Laurie's Blogs.

Hi Laurie,

Its N. again with another question.  I am writing from home - so don’t have some of the details.  Anyhow, we are seeing an 18-month intact female GSD, who sustained a growth plate injury to the right distal radius and developed a carpal valgus.  The dog had surgery at another specialty practice and a plate was placed at surgery.  The dog presented to us several months post-op as she had scar tissue that restricted her carpal flexion.  At presentation, she also had discomfort in her right shoulder.  The main reason that the owner came to us was because we have a therapeutic U/S and was told by the surgeon that it would help to improve the carpal flexion.  We treated the dog with U/S while stretching the carpus in flexion.  We also managed the discomfort in her shoulder using class IV laser and e-stim. After treating the dog for several months, we were able to achieve comfort in the shoulder but really made no headway as far as improving carpal flexion.  In July, the owner returned to the surgeon and the plate was removed.  The owner understood that the removal of the plate may not improve the flexion.  At surgery, the surgeon was able to achieve 90 degrees of flexion.  We have not had the same results with the dog awake (again I can give you exact numbers if it helps.)  We are now seeing the dog twice a week and treating the dog with ultrasound while stretching in flexion, laser to reduce inflammation and prevent further scar tissue formation (?), massage/manipulation of the scar.  We are really not making any headway on improving the flexion in the carpus.  I would call this dog’s lameness 0-1 in the right fore limb at a walk and trot and there is wearing on the nails of P3 and 4 close to the nail bed.  The owner would like this dog to be an agility dog.  She is starting to lose patience.  She is heating and stretching at home.

So after this long-winded history, my questions to you are - are we too early to give up, can we achieve improved flexion, how do these cases usually progress, is our therapy appropriate?

I would love some advice or even just a point in the right direction to where I might find this information.

Thanks so much and have a great night.

N.C., DVM

---------------

Hi N.!

I’d be happy to give you my thoughts.   

So as for your dog... my first thought is ’why do we think it is scar tissue restricting flexion - as compared to a tightening of joint capsule at the carpus?’

I think if we think of joint capsule tightening with or without scar tissue  - around the joint capsule, it would redirect treatment slightly...

So on reading this, my first thought is:  Needs joint mobs and carpal traction.  Your approach thus far has been more to affect tendons / muscles passively (modalities / heat) but I think you need to think about stretching out joint capsule(s) and in order to do so you’ll need to be more targeted.

I’d do carpal traction - and send the owners home doing the same.  Pull and hold.  Pull and release rhythmically for several reps.

Then I’d try to do mobs dorsal glide of the radial carpal bone and ulnar carpal bone while flexing the carpus.

I’d likely spend a whole 20 - 30 minute session doing laser and then the mobs/traction until both you and the owner are bored of it!!!  But it will likely take that long to make headway! 

The rest of what you are doing is fine... but not targeted enough to directly affect the carpal joint capsule OR address a restriction of the glides of the carpal bones. 

Let me know how you make out!

Laurie

------------

Hi Laurie,

Thanks so much for getting back to me.  I really appreciate it.  One question - we  (we, because I have a partner that I work very closely with) focused on decreased flexion due to muscle/tendon contracture/scar tissue since the dog had surgery and placement of a plate.  How does one differentiate between scar tissue vs. tightening of the joint capsule causing the decrease in carpal flexion?

Thanks again.  I admire all that you do to further such an amazing field.

N.

------------

Hey N,

Might very well be one in the same... but I think your treatment selection is targeting superficial / muscle / tendon scarring vs. joint capsule & joint mobility restriction.

Have you ever had your back, neck, SIJ, or ribs ’feel like’ they were ’out’?  You could hot pack and make yourself stretch...but it might not yield the same result as a mobilization / manipulation that targets the JOINT, (joint capsule, joint glide, joint neurophysiology...).  I’m just saying ’target the joint’ a little more.  If it were just superficial scar tissue, then you should have seen more results by now... so I am just trying to redirect your thinking on this a little!

(And how you would differentiate would be by testing your joint glides to see if they are restricted...

Restricted ROM - could be soft tissue scarring / tightening and/or joint mobility restriction.

Do joint glides - if great mobility with joint glides - then you have a soft tissue restriction.

If joint glides are restricted - then you have a joint restriction with or without soft tissue restriction as well.

So in the latter case, you may need to do both joint mobility work and soft tissue work.)

I hope this helps!

Laurie

Laurie@FourLeg.com