Gordon setter with hind limb lameness

[sunami83]

I seem to be on a track of difficult cases lately... Sorry for posting again! Recently I've been seeing a 10 months old Gordon Setter with a hind limb issue. When he was about 3 months he ran into the edge of a table (owner thinks he hit somewhere in the lateral stifle/thigh area) and was lame on the right hind. Owner waited to see if it improved for 3 weeks before she went to see a vet... Pain was then localized to the stifle, but no laxity or inflammation could be found and x-rays and MRI of the stifle were normal. The dog continued to have a low degree lameness for several months and was examined by several vets and rehabilitation professionals without anyone being able to find or solve the problem. In november (when he was about 7 months old) his right hind leg got stuck in a hole in the snow and he panicked to try to get free pulling the leg really forsefully. After this the dog got even more lame. The dog was then put on NSAIDs and gabapentin (which owner had been told to give only when she felt he needed it...). Pelvis, hips, spine, knees have been x-rayed. A PennHip has also been done which placed him in the lower area of moderat risk.

Late January I excamined him for the first time. He had a lot of dysfunctions in his lumbar spine, and his right SIJ was bad. There was a difference in muscle mass between the right and left hind limb - 1,5 cm difference measuring the thigh circumference. I also felt that his right knee had more recistanse upon extension than the left, but end feels were normal and I was able to extend the knees equally on both sides. The most pronunced finding was severe pain upon palpation of one point in the proximal sartorius right at the level of the ventral pelvis (I've attached a picture where I'm pointing to show where I mean). Trying to stretch the sartorius is impossible as he just freaks out. We've done three sessions working on the spine dysfunctions and SIJ and lasering the sartorius. His spine and SIJ has resolved really nicely and the owner has noticed a difference in the dog's general demeanour with him being more happy and playful, however there is no diffence in the lameness and the point in the sartorius is still very painful. Owner can't see any pattern in the lameness - sometimes he's lame in the beginning of the walks and sometimes he can walk almost normally during a walk, sometimes he's lame when getting up and sometimes he's not. Long walk or short walks do not seem to make a difference. She describes the lameness as more of the leg looking "loose". He's been walking normally when I've seen him so I've asked her to video him, but unfortunately I haven't received a video of him yet.

Any idea what could be in play here? I'm at a loss. Apart from finding the area of pain I feel I've not been able to help and I don't know where to go from here. I'm also fearing there could be two different issues; one from the table insident and one from the stuck in the snow insident. Owner is beginning to think about euthanasia... Would be gratful for any input that might help

[lehughes]

Euthanasia! That's crazy! Okay, so let's prevent that!

The things that come to mind are:
1) Femoral nerve... since the femoral nerve is 'tensed' the same way that you would stretch the sartorius and may have been impacted in either or both of the incidents.
Since you already know that putting the nerve on stretch causes pain, try also palpating under the vertebra (rather like palpating for iliopsoas to see if there is pain there as well.) Could be nerve, could be trigger points in iliopsoas. The back pain could have been part of what you were seeing and could have been nerve related.
2) Trigger Points: Where your hands are in the photo is a common place for trigger points. You might actually be on tensor fascia lata as well up there.
3) Maybe the original injury resulted in a myositis ossificans (a muscle injury that repairs itself with bone). Perhaps the second injury tore some of the fibres around the ossifican, and started up some inflammation again. But the ossificans would have shown up on x-rays (not right away mind you... but if you x-rays now, and they were present, you'd see them)

So... to treat the femoral nerve, look up the nerve gliding (Adverse Neural Tissue Tension techniques), you basically 'sneak up' on the nerve to stretch it... never a strong hold. Add any laser to the painful area or path of the nerve (L/S & iliopsoas region). Maybe putting him on gabapentin as a daily thing could help to decide about this as a diagnosis as well as treat it.

To treat the triggerpoints: try myofascial stretches - slow gentle holds, easing into a stretch, try skin rolling as well. And modalities as available.

To treat myositis ossificans - you treat from the outside in. So ultrasound or laser around the outside of where it is most painful, and come up with 'active' stretches. Maybe front feet up to stretch out iliopsoas (but sartorius will be stretched slightly as well).

And for all of them, maybe try overall strengthening. Could be that with all of the issues he 'turned the leg off' (i.e. inhibition of the muscles).

See what you think of each of these when you see the dog next! And let us know!

Laurie