Elbows, shoulders, knees and toes

[puppylove]

OK, it's really only elbows and shoulders but the jingle was in my head. I am working with an active 9 year old dog (slightly overweight) that has had a 2 month hx of intermittent forelimb lameness that worsens with exercise. She was recently diagnosed via CT with R suprispinatus tendiopathy, bilateral mild tenosynovitis, and bilateral medial coronoid dz. The videos have been very helpful with rehab planning and I am continually grateful for the knowledge you share. Here are my questions going into this. Given that the elbows are involved, how do I avoid further damage to the joints with all of the eccentric exercises to help increase the load on the tendon? My thoughts are to do all the eccentric exercises, then perform joint mobs and laser laser laser shoulders/elbows. Regarding progression, if I still get lameness after exercise, how do I know when to add challenges or decrease restrictions? Will it be based on the degree of lameness and length of time she is affected? I apologize if some of this is remedial, I am still learning (daily)! Thanks to anyone that may offer assistance.
Missy

[lehughes]

Hey Missy!
This is a really good question! I've struggled with this exact scenario before! I have come to wonder if the supraspinatus develops due to a compensation for the elbows.
Down hill waking can help the tendons, but can irritate the elbows! Argh!

So, I have come to decide that the Elbows 'trump' the supraspinatus in regards to treatment planning... especially if the elbows are painful.

For elbows, I've found the best rehab therapies to be all modalities (laser, shockwave, PEMF, acupuncture, and alpha-stim CES earclips). You can then add laser or shockwave to the supraspinatus. And if you need to substitute, you can try ultrasound or e-stim (used at 5pps sort of like a TENS).
If the owners are open to other therapies, then they could try PRP injections into the elbow joints as well as the supraspinatus tendons. (I say PRP only because it seems to be more economical, and OA & tendons are where the research seems to be strongest for PRP.)

For specific exercise:
Perhaps the push-ups (rear legs slightly elevated and enticing the dog to take a cookie from the floor) - so that the supraspinatus gets some eccentric action (when the shoulder flexes) and concentric action (when the dog pushes back up). Both directions / uses are beneficial and I think the elbow flexion will be minimal and at least non-jarring.

For general exercise:
Underwater treadmill or even some swimming could be useful. Leash walks on level ground would be advisable.

Now, how sore is okay. If it were just a tendon, then soreness is okay if it's gone the next day. If it were just an elbow, then I'd want minimal flare up - so not worse hours after exercise. This is precisely where 'elbow trumps tendon'. You'll have to aim for no flare ups.

So, not a remedial question at all. It is exactly the kind of combination that requires complex thinking! Thank you for asking it!

Laurie

[puppylove]

Case Follow Up: Opinions welcomed!
So, we are doing massage, stretching, therapeutic exercises, and laser twice weekly (These are the tools available to me). We enrolled this maniac jumper in a training program for long term anti-jump training. For the longest time, there was no limp whatsoever (even after play times). However, this week I saw a lameness return. It was super slight, but it was there. We are headed into week 8.
The clients will not/can not control her to leash activity, and they do not restrict her from playing hard with visiting dogs. Also, they are elderly and do not leash walk her for therapy (or otherwise). They will, however, allow me to come to their house to continue therapy, have their vet give an intraarticular steroid injection, or go elsewhere for rehab where they have access to underwater treadmill, acupuncture, and some more high tech equipment.
Knowing that they can't follow the restriction guidelines, is it in the patient's best interest to go to a facility that can offer more modalities? I want her to have the best chance to heal.
Or, since client's can't restrict her, does it really matter what we throw at her as she will still run around like a happy lab and in the end, most likely need surgery anyway?

Thanks everyone,
Missi

[lehughes]

Hey Missi,

So having battled this before. IF the owners can't do their part, then conservative mgmt won't work.
I'd go ahead with cortisone injection to the elbow... and then just add down hill walking, down stairs, push up type exercises for the shoulders.

Some type of lameness after exercise should be expected for tendon... but not for elbow. Catch 22!

The other thought to throw out there, is: Is a lameness the worst thing? Does it always mean pain? Just go to the shopping mall and watch people walk... lots of lameness out there!

Sometimes there are scenarios where you do the best you can. You can continue and provide some degree of relief and assistance if the owners are willing. Really, if the dog is a maniac, then that might be the best that can be done! Sometimes reality has to come into play.

Laurie

PS
Surgery for what?
UWT not magic for this.
Acup not magic for elbow OA - but might help with pain if that's bad. Could help supraspinatus if that was the main problem... but then I'd needle directly into the tendon. But without the rest of the puzzle pieces, not the be-all-and-end-all.

[David Lane]

I agree with Laurie. My go to's for debilitating elbow OA is shockwave or injections. For injections, I prefer PRP to steroids conbined with HA (HA/S), but if PRP is not available then HA/S is a good option. One paper found them both to be equally effective. PRP costs more but lasts longer.

If there is only mild/moderate elbow OA, then make sure the vet uses triamcinolone (vetalog/kenalog) and not depomedrol. Depo eats cartilage whereas in-vitro data says vetalog is chondro protective. Depo lasts longer though. I only use depo for severe OA, when there is no cartilage left worth saving anyway.

David Lane

[puppylove]

Thank you very much Laurie and David.