Weird gait - Fibrotic Myopathy?

[lehughes]

Hi Laurie
Hope all is going well.
You know the saying: "if it looks like a duck, quacks like a duck and walks like a duck, then it is a duck". Well I have this case where everything looks like a traumatic Fibrotic Myopathy but the palpation of the dog disagrees with the diagnosis.

5 yr old F/S GSD who suddenly became lame on RHL after her housemate ran into her. She is short strided on the RHL, the paw and stifle flick medially and the toes dorsally and the calcaneus laterally, just before landing. I've included a video for you to look at. So the movement and history fit perfectly with traumatic Fibrotic Myopathy, right? But palpation says otherwise. This is a stoic dog, but there is absolutely no limitation or pain on full stretch of the Gracillis or Semitendinosus muscles. Neither muscle shows any pain or a knot on palpation of the muscle bellies. HOWEVER, there is marked muscle trembling every time I palpate the right iliopsoas muscle at about the L3-6 level and the dog does show some discomfort at full iliopsoas stretch.

Hedging my bets, I have lasered all three muscles and have the owner doing full stretches on all three muscles until I hear back from you.

Does it make any sense to you that the iliopsoas should be sore and the gracillis and semitendinosis are not? Truly, this dog's movement is absolutely classic for Fibrotic Myopathy.
Would love your thoughts on this.
Thanks
JS
https://youtu.be/WqM2LjQ1A6U

[lehughes]

Wow! It really does look very ‘Fibrotic Myopathy’!
Check SemiMemb as well as the two you checked as well.

But let’s do some thought processing as well.

So, he could be protecting Sciatic Nerve with this gait adaptation… which could be the result of L/S issues, which would subsequently upset the iliopsoas.
So, perhaps not and iliopsoas primary, but iliopsoas secondary to nerve root irritation L6-S1.

My other thought process in watching him tuck his rear the way he does:
Coxofemoral labrum tear (assess by looking for pain in inner an outer quadrants of the hip (flexion + internal rotation or extension + external rotation), plus just movement all around for the hip looking for clicks, clunks, unexplained pain reactions.
SIJ… but I’m not even bought into that as a real differential
Try sciatic nerve stretches / dural glides. So, as if you’re stretching for hamstrings, and then add on neck flexion, add tarsal flexion, change hip abd / add angles…. add in various pieces to tense up the nerve to see if any one particular movement produces a pain response.
Go back to checkin the L/S…
Try hamstring stretch with and without a tail pull (looking for a NR foraminal stenosis / osteophyte / impingement)

That’s about all I can come up with that I think could actually cause that gait.
I’m with you in that I’d keep Fibrotic Myopathy in the back of your head and retest the region frequently… and treat anything that seems unhappy!

Okay, back to you!

Laurie

[lehughes]

Thanks so much again Laurie. So I had the dog back yesterday and put the semimembranosis on a really big full stretch and yup, did that puppy hurt and the muscle was really spasmed and sore! So I did a set of 5 deep stretches (and yup that hurt, but this is a pretty brave dog) and also lasered the muscle. I am having the owner stretch the dog TID at home right now. I read some of your blogs on Fibrotic Myopathy and you recommend the extreme stretches, laser and ultrasound in clinic. I do not have an ultrasound. Should I refer to some clinic that has one? What is your impression of Shock Wave therapy? How often should I be lasering and doing the really extreme painful stretching? Once-twice weekly?
Thanks again for your help
J.

[lehughes]

Hey J,

Okay… glad we weren’t both out to lunch on thinking it was a classic Fibrotic Myopathy gait!

So, continue on as you are. Don’t worry about referring for US. There was a patient I had YEARS ago with a traumatic fibrotic myopathy and I used Ultrasound on (because I didn’t own a laser).

I love my shockwave. Haven’t had a chance to use it on these kinds of cases yet. But I would!

I’d do the painful stretching and laser 1 - 2 x a week if able.

Keep me posted!

Laurie

[David Lane]

I know I’m coming late to the party, but just want to add a thought: The acute onset lameness immediately suggests to me that this is not a fibrotic myopathy. In my experience, fibrotic myopathy starts with some degree of muscular trauma (which is where I suspect this case is at), then slowly fibrosis and constriction forms over time as the scar tissue matures. The slow progressive worsening of the gait is was eventually brings the owner in. At that point, the acute trauma pain is gone and instead you feel a firm restriction preventing full ROM. Treatment options at this time are limited.

Acute trauma will cause pain and a similar gait due to the restriction induced by that pain, but not due to fibrosis. At this point, you are dealing with a myopathy and not a fibrotic myopathy.

My approach is to diagnostic ultrasound myopathies (if client is looking to do all they can) to look for significant fiber disruption. One paper that looked at MSC’ing semimembranosus tears by US guided injections got very good results in terms of regenerating normal muscle (no control group in the paper). I use laser, acupuncture, stretching, and gentle isometrics for initial treatment, and watch the leg closely for reduced PROM hamstring stretch afterward – in doing so, I am specifically looking to see if secondary fibrosis is kicking in. If I get a sense that it is, I would ESWT the entire muscle. Weak anecdotal reports that ESWT’ing these cases early before the fibrosis can fully form, will reverse the early stages. I am only n=1 for this, but in that case it worked.

[lehughes]

UPDATE!!

The GSD that you gave me advise on with the traumatic Fibrotic Myopathy is doing extremely well with the extreme stretching and the gait anomaly is greatly reduced. Thanks so much for your help! Owner is thrilled.

JS