Laurie's Blogs.

Hi Laurie!

I've got a patient that I could need some advice on.

The patient is a German Shorthaired pointer, 5 year old intact male. Diagnosed with MSI at our clinic. Before that he had more than half a years history from a couple of other clinics not being able to figure out what was wrong with him. They identified right shoulder as being the problem, did x-rays with no findings and prescribed NSAIDs and rest, which kind of worked until they increased activity again. 

When they came to see us, the dog was lame for the third or fourth time. Abduction angle was 50 degrees, so probably a bit more than what is ideal for conservative treatment. No one in the area does arthroscopy of the shoulder and as far as I know no one in my country does radiofrequency treatment as I've seen being described in articles on the internet. We offered to send him to a clinic in a different part of the country for arthroscopy but the owner wanted to try conservative treatment. We put the dog in a Dogglegs shoulder stabilization system and the lameness resolved quickly. The owner lives quite a distance from the clinic so we prescribed  home treatments and exercises with massage and PROM for the first couple of weeks, then some stabilization work and stretching after that. 

Three weeks into the treatment, the owner went away on holidays, and when I phoned him up after a week, the dog was lame again. When I saw him again, when owner was back from holiday a couple of weeks ago (six weeks after we started treatment), the dog was constantly 1-2 degrees lame both at a walk and trot. The owner reports lameness to be the same, both after rest and activity, nothing seems so better it or worsen it. 

When we examined the dog he was really tight in his caudal shoulder and upper arm muscles and had decreased shoulder extension. This tightness I managed to resolved with a couple of treatments, but lameness was still the same. Abduction angle is not the same as the other shoulder. The only significant finding now is pain on pure glenohumeral extension. We did x-rays to rule out OA. Plain x-rays were fine, while x-rays with contrast showed some changes in the medial joint capsule which the vet thinks is most likely is due to scar tissue formation. 

What I'm wondering is whether the injury to the medial structures might have been to large to treat it conservatively and that scar tissue now limits motion. When the dog moves, it is quite obvious that he doesn't extend his shoulder properly. I worry that I've screwed this one up and don't really know what to do now. There is no one in the area that I feel is competent enough to refer it to either! Do you have any thoughts as to what we could do to try to help him? We could organize MRI at a human institute in the area, but fear that that won't really give us any new information. Do you have any suggestions to which treatments we could try to help with the getting the scar tissue more flexible? I see that some articles suggest using ESWT. I have no experience with this, but know one vet in the area that I could refer to for this treatment… but I'm unsure as I don't know enough about it. If you think there is anything we're missing or should do I'll be really grateful to hear as I want every stone turned before giving up on this really nice dog.

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Hey there…

So, I have found that usually after a point in time, the dog begins to restrict motion on their own - not allowing full motion... which would account for the increase in tension of the muscles.

So you need to get the dog to 'buy into' extending etc... not by PROM but by specific exercise.

I have rehabbed plenty of dogs with 50 degrees.  One with 90 even!!!!  I don't buy into the radiofrequency to be quite honest!  From what I know and understand - the dogs that do well with that are the ones that would do well with conservative management.  I am using ESWT right now with an MSI dog that I think has a glenoid labrum tear (soft clunk going into extension - x-rays clear...), and it's working pretty good... but in that case something need to repair or be resorbed... so the ESWT makes sense.

Exercises:  

3-leg standing:  lift the good one and use theraband to pull outwards on the affected / standing leg.

Walking backwards on a treadmill... hold under the abdomen with one hand to keep the dog in place, and resist the good arm when it is under the body (so that the other arm has to extend a little further).

For that matter, if the owner can get the dog to backup UP a hill... that might be good!

Down hill walking - forwards.

(There is a video on this on the website....)

Cheers!

Laurie