Managing Disorders of the Canine Front Limb
- 1 Introduction
- 2 Shoulder
- 2.1 Osteochondrosis
- 2.2 Supraspinatus Tendinopathy
- 2.3 Biceps Brachii Tendinopathy
- 2.4 Medial Shoulder Syndrome
- 3 Elbow
- 4 Carpus and Digits
- 5 References
Forelimb lameness in dogs is very common, but it can be difficult to determine its exact cause. This page discusses some of the more common types of forelimb lameness in the canine patient.
The shoulder joint is the most mobile of all canine limb joints. Motion at the shoulder includes abduction, adduction, internal rotation, external rotation, but the primary movement is in the sagittal plane. Stability of the canine shoulder is maintained by the joint capsule, the medial and lateral glenohumeral ligaments, as well as large tendons located inside or just outside the joint.
The most common cause of shoulder lameness is osteochondrosis (OCD). OCD occurs when cartilage grows at a faster rate than the underlying bone, which causes areas of cartilage thickening. The thickened cartilage becomes prone to shearing forces and may detach from the subchondral bone. Once there is detachment, the synovial fluid comes into direct contact with the subchondral bone, which causes inflammation. At this stage in the disease process, the syndrome becomes known as osteochondrosis dissecans and has an inflammatory component.
Early diagnosis is important as it can influence recovery rate and may prevent degenerative changes from occurring.
- Dogs are aged between 6 and 9 months of age (although it can present up until 12 months of age)
- Affects medium to large-breed dogs more than small-breed dogs
- Around one third of dogs are affected bilaterally
- The shoulder joint is most often affected, but it can occur in other joints and multiple joints can be affected
- There will usually be a history of intermittent lameness
- There will usually be some shoulder muscle atrophy
- Pain is provoked with passive shoulder extension and flexion, as well as with digital pressure over the humeral head
- It can be imaged with x-ray, ultrasound, CT and MRI
Surgical management is usually required. Once the cartilage flap is removed, the area will fill with connective tissue. If this flap is not removed, there will be ongoing joint irritation, which will cause long-term deficits and degeneration of the joint cartilage (i.e. there is a high risk of osteoarthritis). Young dogs aged between 6 and 10 months have the best outcomes following surgical interventions.
There are few evidence-based recommendations for rehabilitation following the surgical removal of an OCD lesion. Some studies recommend between 4 and 12 weeks of complete non weight bearing, which usually means 4-12 weeks of cage rest.
Physiotherapy in the initial phase aims to:
- Restore full passive range of motion (ROM)
- Reduce joint swelling
- Introduce static strengthening exercises
- Gradually introduce non-weight bearing exercises through range (e.g. swimming)
In order to progress to weight bearing exercises, the dog needs to have:
- No pain or swelling in the joint
- Full passive ROM
- Radiographic evidence that the OCD lesion is healing / filling
After 4 to 6 months, the dog may be allowed to start with progressive cardiovascular exercises - i.e. longer walks, straight-line running. They must be on their leash so that they do not twist / turn and strain the joint surface. Dogs can only start more strenuous activities (i.e. sudden turning, sudden stops, acceleration etc) 6 months after surgery if they have no recurrence of pain or joint effusion.
Supraspinatus tendinopathy usually occurs in working / performance dogs. There is no specific age, sex, or breed predisposition to developing this condition. It is believed that supraspinatus tendinopathy is caused by overuse (i.e. chronic, repetitive activities). Inflammation may be present in the early stages, but it is not typically involved in the later stages of the disease process.
- Canine patients with this condition usually present with varying degrees of lameness
- Weight-bearing lameness is often worse with activity
- There may be atrophy of the supraspinatus muscle
- There is usually pain on direct palpation of the supraspinatus tendon and with shoulder flexion
- There is often concurrent elbow dysplasia and or other pathological changes in the shoulder
- After function returns, dogs remain susceptible to re-injury
The medical management usually involves non-steroidal anti-inflammatories (NSAIDs) and controlled activity for a period of time alongside physiotherapy management. Other treatments may include: acupuncture, deep cross-friction massage, heat, ultrasound, range of motion exercises / stretching, therapeutic laser extracorporeal shockwave therapy, regenerative medicine therapy and ultrasound-guided injections of platelet-rich plasma.
Canapp and colleagues found that 74.6 percent of canine patients do not respond well to NSAID therapy and 40.8 percent do not respond to rehabilitation therapy. However, surgical options tend to have low efficacy and lameness often persists.
In 2009, Cook and Purdam proposed the continuum model for tendinopathies. They divide tendinopathy into three phases:
- Reactive tendinopathy
- Tendon dysrepair
- Degenerative tendinopathy
In the reactive stage, there is diffuse increased cellularity and ground substance. This is followed, in the second phase, by the emergence of areas of collagen disorganisation and neurovascular ingrowth. Finally, this progresses to degenerative tendinopathy. However, as Cook and colleagues note in a later study, the relationship between structure, pain and function in tendons is not yet fully understood and this contributes in part to the complexities surrounding the management of tendinopathy.
- Reducing pain
- Avoiding activities that cause compression of the tendon (for supraspinatus this means avoiding activities that occur in full shoulder flexion)
- Avoiding the stretch-shortening-cycle. Swimming is NOT an appropriate choice for this reason
- Introducing isometric exercises in a mid-range position to avoid excessive strain on the tendon. In highly irritable tendons, bilateral exercises with shorter holding times and fewer repetitions may be indicated
Once the dog’s pain is controlled, it has good static stability of its limb, and it can achieve an isometric static contraction without an increase in symptoms, it is possible to move into phase two of tendon rehabilitation.
Phase two focuses on strengthening. The aim is to gradually increase the tendon’s ability to produce force and manage load.
- Repetitive loading such as running / walking are unlikely to stimulate significant adaptive changes
- The focus is rather on heavier loads that can promote change in muscle and tendon and improve their load capacity
- It remains important to continue to achieve strength changes in the mid-range position and to avoid tendon compression and rapid cycling of the tendon
Exercise prescription must be tailored to the patient in terms of:
- Pain level
- Specific weakness
- Patient goals
- Requirements of sport / work
Tendinopathy loading programmes generally fall into three categories:
- Eccentric loading
- Heavy slow resistance training
- Combined approach
Eccentric exercises have been the mainstay of tendinopathy treatment for many years. More recently, however, research has highlighted the benefit of also focusing on the concentric phase of exercises with heavy slow resistance training.
- Tendon rehabilitation tends to take time
- For the first 24 to 36 hours after loading, there is a net loss of collagen production - this means there must be adequate time for recovery to allow any strain to the tendon to recover. A fatigued tendon will be at greater risk of regressing.
It is possible to progress to phase three (i.e. functional rehabilitation) when the patient has good neuromuscular control, relatively even muscle development, no recurrence of pain and swelling or any regression in function. For sporting / working dogs, it is particularly important to include functional rehabilitation. Functional rehabilitation falls into three categories:
- Exercises that are specific to the functional requirements of the affected muscle and tendon
- Improving load capacity of the entire kinetic chain
- Addressing movement dysfunctions that could cause recurrence of the tendinopathy
It is also important to achieve neuroplastic training of the tendon. There are significant neuromotor changes in tendinopathy that affect the descending control of the neuromuscular junction where there is pain and swelling in a tendon. It is, therefore, important to restore optimal communication between the central nervous system and the tendon to ensure it can function under high loads. This can be achieved by the use of an external marker (e.g. treats for dogs).
Biceps Brachii Tendinopathy
Canine patients often also present with biceps brachii tendinopathy, particularly of the long head of the biceps. Damage to the tendon either occurs from repetitive strain (so it is relatively common in agility dogs who perform repetitive tight turns and repetitive landing on their front legs) or as a result of a single, significant loading event that exceeds the tendon's capacity.
Biceps brachii tendinopathy is often associated with a supraspinatus tendon lesion. It does not usually occur in isolation. It tends to occur in medium- to large-breed middle-aged or older dogs.
Animals present with variable degrees of lameness. Dogs may start to:
- Knock jumps during agility
- Avoid turning tightly
- Avoid performing two-on two-off contact behaviour
Other features include:
- Shortened stride
- Weight bearing lameness that can range from subtle to severe
- Symptoms worsen with activity
- Direct palpation over the biceps origin may elicit a pain response
- Pain and spasm may be noted with a biceps stretch (flexing the shoulder with the elbow in extension)
Conservative management is recommended in acute cases. This usually consists of:
- Controlled activity
- Anti-inflammatory medications
- Intra-articular injections of hyaluronic acid, cortisone
- Regenerative therapy approaches such as PRP or STEM cell therapy
Surgical management is recommended when there is an avulsion of the biceps tendon from the scapula, significant tears, or when the injury does not respond to conservative management.
There are two surgical options:
Tenotomy usually has the most favourable long-term clinical results and a high level of owner satisfaction. Even though this results in the loss of function of the long head of the bicep, canine patients usually adapt fairly successfully.
Conservative management is similar to that discussed above for supraspinatus tendinopathy. The position of compression of the bicep tendon is also in shoulder flexion, so this position needs to be avoided in the early phases of rehabilitation.
There is little literature to support specific rehabilitation programmes following tenotomy. It is, therefore, important to remember that if the dog has had a resection of its biceps tendon, there is not a tendon to heal per se. However, the joint capsule is typically quite inflamed, and there will likely be some deconditioning of the shoulder joint. These features will inform treatment options going forwards.
Because the long head of biceps plays a significant role in shoulder stability, both in flexion and neutral, the biceps tendon contributes to cranial and medial stability of the shoulder. Rehabilitation must, therefore, focus on helping the dog to find other effective stabilising strategies. Thus, rehabilitation must include:
- Motor control
- Joint stability
- Strengthening of the synergistic muscles around the shoulder
Throughout rehabilitation, you want to ensure that you achieve and maintain pain-free passive and active range of motion. Like in supraspinatus tendinopathy, heavy, slow resistance-type training will be most effective in terms of enabling the shoulder to cope with heavy high demands during sport and activities.
Medial Shoulder Syndrome
Medial shoulder syndrome is a common cause of front limb gait-related issues in dogs. Its aetiology is unknown, but it is usually related to repetitive activity and overuse rather than trauma. Performance / working dogs who do a lot of turning or jumping are prone to this condition (particularly agility dogs). Repetitive strain predisposes the dog to degeneration of the tissues, which reduces tensile strength in the medial shoulder compartment and can cause fraying, disruption, and eventually a complete breakdown of the tissues.
If this syndrome continues to progress, instability and subluxation of the shoulder can occur. Medial shoulder instability is essentially the end stage of a chronic progression of medial shoulder disease. It is, therefore, important to identify this condition and start treatment early on to achieve the best long-term results.
- Front leg lameness is intermittent, and tends to worsens with exercise / heavy activity
- Does not respond well to rest and anti-inflammatory medications
- Usually unilateral
- Variable presentation from slightly shortened stride to significant weight-bearing lameness
- Some atrophy is usually associated with chronic cases
- Restricted shoulder extension common on passive range of motion testing
- Muscle spasm in the muscles around the shoulder and discomfort on passive glenohumeral abduction of the shoulder is common
Medial shoulder pathology can be seen on ultrasound and it is usually classified as either:
- Mild medial shoulder syndrome - this includes mild pathological changes
- Moderate medial shoulder instability - this includes more significant subscapularis tendinopathy
In mild cases, treatment is usually focused on physiotherapy management. A key component of early rehabilitation is the use of shoulder hobbles (i.e. an external brace used to limit abduction during movement). If the dog has moderate or severe medial shoulder syndrome, it will usually require arthroscopic intervention.
For the first two weeks post-arthroscopy, the mechanical properties of the tissues are reduced. Strength gradually returns after two weeks and it is usually possible to progress dogs to normal activity between six and 12 weeks, depending on the extent of the damage. It is recommended that the patient is placed in hobbles for the first three months after arthroscopy.
There is little high-level evidence to support / develop postoperative rehabilitation protocols. Recent animal studies suggest that immobilisation after rotator cuff repair of at least two weeks significantly reduces postoperative stiffness.
- Protect healing tissue
- Reduce pain
- Minimise the formation of adhesions
Collagen deposition peaks at around ten days after surgery, with ongoing deposition for one to two months. During this time, it is important to guide the alignment of tendon deposition to ensure that the scar is functional and that the risk of adhesions is minimised. By about ten days, the animal therapist will start working towards restoring full passive range of motion. Early exercises to maintain mobility in the thoracic and cervical spine are also important, as are active range of motion of the carpus and elbow.
Usually after around two weeks, the patient can progress to phase two. Dogs need to demonstrate that they have:
- Equal muscle strength in static positions between the affected and unaffected sides
- Good weight-bearing
- Equal resistance to external perturbation between the affected and unaffected sides
During phase two, active ROM exercises of the shoulder should be encouraged (e.g. “give paw”). Check for discomfort and any increase in symptoms after the exercises are performed.
At this stage, slow active range of motion exercises underwater can be commenced (NOT swimming). The hydrostatic pressure and water temperature reduces pain and reactive muscle spasm /guarding and encourages more efficient neuromotor responses in a safe, supported environment.
Aquatic exercises include:
- Figure of eights to introduce rotation
- Active flexion through carpus, elbow, shoulder when a Cavaletti rail is placed in the water
- Step on and off a raised step to achieve concentric and eccentric muscle work, and progressively load the tendon tissue
- Side-stepping - this isolates abduction and adduction, ensuring that all the dynamic components of the kinetic chain can be strengthened and enhances proprioception
In phase two, the dog can start to progress to:
- Single-leg stability exercises
- Controlled rotation components in exercises
It is possible to progress to phase three when the dog’s active ROM is the same on both sides. This usually occurs two or three months post-surgery. It is also possible to increase the load on the medial shoulder structures with more strenuous isotonic-type stability exercises.
- Controlled, progressive swimming exercises or potentially underwater treadmill therapy can be introduced
- Stability exercises can be progressed to single-leg exercises on unstable surfaces
- Dynamic rotation components can be introduced
- Challenge muscles and joints through full range
Advanced strengthening can typically be started by around three months. In order to progress to phase four, the patient needs to be:
- Pain-free with activities of daily living and during / after training
- Able to tolerate all phase three exercises
Exercises are progressed by increasing the load, repetitions, challenge of the surface and the degree of movement during the exercise. It is now possible to work through range with external resistance. It is also possible to introduce plyometrics, but to avoid fatigue, as this increases the risk of regression. There must, therefore, be adequate recovery between training sessions. One day of strenuous training should be followed by two days or rest, relative rest and recovery.
Elbow dysplasia is a common condition that affects large- and giant-breed dogs. The pathogenesis of elbow dysplasia is not completely understood, but it is thought to be due to asynchronous growth of the radius and ulna with genetic and environmental origins, including nutrition. Dogs with elbow dysplasia may develop secondary osteoarthritis.
Elbow dysplasia encompasses three distinct syndromes that result from abnormal growth and development:
- Ununited anconeal process (UAP)
- Fragmented medial coronoid process (FCP)
Dogs may present from around four months, and surgical management is recommended to reduce the risk of arthritis.
Post-Operative Physiotherapy Management
There are no evidence-based guidelines. The length of cage rest is determined by the surgeon. Physiotherapy focuses on:
- Pain management
- Restoring function as per assessed deficits:
- ROM (active and passive)
- Motor control / stability
- Proprioceptive retraining
Physiotherapy Management for Elbow Osteoarthritis
The pharmacological management is determined by the veterinarian. Physiotherapy interventions are determined based on specific deficits:
- Loss of motor control
- Proprioceptive deficits
- Education and self-management
- Exercise and weight loss
- Low impact land- or water-based exercise
- Active ROM
- Weight management
- Thermal modalities
- There is inconclusive evidence for bracing, but it can be used if it improves pain-free function. However, many dogs will not tolerate a brace and chew it off
- Taping can provide clues about response and tolerance to external support
Carpus and Digits
Carpal hyperextension injuries can result in damage to the flexor retinaculum and the palmar fibrocartilage. They are often traumatic (i.e. occur after falls, stepping in a hole, or from a twisting motion at the limb), but can also be caused by chronic overloading of the carpi due to pelvic limb impairment such as chronic cranial cruciate ligament injuries.
- Grade 1 sprains are mild and are described as an overstretching of the ligament without disruption or loss of function of the ligament
- Grade 2 sprains are moderate in severity and are described as a partial tear of the ligament. The general continuity of the ligament is intact although the strength of the ligament is significantly reduced
- Grade 3 sprains are severe and result from complete disruption or tearing of the ligament, resulting in instability of the joint
- The degree of damage (grade 1, 2, or 3) will dictate the appropriate treatment; however, conservative management of grade 3 carpal hyperextension injuries is rarely successful and surgical fixation is recommended (pancarpal or partial carpal arthrodesis)
- Ligament healing times can be quite lengthy
Grade 1 and 2
Physiotherapy treatment aims include:
- Preventing abnormal scar tissue formation, joint stiffness, muscle weakness
- Restoring as normal as possible movement patterns
- Pain relief through joint mobility techniques, soft tissue massage, electrotherapy
- Improving scar tissue quality
- Loosening or strengthening the injured region
- Improving performance when the client returns to sport, work or daily life
- Correcting any biomechanical faults that may be affecting movement, technique or predisposing the client to injury
The amount of rehabilitation and the time needed for full recovery after a sprain or strain depend on the severity of the injury and individual rates of healing (from weeks for a mild sprain to months for a severe sprain). Extra care should be taken to avoid re-injury.
- POLICE (protection, optimal loading, ice compression, and elevation) - this promotes and guides safe and effective loading in acute soft tissue injury management
- Early (protected) mobilisation
- Functional treatment is superior to immobilisation
- Bracing is important to allow for early safe loading
- Aquatic exercises in the initial phase of rehabilitation may be superior to land-based rehabilitation
If patients require repair or arthrodesis surgery (i.e. for Grade 3 injuries) they will need a post-operative external splint (for 6 – 8 weeks after repair surgery and for 8 weeks after arthrodesis surgery). After this, rehabilitation is as for Grades 1 and 2 sprains.
Toe injuries are often under-diagnosed as a cause of lameness in dogs. They are most commonly due to tendon strains or collateral ligament sprains. They are usually caused by sudden excessive force on the interphalangeal joints due to uneven / deep / slippery surfaces, getting stuck on a surface, and stubbing toes against an object. These same forces can also result in a fracture.
Patients with digit injuries usually present with severe weight-bearing to non-weight-bearing lameness. With acute injuries, there may be significant swelling, as well as pain and crepitus on manipulation. With chronic injuries, there may be swelling at the site of injury and pain on manipulation.
Once fractures of the metacarpal, phalanges or sesamoid bones are excluded, these injuries are mostly managed conservatively (see above recommendations for carpal injuries):
- Taping / bandaging can prevent lateral movement of toes
- Walking in soft surfaces has been described as a useful exercise for reconditioning toes, but there is no evidence to support this
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