Laurie's Blogs.

Hi Laurie,

I got your email and figured I would send you a question!  Today I saw a 6-month-old puppy who had a tibia/ fibula fracture that was splinted for the last 6 weeks.  It was originally placed in a bi valve splint by our surgeon (owner could not afford surgical repair) but the owner elected for her regular vet to change the bandages and resplint the limb.  Somewhere along the way the bivalve splint was not used and some sort of lateral straight, splint was applied.  The dog presented to our ER last week for a change and the Dr. noticed there was significant tarsal hyperextension and recommended either a surgical consult or a rehab consult with me.  On exam, this puppy has obvious tarsal hyperextension at a stance and will occasionally flex it normally when walking, but it wants to hyperextend if given the chance.  She hyperextends about 20 degrees past 180 on the goniometer with a bony end feel.  She has extreme disuse atrophy to all of her muscles in the limb.  She is also quite tight in her gastocs and will flex to about 55 degrees with a soft capsular end feel.  She sits with the limb straight out, but she also has a very lazy puppy sit with both pelvic limbs.  She will flex the tarsus when her toes are tickled. Our surgeon and I agree that she will likely tighten her ligaments as she is allowed to use the limb (the fractures are healed now and I removed the splint and won't replace it), but my question is regarding rehab exercises for her and what your experience is with these cases.  I recall you saying we need to strengthen gastrocs in these dogs, but are there specific exercises that work best?  She does well walking up stairs and with cavalettis and will flex the tarsus and push off which I think is helpful and I have given her some PROM and stretching for the calcanean tendon to work on.  I am also having her work on square sitting.  I do have an UWTM and thought this may be beneficial for her as well.  So, when you get a chance, let me know your thoughts.  Am I on the right track? Owner does not have lots of $$ to spend and I did recommend a surgical consult so the she is aware of all of her options. Thanks for your time and input!

-JS

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Hi JS!

I think I have a good picture of this dog in my mind based on your description.  The only thing I question is the end feel for flexion.  A soft capsular end feel could only occur with tarsus flexion if there was a rupture of the Calcaneal tendon... which I don't think there is.  The end feel would have to be elastic still... so I'm going to go with that... because the other would really be messed up!  

I think you are pretty much on track with your therapy regimen.  My 'tweeks' or additions to your program would include:

Sit to stand exercises facing up hill.

If you do use the UWT - I would go with low water height (between the stifle and tarsus) to get them to 'high step' and have more of an upright gait instead of a longer stride (where the dog is most likely to hyperextend)

So the same goes with the cavaletti poles - closer together to get an upright prancing kind of action.

I'd also get the dog jumping up onto something.  Try from a stand and also from a sit position!

I'm waffling back and forth about going with a tarsal splint (not rigid) just something that braces / blocks hyperextension.

You might need to start simply with E-stim on the gastrocs with weight shifting.

Crawling under exercises (actually this would be great!)

Walking backwards....

I'm thinking of anything that can get the dog using / walking on the leg in a flexed position would be good.

I hope this helps to get your wheels spinning!

Cheers! - Laurie