MSI/MSS

[Kriszty]

Hi Laurie,
This is a continuation of the previous topic/same dog but I've started a new thread as her Teres feels fine but she is still lame I'm very concerned about MSI. She doesn't have pain on abduction but her dorsal shoulder muscles have been consistently super tight as have her pecs, and she keeps loosing shoulder extension (I mobilise and she gets it back then next day gone again). it's about the only thing left as her biceps and supraspinatus feel fine.
I've been conservatively rehabbing this shoulder since March. Strengthening exercises most every day (a mix, got some more ideas from Anna Saunders website) and quite advanced exercises. Lots of shockwave. Exercise modification. She's not getting better
Today a dog came from nowhere and she chased it for 50m before I got her back and went 4/5 lame almost immediately Sadly I feel like I am not winning!
Questions: we now (just) have a surgeon who is doing arthroscopies and placing a synthetic medial ligament , I had 1 patient so far who has had this done and gone well. It's about 7k and she's not insured (cancelled it this year :/) the surgeon could not tell me if the dog could go back to agility.
Have you seen this Tx and what do you think?
2) I haven't put any sort of hobble/bandage/dogleg on her- do you think this is worth a try?
She's 6, and ideally I would like to go back to agility but the main aim is long term soundness.
TIA!!

[lehughes]

Well I'm hoping that David Lane will jump onto this discussion thread.

So, most of my MSI dogs rehab conservatively.

I've had one recently that required surgery because of a suspected tear of the labrum as well as instability. She has done okay... but the owner still sees periodic lameness. My point in this, is that surgery does not guarantee soundness.

It MAY be the best option to try, since straight-away chase caused 4/5 lameness... as I am thinking that there is something additional to just a loss of ligament that is creating such a dramatic reaction and/or lack of improvement. The 'ligament-only' dogs I've seen have all rehabbed conservatively!

Sadly, nobody can guarantee a 'return to agility'. (And distrust those who provide that promise).
But from the sounds of it... surgery might very well be your next best hope of getting close to that, given what you are describing.



Laurie

[Kriszty]

Thanks for the reply, Laurie.
Yes, that's what I'm leaning towards sadly. Hopefully David will chime in, I am seeing the surgeon tomorrow for an MRI on my other dog but I will discuss with him. My experience with it so far is n=1 , as this surgeon is relatively new to perth and the others don't believe in the disease...
In your experience, would you say dogleggs/hobbles unlikely to produce a good outcome over everything I've done so far?
TIA

[lehughes]

I would get the dogleggs / Hobbles post-op only. At this stage, I don't think they will do anything!
For a test, you could try doing the bandaging. Check the videos for Bandaging for MSI.
(I prefer the bandaging for rehab anyways, but for post op, I think better to have a bit more rigidity for support.

L

[David Lane]

Given the history, I agree that MSS has to be high on the diagnostic rule out list. This would be an example where we call it MSS, not MSI, because no instability has been detected. I’ve lost track of how many MSS/MSI cases I’ve treated over the years, but none (zero) of them required surgical imbrication to fix. In my mind, that surgery is reserved solely for glenohumeral luxations with gross instability, not for lame dogs with only an increased abduction angle. It is not a procedure that fills me with hope about returning to a high level of activity.

I forget what imaging this dog has had, but would recommend an ultrasound at the very least. If the hospital has a high field MRI capable of sufficiently resolving detail in shoulder of that size, then consider that. Alternatively, scoping is the other good option. Ideally, you want a full inventory of everything that is going wrong in that shoulder so that your treatment plan includes it all.

Treatment wise, you need to kick start the healing process and trick the body into thinking it is a fresh lesion. I’ve personally had the best success with combined “stem cells” and PRP, second best with shockwave, and third best with rehab (laser, hobbles, therex). Both the stem cell a/o shockwave options automatically include the rehab/therex/laser. If you’ve been hitting the medial compartment with the shockwave already and it hasn’t worked, then I’m thinking that likely only either the stem cells or surgery will turn this situation around. If considering the surgical option, ask very direct questions about how the surgeon defines success, what sort of pain free activity he expects your dog to return to, what his major complication rate is, and how many he has done.

[Kriszty]

Thanks for the reply, David.
Yes she's had quite a lot of shockwave, hitting the medial aspect of the shoulder as best I can.
No one doing stem cells here currently, to my knowledge.
May I ask why you think the surgery doesn't have a high chance of returning to high level activity? Would the suture not just act to support/in place of the torn ligament? Or is it more like the old cruciate Sx (pretty useless).
I will go ahead with the scope, at least. This lameness started when she had a fall when she was 1 and has been rehabbed/treated intermittently but now doesn't seem to be improving.
I will certainly ask the surgeon of his results
Thanks
Kriszty

[Kriszty]

Sad update- she went in and had the scope and found the shoulder was in a bad way. Marked damage to medial ligament, supraspinatus and biceps (approx 50%) torn. Damage to the cartilage.
He took her to MS surgery/stabilisation and then decided to cut her biceps tendon (without bothering to pick up the phone to me). I've just got her home and am very upset, the discharge was awful as he got extremely aggressive when I said I was very upset about not being consulted re the biceps, he told me I wasn't a specialist, that regenerative medicine did not work and there was no other option for treatment. Oh and my training was worth nothing and he was the only one who could decide re treatment. I never would have agreed to cutting the biceps
All very upsetting, obviously agility is out of the picture and I am concerned about her function as an active pet dog, we are on acreage and she is +++++ active. He assured me pet function would be fine but I'm not feeling like I can trust him currently.
Any thoughts re rehab, not something I've had to rehab before, obviously as I'd never recommend this "treatment"
TIA

[lehughes]

Oh gosh Kriszty, I'm sorry you had this experience. Even if the surgeon was correct that this was the only option, it's too bad you weren't better informed about this decision. (It all comes down to communication, doesn't it?!)

So, I wouldn't worry about active farm function. And, just wait and see in regards to Agility. She could likely still do some version of agility at a lower level, just for fun. You might need to play that by ear.

As far as rehab, just look at function. Get her to use it slow and steadily increasing strength. You can follow the MSI protocol I have and just gauge her function and abilities.

Don't feel devastated just yet. Onward and upward. See how it goes.
And hang in there!

Laurie

[David Lane]

Hello,

Sorry I missed your response to my comments (and thus didn't reply until now), and sorry about your experience with being dismissed by the surgeon.

My opinion on the outcomes for placement of a medial shoulder suture are based on hearsay, as I'm not aware of any peer reviewed paper demonstrating a consistent return to athletic function, and because I am fortunate enough to have never needed to send one of my patients for that surgery. Did you ask the surgeon what his definition of success is? Or what sort of athletic function he expects this surgery will provide your dog in the future? If he has performed this procedure on competition dogs before, consistently returning them to a high level of athletic function, then his opinion trumps mine. I'm just not aware of other surgeons claiming this.

If there is anyone else out there reading this and has a different experience, I would love to hear from you.

[Kriszty]

Thanks Laurie and David. She went in 1/5 lame and is 2w post op 4/5 lame and knuckling on her foot so not feeling very happy about it all.
I don’t know what you asked David, but this was a paper I read. https://www.veterinary-practice.com/art ... nstability