4 year old FS Chessie with amputation of the toes of her left PL

[JuliPotter]

Laurie,
I would appreciate some guidance on working with Maka, a 4 year old FS Chessie who was hit by a car in September. Trauma to her left pelvic limb/foot resulted in amputation of her toes. I saw her for the first time this week. The owner has purchased a custom made prosthesis to help with Maka's mobility. I have pictures and videos!! I will have to email you the videos for the files are too large.
Maka is non-weight bearing on the left pelvic limb while walking and standing. She does shift her weight forward and to the right pelvic limb; there is lordosis present. Her body condition is good – BCS 5/9.
Her dorsal neck is quite tight/tense, there is decreased shoulder extension, bilaterally, paraspinals seem tight thought there is no obvious pain/reactivity with side glide of C-spine or T-spine, there is slight reactivity at the T-L junction. There is significant muscle loss of the quadriceps, hamstrings, inner thigh and gastrocnemius of the left pelvic limb. Her quadriceps and sartorius muscle are quite tight bilaterally and there is low tone in the hamstrings, L>R, there is decreased hip extension on the left though I feel this may be more soft tissue related since I did not check pure CF extension at this time. Maka loses her balance quite easily, it is difficult to get Maka to stand squarely, she tends to slightly twist her rear to the left and she wants to move her right PL forward. Quadratus lumborum is tense bilaterally and I feel that she is tender with palpation of the left Iliopsoas muscle. It appears to me as if her left Ilium is more cranial, I did not check for symmetry of the Ischial tuberosities today. she seemed slightly reactive with palpation of the left dorsal SIJ ligament and she was quite reactive when I strummed the left piriformis. On her left foot/area of amputation, the skin is red and there is a small excoriation on the pedal surface, she appears sensitive to the touch, there appears to be slight edema on the dorsal surface of the tarsus and the tarsus is warm to the touch.
When owner placed the prosthesis from Animal Ortho Care on Maka’s left pelvic limb, she does appear more stable while walking.
Maka had a recheck with the surgeon yesterday, I am curious to hear what he had to say! I feel that she is uncomfortable at the sight of amputation!
So, first I want to make sure she is comfortable. I would love to laser the area of amputation! I feel manual therapies (massage, myofascial release, stretching) will be very helpful with the tight muscles, I will continue to monitor her SIJ as well and work on strengthening......my question is, how do I work with the prosthesis? should the therapeutic exercises all include the prosthesis? What can or should I do without it?
Thank you so much!!
Juli

[lehughes]

Just uploading more of the pictures you sent to me via e-mail.

And the video you sent me, I uploaded onto Youtube.

https://youtu.be/rZkMHAmZDOk

[lehughes]

Hey Juli,

I think this looks awesome! So, all of the things you are finding are some compensations and some primary problems. Just start working away at them one by one.

Mobilize the SIJ. Sounds like there is pain there... so go ahead and do some general techniques. You can laser everywhere! Foot, tarsus, iliopsoas, SIJ, L/S, etc.

It looks like she is very accepting of the prosthetic, so do some of the exercises IN it:
Front feet up on a low stool / step / platform to get some active stretching of iliopsoas.
Figure of 8's to work on weight shifting and spinal bending.
Retraining backing up - sounds simple, but it might not be.
Try low cavalettis.
Even simple cookies at the hip will help to normalize the soft tissue tightness and promote use of the limb.

Keep everything rather low key for exercises, especially if she is new to this prosthetic. Her skin needs to toughen up a bit - so don't over do it in the early stages.

Then any kind of massage, myofascial work, and gentle passive stretches would be in order, I think. The tightness is likely from holding the leg up / off the ground, so massage, release, and stretch the iliopsoas and sartorius.

In regards to what to do in vs out of the brace. I think you sort of have to put skin breakdown (or potential) as the limiting factor to how much you do in the brace. I'm sure that Derek (Animal Orthocare) provided some guidelines for getting used to the brace. (i.e. might be something like start with 30 minutes, check skin, go 1 hour check skin), with time limits for the first few days / week. Stick with those. Some of the easier exercises (i.e. cookies at the hip and front feet up on a step) you could do without the brace. Actually cookies in all sorts of directions would be good as 'active stretching'.

Slow and steady. I'm sure she'll make leaps and bounds by adding in some really simple therapies. It's often overwhelming with a case like this... but when you step back and look at the pieces, and just start adding in some simple things at first, I think you'll be amazed at the progress!

Best of luck!

Laurie

[JuliPotter]

This is Awesome, Laurie!!
Thank you so much!!
I can't wait to work with Maka again!
All my best to you,
Juli

[JuliPotter]

Update on Maka -
Dear Laurie, I saw Maka again this week, June 10, and I am concerned about her foot....it just doesn't seem normal to me that almost 9 months post op she continues to lick it, her foot is sensitive to the touch and she has a serous discharge on the sock after wearing her prosthesis, regardless of how long she has been wearing it. Maka did have a follow up with the surgeon last week and he did not seem concerned, according to the owner. The surgeon said that she just needs to develop a callous so that her foot is not as sensitive....but it's been 9 months since she had surgery!
....she seems to prefer walking on the carpet vs their hardwood floor and she does put her foot down more on the carpet...... I noticed her putting this foot down a little more as we practiced figure 8s as well!
maybe she just needs more protection on her foot? We will be measuring her foot for a custom made paw protection through Thera-paw.....I am just afraid that we are missing something! I would love your opinion!!
I did do quite a bit of manual therapies/myofascial release/massage as well as addressed her left SIJ (she was quite reactive with palpation of the left Sacrotuberous ligament and the Piriformis) performing the thigh thrust and ventral traction, her left Iliopsoas feels thickened and tight as well and I did attempt to address this with gentle massage, myofascial release/stretch, hand over hand, and to have the owner do active stretching with front legs on the step/bench as you suggested....
as for her foot, I have attached a few pictures for your review!!
Thanks so much!!
Juli

[lehughes]

Just posting for Juli - the potential Therapaw foot protection bootie!
Sweeeet!
I like the looks of this!
L

[lehughes]

Okay... So, lots of questions / comments to address.

1. I don't find that surgeons get involved much at this stage of the game. If it's weird, but not surgical. They often tap out. And really, there isn't much for them to do - it's not surgical. And it's why our discipline is such an important part of the care in a case like this (and so many others). So, it's all on you Juli from here on in.

2. It's likely worthwhile to show the pictures and ask the questions you are asking to the orthotist. In looking at the wear / rub patterns on the foot, perhaps he would have thoughts as to the need to adjust the fit of the prosthetic. This is common in people prosthetics, and the orthotist/prosthetists working in this field are 'human practitioners' and should be open to the questions and understanding of the potential need to make adjustments.

3. You may also have two - no 3 factors coming to play with the dog licking the foot. a) The dog may be experiencing some phantom limb sensations and/or b) the rubbing of the prosthetic, creating the wounds... makes for an itchy wound as it heals and/or simple existing. c) sensitization of the foot subsequent to the amputation. Your options here: Maybe a trial of gabapentin for neuropathic pain; Try adding some therapies to the opposite foot and the nerve roots that supply both areas (i.e. Laser, TENS, acupuncture, massage); Utilize desensitizing techniques on the foot (i.e. touch it with different textures / fabrics and stimulus such as brief encounters with hot or cold).

4. The tight iliopsoas is not a surprise. He's likely holding his leg in slight flexion in stance and walking etc... so he's over using it. Good to keep a handle on it, but it's secondary, explainable, and not likely to ever go away 100%.

5. Wound care - In order to heal the dog will need some time when the wound is exposed to air. Laser can help. Maybe a wound covering while in the prosthetic will help (Duoderm? You'd have to look up what's available these days. I practiced wound care over 25 years ago... my information is old! Maybe someone else will pipe up.

Okay, I hope this helps with the next phase of your rehab planning!

Cheers,

Laurie

[JuliPotter]

Thank you, Laurie,
I really appreciate you!! I have been thinking that maybe the next step would be to follow up with Animal Ortho care to discuss whether there may be an issue with the way the prosthesis fits....thank you for this suggestion!
At our last appointment, I did do a sink and circle between several of the lumbar vertebrae hoping this might effect the nerve roots (this is as much as I know about acupressure, thanks to you, right now). I would love to offer laser therapy as well.....I do not have a laser yet so I have to refer her to someone who does....such a bummer.....but if I can just get a few more clients, my next purchase is a therapeutic laser!!
With much gratitude,
Juli