Hi all,
I would love some help thought processing through this case:
5yr old F/S Border Collie. Does agility and herding. Has been lame intermittently on the left hind since September. Did some acupuncture and laser elsewhere, which seemed to help briefly but the lameness has returned. I saw her this week.
On my physical, her thoracic spine was tender with D/V glides.
Her pelvis seemed symmetric to me, but she did have some R piriformis pain.
The only other reaction I could get out of her was she consistently turned her head and licked her lips when I palpated her left iliopsoas. She did not seem to care about the right iliopsoas. No pain when I palpated over the sacrum. L stifle seems fine, digits seem fine. No gluteal pain, equal muscle mass between the two hind limbs, and I didn't appreciate any resistance to L coxofemoral joint extension or abduction.
She did have x-rays taken by her referring vet and the radiologist noted that L7 is transitional, with sacralization of the right transverse process of L7, static disc space narrowing and bridging spondylosis at L7-S1, and mild thickening of the left femoral neck.
I mobilized the thoracic spine and lumbar spine. Wasn't sure what to do with the pelvis/SI joint since it seemed symmetric, but she did have that R piriformis discomfort. Did some laser and sent her home with exercises--3 legged standing, elevating the hind end and stretching the psoas, stuff I didn't think would make things worse while I think about this.
I don't think the left iliopsoas was painful enough to be a strain. Could it be that it is tight or irritated because it has to run over the spondylosis?
Should I try some nerve stretches to try to figure out if something is being entraped at L7-S1?
I've found R piriformis discomfort, but am not sure what to do with it.
Thank you,
Diane
L hindlimb lameness
L hindlimb lameness
Diane M Paster, DVM, DABVP, CCRT, CVPP, cVMA
Re: L hindlimb lameness
Hey Diane,
So, some great thought processing here!
So, from my unpublished research, I believe that all pirifomis pain is related to SIJ dysfunction.
And in some cases where the SIJ is very stiff and in a combination position (i.e. dorsally rotated and cranially slipped OR ventrally rotated and caudally slipped), the pelvis can look symmetric. Or, if, as research is eluding to, there isn't so much a malposition but a stiffness of the joint and an irritation of the joint, then it could be that you just need to move it in any direction to reduce the pain signalling from the joint. So any mobilization, or the 'gapping' technique that I teach would be appropriate.
Now, as for the transitional vertebra. We've been finding that these really mess with the lumbar spine and SIJ. They are very hard to get them to be consistently 'happy' in that region. So, I'd show the owner tail pulls as well, and continue on with your existing plan.
While I don't think that the iliopsoas would be tender because of the presence of spondylosis, I do think that the iliopsoas could be from nerve irritation. But usually that ends up affecting things biltaterally. But if the SIJ, and/nerve irritation are causing a slight off loading of that limb, it could be that the dog is holding the leg up a bit / holding it tighter, and as such could be keeping the iliopsoas in some degree of tension... and is then causing tightness and/or myofascial trigger points.
Which then leads to perhaps trying some myofascial trigger point releases: stretching, massage, slow pressure holds, laser, etc. Check sartorius and TFL as well.
I don't know what to make about the thickened femoral neck. That one has me stumped for now. Perhaps someone else will chime in with thoughts on that!
Okay... and so when I go back and reread everything again. It's a border collie. I'd treat lumbosacral & L6/7, and SIJ. All of it. Any mobs. Any healing / pain modifying modalities. Some abdominal strengthening exercises. And see where that takes you.
I'd say good job so far!
Laurie
So, some great thought processing here!
So, from my unpublished research, I believe that all pirifomis pain is related to SIJ dysfunction.
And in some cases where the SIJ is very stiff and in a combination position (i.e. dorsally rotated and cranially slipped OR ventrally rotated and caudally slipped), the pelvis can look symmetric. Or, if, as research is eluding to, there isn't so much a malposition but a stiffness of the joint and an irritation of the joint, then it could be that you just need to move it in any direction to reduce the pain signalling from the joint. So any mobilization, or the 'gapping' technique that I teach would be appropriate.
Now, as for the transitional vertebra. We've been finding that these really mess with the lumbar spine and SIJ. They are very hard to get them to be consistently 'happy' in that region. So, I'd show the owner tail pulls as well, and continue on with your existing plan.
While I don't think that the iliopsoas would be tender because of the presence of spondylosis, I do think that the iliopsoas could be from nerve irritation. But usually that ends up affecting things biltaterally. But if the SIJ, and/nerve irritation are causing a slight off loading of that limb, it could be that the dog is holding the leg up a bit / holding it tighter, and as such could be keeping the iliopsoas in some degree of tension... and is then causing tightness and/or myofascial trigger points.
Which then leads to perhaps trying some myofascial trigger point releases: stretching, massage, slow pressure holds, laser, etc. Check sartorius and TFL as well.
I don't know what to make about the thickened femoral neck. That one has me stumped for now. Perhaps someone else will chime in with thoughts on that!
Okay... and so when I go back and reread everything again. It's a border collie. I'd treat lumbosacral & L6/7, and SIJ. All of it. Any mobs. Any healing / pain modifying modalities. Some abdominal strengthening exercises. And see where that takes you.
I'd say good job so far!
Laurie
LAURIE EDGE-HUGHES
Re: L hindlimb lameness
Thanks!
I am going to see the dog again on Thursday, so I will do some of the mobilizations that I learned from you in San Diego this year.
Hmm, wish I could go to Norway for the advanced class!
Diane
I am going to see the dog again on Thursday, so I will do some of the mobilizations that I learned from you in San Diego this year.
Hmm, wish I could go to Norway for the advanced class!
Diane
Diane M Paster, DVM, DABVP, CCRT, CVPP, cVMA
Re: L hindlimb lameness
Ha! You really should come to Norway for the Advanced!
A great reason to see Norway!!
Best of luck!
Laurie
A great reason to see Norway!!
Best of luck!
Laurie
LAURIE EDGE-HUGHES
Re: L hindlimb lameness
Update on this case:
I saw the dog again, made sure she was standing square and carefully looked at the pelvis again. Sure enough, now I think the left side is cranially slipped and a wee bit dorsally rotated.
So, I mobilized both SI joints, her lumbar spine, showed owner how to do tail pulls at home, lasered, and dry-needled TFL and sartorius—got some nice trigger points in both TFLs.
She seems to be off-loading the left hind leg less, and it’s very subtle when I do notice it.
Owner is already asking when she can plan her next agility trial
My goals before doing agility again are:
Eliminate the off loading of L hind.
Have her more comfortable on exam and when doing mobs (she was not happy with the left side)
Be proficient at her core exercises on unstable surfaces, add some motor control and timing exercises too.
THEN introduce some low jumping and film it to make sure she is pushing off of both hind legs equally before we think about going back to real agility work. We can do some UWT work if the dog is so bored that she is driving her owner nuts.
I also think she should lower her jump height—I mean why make the dog work harder than she has to? She is only 5 and already has spondylosis. Am I being too conservative?
I don’t have a stance analyzer, so there might be some off loading I am unable to detect. Has anyone played around with bathroom scales to see how they are distributing their weight?
Any help is much appreciated!
Diane
I saw the dog again, made sure she was standing square and carefully looked at the pelvis again. Sure enough, now I think the left side is cranially slipped and a wee bit dorsally rotated.
So, I mobilized both SI joints, her lumbar spine, showed owner how to do tail pulls at home, lasered, and dry-needled TFL and sartorius—got some nice trigger points in both TFLs.
She seems to be off-loading the left hind leg less, and it’s very subtle when I do notice it.
Owner is already asking when she can plan her next agility trial
My goals before doing agility again are:
Eliminate the off loading of L hind.
Have her more comfortable on exam and when doing mobs (she was not happy with the left side)
Be proficient at her core exercises on unstable surfaces, add some motor control and timing exercises too.
THEN introduce some low jumping and film it to make sure she is pushing off of both hind legs equally before we think about going back to real agility work. We can do some UWT work if the dog is so bored that she is driving her owner nuts.
I also think she should lower her jump height—I mean why make the dog work harder than she has to? She is only 5 and already has spondylosis. Am I being too conservative?
I don’t have a stance analyzer, so there might be some off loading I am unable to detect. Has anyone played around with bathroom scales to see how they are distributing their weight?
Any help is much appreciated!
Diane
Diane M Paster, DVM, DABVP, CCRT, CVPP, cVMA
Re: L hindlimb lameness
Good job Diane!
I don't think you are being too conservative in delaying return to Agility. This kind of thing is a great way to blow out the contralateral cruciate or cause other soft tissue or joint injuries. Argh!
I also think it is wise to drop a jump height when able. I advise it to all dogs over the age of 7 or if there is an injury. It should be about health of the dog!
In regards to minimizing the off-loading, in addition to the manual therapy you are providing, you may need to retrain the brain to balance the leg loading. I like using a bootie, sock, plastic bag etc on the 'good leg/foot' in order to reset the balance. Also strong muscular contraction exercises can help do the same (i.e. tug of war or pulling, or steep up hill walking, or jumping onto a platform...). Add in pieces of agility to reintroduce training - but only a piece or two at a time.
i.e. practice weave poles, or two jumps and a recall... but not a whole course. Skill training vs speed training.
And yes, bathroom scales have been validated! You can use 4 scales (but who has 4 scales lying around?), or two scales and two books (or something of equal height).
Best of luck!
Laurie
I don't think you are being too conservative in delaying return to Agility. This kind of thing is a great way to blow out the contralateral cruciate or cause other soft tissue or joint injuries. Argh!
I also think it is wise to drop a jump height when able. I advise it to all dogs over the age of 7 or if there is an injury. It should be about health of the dog!
In regards to minimizing the off-loading, in addition to the manual therapy you are providing, you may need to retrain the brain to balance the leg loading. I like using a bootie, sock, plastic bag etc on the 'good leg/foot' in order to reset the balance. Also strong muscular contraction exercises can help do the same (i.e. tug of war or pulling, or steep up hill walking, or jumping onto a platform...). Add in pieces of agility to reintroduce training - but only a piece or two at a time.
i.e. practice weave poles, or two jumps and a recall... but not a whole course. Skill training vs speed training.
And yes, bathroom scales have been validated! You can use 4 scales (but who has 4 scales lying around?), or two scales and two books (or something of equal height).
Best of luck!
Laurie
LAURIE EDGE-HUGHES