensure that any macroscopic deterioration would not go unnoticed. After the first follow-up visit, we continued to see the patient annually to monitor physiological motor development and to measure the range of motion (ROM). Because of the patient’s clinical improvement and well-being, we decided to delay exposing the child to X-rays until 2017.

Treatment

The MBM is rooted in the theoretical framework conceived by Françoise Mézières, with its application being a derivative developed by her disciple, Dr. Laura Bertelè [19]. A fundamental aspect of Mézières’ theory that underpins the MBM is the concept of ‘muscular chains.’ The heightened tone and rigidity of these muscle chains are believed to cause postural changes and deformities. Therefore, the primary objective of the MBM is to restore equilibrium between tensions and joint mobility, aiming to regain symmetry and achieve an optimal body posture and shape [34].

The MBM specifically targets symmetry and muscle chain elasticity and tone correction. The therapist conducts a detailed clinical evaluation using the Mézières method to assess posture, muscle chain flexibility, respiratory function, and joint system mobility. The findings of this initial evaluation guide the setting of treatment goals, the selection of stretching positions, and the therapeutic approach. Thus, the treatment is tailored to the individual’s needs [35].

When dealing with infants and toddlers, a gentle approach is required to lengthen their trunk and limbs, with a particular focus on the posterior chain. Indeed, according to the Mézières principles, the dorsal muscles, which insert from the neck to the sacrum, are functionally interconnected with the posterior muscles of the thighs, legs, plantar muscles up to the anterior aspect of the shin. Therefore, stretching this chain is crucial to reposition the pelvis and allow for correct bone relationships at the hip joint.

The child is positioned supine on a semi-rigid surface (Figure 3), with one operator (Operator A, preferably the mother to reassure the patient) gently exerting traction on the nape without squeezing, while making sure not to lift it from the supporting surface (Figure 4). Hands should form a cup shape, with the fingertips positioned on the occipital squama.

Figure 3. The child is positioned supine with legs extended.

Figure 4. Traction on the nape exerted by Operator A.

A second operator (Operator B) should position himself at the child’s feet. Initially, his task is to ensure that the child’s legs are fully extended. Afterward, in coordination with Operator A, he should gently traction the dorsal muscles toward the pelvis, with the aim of reducing lumbar lordosis (Figures 5 and 6). This traction should be maintained for a few minutes and repeated 2–3 times. If feasible (i.e. if the child remains compliant and relatively calm), traction can also be applied to the gluteal and thigh muscles.

Figure 5. Operator B begins traction starting from the lumbar dorsal muscles.

Figure 6. Operator B continues the traction, descending with their hands down to the pelvis.

In November 2014, the child began receiving manual therapy based on the MBM method. The therapy was administered on a daily basis, with each session lasting approximately 10 minutes. The treatment was a collaborative effort involving the mother and another person who secured the child’s back. An experienced manual therapist was present once every 15 days to ensure the correct application of the therapy and monitor progress. On other days, a third collaborator, like the father, grandmother, or aunt, assisted with the therapy. Each session was approximately 10 minutes long, but the duration was adjusted based on the patient’s tolerance levels. This meticulous and consistent application of the MBM method aimed to address the specific biomechanical considerations associated with DDH, as detailed in the Discussion section, and promote optimal child musculoskeletal development. Additionally, the child was encouraged to play freely and spend a significant amount of time in water environments, such in the sea. However, it was not recommended to swim as a sport. This advice was aimed to stimulate proprioception development, promote weightless physical activity, and boost the natural production of Vitamin D, all of which could potentially enhance bone health.

Outcomes

A follow-up visit at 2 years and 1 month of age, 5 months after presentation, showed clinical improvements. Although the patient still couldn’t alternate legs on the stairs, she gradually reduced her limp while walking and became more capable of climbing stairs. The MBM treatment began in November 2014, with a prescribed daily regimen of 10 minutes, which was followed until April 2015. The procedure was well-tolerated by the patient up until this point. However, at that stage, the child started resisting physical contact from family members, which was part of the child’s natural development. This behavior was not directly related to any discomfort or dissatisfaction with the procedure. As a result, the patient was advised to continue maintenance sessions with the manual therapist every 2–3 months.

At the follow-up visit at 2 years and 10 months of age (1 year and 1 month after presentation), she was able to walk, jump, and run normally. Her psychomotor development was normal, and she walked and climbed stairs while alternating legs. Remarkably, there were no complaints of pain. During a physical examination in the orthostatic position, her legs were found to be symmetrically aligned. ROM measurements for the hips revealed the following: on the right side, external rotation at 60°, internal rotation at 20°, and flexion exceeding 90°; on the left side, external rotation at 70°, internal rotation at 30°, and flexion exceeding 90°. The improvement was even more significant considering that spontaneous resolution of Graf’s type II DDH after 6 months of age is very rare [36].

A subsequent X-ray was conducted at 4 years and 6 months of age, 2 years and 10 months after the initial presentation. The X-ray was taken in the orthostatic position and revealed a continuous Shenton line bilaterally. The Shenton line is an imaginary curve drawn along the inferior border of the superior pubic ramus and along the inferior border of the neck and head of the femur on an anteroposterior pelvic radiograph. Disruption of the Shenton line indicates a hip dislocation or subluxation, while in normal anatomy it should be continuous and smooth (Figure 7). Specific measurements included an Acetabular Index (AI) of 14° on the right side and 25° on the left side, as well as a Central Edge Angle (CEA) (of Wiberg) of 30° on the right side and 20° on the left side.

Figure 7. X-Ray of the pelvis at 4 years and 6 months of age. The white lines display two continuous Shenton lines. The Shenton line is an imaginary curve drawn along the inferior border of the superior pubic ramus and along the inferior border of the neck and head of the femur on an anteroposterior pelvic radiograph. Disruption of the Shenton line indicates a hip dislocation or subluxation, while in normal anatomy it should be continuous and smooth.

Long-term outcomes

The patient presented for long-term follow-up at 7 years and 7 months of age, demonstrating normal walking and running abilities without observable signs of limping or pain. Moreover, the child exhibited typical neuromotor development. During a late follow-up X-ray which was conducted in October, 2020, while in an orthostatic position, measurements indicated an Acetabular Index (AI) of 11° on the right side and 21° on the left side, while the Central Edge Angle (CEA) recorded 0° on the right and 15° on the left. The femoral head’s upper epiphyses of both legs were found to be in the inferomedial quadrant in relation to Hilgenreiner’s and Perkin’s lines (Figure 8). Additionally, the femoral adduction angles were measured at 10° on the left and 6° on the right. However, coxa valga were present, with a bilateral angle of 140°.

Figure 8. X-Ray of the pelvis at 7 years and 7 months of age. It depicts several white lines offering crucial measurements for developmental dysplasia of the hip (DDH). The Hilgenreiner’s line, a horizontal line through the inferior portion of the iliac bones at the triradiate cartilages, and a line from the sourcil’s medial edge to its most lateral point are represented. Their intersection creates the Acetabular Index. The Perkins’ line, a line perpendicular to the Hilgenreiner line intersecting the acetabular roof’s lateralmost point, is also illustrated. The femoral head’s upper epiphysis should be in the inferomedial quadrant, below the Hilgenreiner line, and medial to the Perkin line. Lateral displacement of the femoral head is a characteristic of DDH.

Observations suggest a connection between the administration of MBM treatment, which was initially given every day at high intensity and later reduced to once every two months, and sustained positive outcomes. Throughout the extended follow-up period, an improvement in hip joint parameters and overall musculoskeletal health was observed.

Table 1 displays the timeline of therapy characteristics and progression of outcomes.

Table 1. Summary of the chronological evolution of the case.

Date	Therapy	Outcome progression
11/2014–04/2015	MBM manual therapy performed by two operators each day for 10 minutes, supervised by a physiotherapist every 15 days.
04/2015		Follow-up visit: Clinical improvement noted as the patient gradually reduced her limp while walking and demonstrated increased capability in climbing stairs. However, she still struggled with alternating legs on the stairs.
04/2015–03/2017	Reduced to 1 session of 60 minutes of MBM manual therapy every 2–3 months due to the child’s lack of compliance for more frequent treatments.
01/2016		Follow-up visit: Significant clinical improvement observed, with the patient now able to walk, jump, and run normally. Both legs exhibit symmetrical alignment, and range of motion measurements are very close to normal.
09/2017		X-ray examination showed radiological improvement with close-to-normal AI and CEA measurements, but a contained asymmetry remains.
10/2020		Follow-up visit and X-ray examination confirmed that the improvements have remained stable in both clinical and radiological perspectives in the long term.

Discussion

This case report suggests a possible association between the use of manual therapy, specifically the Mézières-Bertelè Method (MBM), and the management of challenging cases of Graf type IId Developmental Dysplasia of the Hip (DDH). Conventional orthopedic treatments, including one month of Leopardi divaricator diaper and nearly three months of Pavlik harness, failed to produce positive outcomes for the 20-month-old female patient. The unresolved DDH condition was characterized by persistent femoral subluxation, a shorter leg, and limping.

The MBM manual treatment was administered as per the following schedule: daily sessions with family members for 6 months, followed by maintenance sessions with a manual therapist every 2 months. Additionally, it is worth noting that the patient spent a significant amount of time in the sea every year during summer vacations (4 months). Significant improvements were observed following the application of manual therapy. The patient showed normal neuromotor development, regained the ability to walk and run without any signs of discomfort, and X-ray parameters returned to the normal range. Impressively, they maintained these improvements until 2020, as documented by X-ray, which revealed consistently normal bilateral hips (Figure 8). Afterward, the patient decided to discontinue treatment.

Graf type IId DDHs, which are characterized by dislocated femurs, are relatively uncommon and comprise less than 4% of patients in DDH population studies [4]. Although some IIa hips may mature normally, the treatment of type IId hips is crucial, as they may progress to type III, requiring intervention to prevent severe dysplasia and subsequent osteoarthritis [37]. While some argue that most type II hips may normalize within the first 3 to 6 months of age, spontaneous resolution beyond this period is rare [36].

Despite extensive historical knowledge and specialist involvement, the exact etiopathogenesis of DDH remains poorly understood. Genetic factors have been extensively studied, with implications in chondrogenesis, skeletal morphogenesis, osteogenesis, and bone development [38]. Mechanical factors, including fetal mechanical constriction, also play a significant role in DDH. Factors such as large birth weight for gestational age, breech presentation, and oligohydramnios have been identified as contributors to DDH by The Lancet [39]. Vaginal delivery of breech-presenting babies can potentially be an avoidable risk factor. Accordingly, mechanical constriction after birth may also be involved, with long periods of extension and adduction of the newborn’s thighs being associated with DDH in some populations [39]. Interestingly, abnormal reflex contraction in soft tissues, which should fixate the hip joint may cause DDH in infants under six months of age [38].

The posterior chain, as described by F. Mézières (see Background section), is a complex network of muscles and connective tissues. It extends from the occiput (the base of the skull) to the thoracolumbar fascia and continues down the posterior side of the legs, all the way to the tibia. This interconnected system is intricately involved in the movements and stabilization of the femoroacetabular joint. When considering DDH, it may be helpful to look at the dislocation of the femur as a mechanical imbalance within the posterior chain. This imbalance results in an abnormal adduction of the femur, which leads to a series of cascading effects. It is hypothesized that the shortening of the posterior chain contributes to increased lordosis in both the cervical and lumbar spine. This creates a biomechanical environment that favors pelvic imbalance and exacerbates femoral adduction. As a result of this mechanical imbalance, a force is exerted that pulls the femoral head out of its socket (acetabulum). This disruption in the normal alignment and articulation of the hip joint is a hallmark of DDH. By examining the condition through this mechanical perspective, we can better understand the primary risk factors associated with DDH and emphasize the importance of addressing the underlying musculoskeletal aspects of this condition.

Publications on manual therapy or mobilizations for refractory DDH are extremely scarce. One study focused on the hip mobilization of a preterm infant diagnosed with DDH and suggested that an early treatment protocol aimed at optimal hip positioning may be beneficial for premature newborn patients with DDH [40]. Another case report discussed the effect of Korean medicine treatment, including acupuncture, electroacupuncture, cupping therapy, and chuna manual therapy for adult DDH over an eight-week period [41]. However, the study was published only in Korean, limiting its accessibility. A study protocol focused on the impacts of traditional Chinese medicine fumigation and washing as a complementary and alternative therapy in the treatment of DDH in children [42]. Although it primarily focuses on postoperative joint function recovery following surgery, it may offer a different perspective on DDH treatment. There is a notable case about a 75-year-old man with untreated bilateral hip joint dysplasia who presented with mild acute mechanical low back pain. The patient had severe bilateral hip dysplasia, which caused substantial postural and gait abnormalities, and was associated with an unusual pattern of osteoarthritic change in the spine. The patient benefited significantly from the manual therapy performed by the study’s authors, and his back pain was resolved. However, manual therapy in this case did not involve specific DDH treatment [43]. Another case report proposed a non-surgical intervention for a 31-year-old female with mild acetabular dysplasia and hip and groin pain. The patient’s posture was corrected, which resulted in a significant reduction in hip pain. This suggests that changing posture can have an immediate and lasting effect on hip pain in individuals with structural abnormality and labral pathology [44]. This finding is interesting from our perspective.

In two related pediatric DDH cases in the literature, manual therapy was employed to improve sacral and cervical spine joint function [15]. The authors of the study suggested that manual interventions could positively influence mechanotransduction, a process that could also benefit from reducing tension in the posterior muscle chain, as they stated, ‘[a technique] designed to improve the sacral and cervical spine joint function’ [15]. The authors posit that manual therapy can potentially assist in treating DDH by inducing alterations in mechanotransduction. From our perspective, we propose that this mechanotransduction could be further facilitated by alleviating tension in the posterior muscle chain. This suggests a complementary approach where manual techniques targeting the posterior muscle chain may contribute to the management of DDH.

This case provides additional insights that point toward a possible correlation between manual therapy and observed improvements in complex DDH cases. Deeper investigation into the mechanisms behind the positive observations in this case could provide new perspectives on therapeutic approaches that have not been considered previously for the management of DDH.

Limitations and future research

It is important to note that, as with all case studies, the findings of this case study may not be applicable. The treatment outcome was specific to this particular patient’s condition, age, compliance, and other individual factors, and therefore cannot be generalized. Moreover, there are inherent limitations to the study design. As a case report, our study provides detailed clinical observations but lacks a control group, making it difficult to establish a causal relationship between the MBM and the observed improvements in the patient’s condition.

Additional research is required to further assess the effectiveness of MBM as a complementary manual treatment for DDH. Ideally, randomized controlled trials should be conducted to rule out potential confounding factors and biases, and to establish a causal relationship between MBM and improved DDH outcomes. Moreover, further studies should also investigate the optimal timing, frequency, and duration of MBM in treating DDH. It would also be beneficial to explore the potential of MBM in managing other musculoskeletal conditions to better understand the wide-ranging applicability of this method.

Conclusion

In summary, this case report highlights the correlation between the use of manual therapy, specifically the Mézières Method in its Bertelè variant (MBM), and the improvement observed in a case of Graf Type IId Developmental Dysplasia of the Hip (DDH), which had previously shown resistance to conventional orthopedic interventions. Despite the initial failure of traditional treatments involving a Leopardi divaricator diaper and Pavlik harness, the patient showed remarkable improvements in neuromotor development, walking, and running after six months of daily MBM sessions, and subsequent maintenance once every 2 months. Furthermore, a follow-up X-ray examination three years later revealed normal bilateral hips.

Severe cases of DDH may not respond well to conventional orthopedic treatments. As an alternative, this report suggests exploring manual techniques. The mechanotransduction hypothesis and muscle chain theory provide insights into how tension relief could improve outcomes for patients with DDH. Since the causes of DDH are not yet clear and the results of treatment vary, this report emphasizes the potential benefits of manual therapy. However, further research is needed to confirm these findings and understand the role of manual therapy in managing DDH in the pediatric population. Therefore, conducting more comprehensive and rigorous research, such as randomized controlled trials, is of utmost importance in this area.

Statement of informed consent

Informed consent was obtained from the patient’s mother for publication of the case data.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10669817.2024.2349334.

Additional information

Notes on contributors

Valeria Giorgi

Valeria Giorgi, MD is a Assistant physician in internal medicine at the GOM in Lugano (Switzerland), acupuncturist, and kinesiologist, Dr Giorgi has always been interested in chronic pain; she closely collaborates with Dr Bertelè at the Apostolo Foundation from the research point of view.

Giovanni Apostolo

Giovanni Apostolo, is a Mathematical Engineer and last year Medical Student at Università Vita Salute San Raffaele in Milan. For years, he has been working at Fondazione Apostolo, supporting organizational, technical, and research aspects.

Laura Bertelè

Dr. Laura Bertelè, MD is a physician specialized in physical therapy and motor rehabilitation. She has made notable contributions in the field of physiotherapy, medicine, psychology, and bioengineering with her innovative methods, particularly in the treatment of scoliosis. She honed her skills through training with Françoise Mézières, an internationally renowned French physiotherapist, and developed her own method based on biomechanics and kinesiology. Dr. Bertelè is also a registered member of the Italian Association of Psychology and conducts training seminars for healthcare professionals. She primarily practices at the “Gino Rigamonti” Rehabilitation Centre in Merate, Italy. Her expertise is well recognized in her numerous publications about body and emotional language, healing, and pain management.