Hi Laurie,
Hope you are doing well! I have a case I need some advice on. A few days ago I saw Murphy who is a 3 year old MN 130# Malamute that was seen at Michigan State University in Dec 2016 for one month hx of hind limb lameness. He was diagnosed with bilateral cranial cruciate disease and bilateral luxating patellas grade 2/4. He did not have surgery until July 2017 on the left stifle due to growth plates not being closed. In July it was noted that he had pronounced tarsal hyperextension when walking. This has gotten worse over the last year. He had a TTTA on the left stifle in July 2017 and then on the right stifle in December 2017. He had a recent recheck at MSU and they performed radiographs and he is healing well, no abnormalities of the tarsus seen. They then recommended rehab and that is where he is now. I have not had a case like this yet so wanted to make sure I do whatever I can to help Murphy. I have started him on a home rehab program as the owner lives a distance away. He is on Galliprant and Tramadol for discomfort, Amantadine at times and Glycoflex. I have started him on massage, PROM and a few strengthening exercises to start such as sit to stands, uphill walking, Front feet on step and hold, cavaletti's, backwards walking, trying 3 leg stands. He does gets leash walks as well. I do not have an UWT but do have a land treadmill so not sure if this would be a good idea for him or not.
My questions are: do you recommend braces for the hocks and which one would you use, what other exercises do you suggest and how long have you seen it take for these patients to improve? Owner is open to anything!
I have enclosed a video of him walking so you can see what he is doing.
So sorry for the lengthy email but I would greatly appreciate your advice on this case.
Thank you so much for your time!!!
Sincerely,
A
https://youtu.be/git-lqHtriU
Bilateral cruciate repairs - Need advice
Re: Bilateral cruciate repairs - Need advice
Hi A.!
Fascinating gait. I’ve seen this with Triple Pelvic Osteotomies, but not with TPLOs.
So, just to cover bases, be sure to check on his hips as well.
Okay. Firstly, I think that WHY a dog develops this gait pattern is because he/she has lost extension elsewhere in the leg and hyperextending the tarsal joints is a mechanism to gain further extension & end stance phase.
So, to that end, I’d check and mobilize the stifle joints into extension…
But more importantly is likely to be getting him to use his legs correctly again. One of the simplest (but most profound) things I learned from Ilaria Borghese of Therapaw, when she was up doing a splinting (etc) course for us up here in Canada, was that is you want to see how an animal will do with a splint / brace / orthosis, DO A MOCK UP! Brilliant, eh? So, try using some vet wrap on the tarsal joint, maybe put something on the ventral surface that would act as a reinforcement (i.e. padding, foam, a face-cloth) and see if you get better extension elsewhere (i.e. stifles & hips) with walking. I am inclined to think that a brace of some sort would be of use. In this case, I’d likely go with Therapaw’s Tarsoflex X, because I don’t think the issue is permanent. I think you can support the joint while building muscle and relearning normal functioning.
Next, who do you want to strengthen? This is a trick question. One I loved to pose! It’s the gastrocs. The Gastrocs need to be stronger in order to hold the tarsus in slight flexion without dropping the hock altogether. When gastrocs are weak, they overfire and dump the joint into hyperextension so that they don’t have to hold a permanent tension. (lazy fellow, the gastrocs!) To that end, jumping up or over something uses gastrocs, slow trotting would use gastrocs, as would backing up, sit to stands, sit to stands facing up hill or with front feet elevated, tug of war, walking backwards down a hill. Since you have a land treadmill try getting him to walk backwards on it. This tends to put all muscles on high alert!
If there isn’t something structural going on, and this dog didn’t walk this way before… I would hope that you’d see improvements in 2 - 3 months. I tend to think it would take that long for muscle memory to kick in and for proper limb use to become the norm!
BUT… try this out and let me know what you find!
Best of luck!
(And I’m going to post this on the FourLeg Forum as well for others to see, think about, & learn from!)
Cheers,
Laurie
Fascinating gait. I’ve seen this with Triple Pelvic Osteotomies, but not with TPLOs.
So, just to cover bases, be sure to check on his hips as well.
Okay. Firstly, I think that WHY a dog develops this gait pattern is because he/she has lost extension elsewhere in the leg and hyperextending the tarsal joints is a mechanism to gain further extension & end stance phase.
So, to that end, I’d check and mobilize the stifle joints into extension…
But more importantly is likely to be getting him to use his legs correctly again. One of the simplest (but most profound) things I learned from Ilaria Borghese of Therapaw, when she was up doing a splinting (etc) course for us up here in Canada, was that is you want to see how an animal will do with a splint / brace / orthosis, DO A MOCK UP! Brilliant, eh? So, try using some vet wrap on the tarsal joint, maybe put something on the ventral surface that would act as a reinforcement (i.e. padding, foam, a face-cloth) and see if you get better extension elsewhere (i.e. stifles & hips) with walking. I am inclined to think that a brace of some sort would be of use. In this case, I’d likely go with Therapaw’s Tarsoflex X, because I don’t think the issue is permanent. I think you can support the joint while building muscle and relearning normal functioning.
Next, who do you want to strengthen? This is a trick question. One I loved to pose! It’s the gastrocs. The Gastrocs need to be stronger in order to hold the tarsus in slight flexion without dropping the hock altogether. When gastrocs are weak, they overfire and dump the joint into hyperextension so that they don’t have to hold a permanent tension. (lazy fellow, the gastrocs!) To that end, jumping up or over something uses gastrocs, slow trotting would use gastrocs, as would backing up, sit to stands, sit to stands facing up hill or with front feet elevated, tug of war, walking backwards down a hill. Since you have a land treadmill try getting him to walk backwards on it. This tends to put all muscles on high alert!
If there isn’t something structural going on, and this dog didn’t walk this way before… I would hope that you’d see improvements in 2 - 3 months. I tend to think it would take that long for muscle memory to kick in and for proper limb use to become the norm!
BUT… try this out and let me know what you find!
Best of luck!
(And I’m going to post this on the FourLeg Forum as well for others to see, think about, & learn from!)
Cheers,
Laurie
LAURIE EDGE-HUGHES
Re: Bilateral cruciate repairs - Need advice
When i look at this dog, from my experience, i see issues from laxity of the tarsal joints that may have caused the CCL tears, and as you mention the luxating patellas (Although i feel the luxating patellas are related to the tarsal hyperextension?!).
If it were my patient, as laurie mentioned, i would focus on Gastroc and glutes...exercises the have the stifle and tarsus in flexion. I will be uploading a video for Laurie shortly that has some great home exercises for this..
Basically uphill backwards, sqats, Sit to stand, and lots of work on balance equipment (hind limb focused)
I hope this helps
Tania
If it were my patient, as laurie mentioned, i would focus on Gastroc and glutes...exercises the have the stifle and tarsus in flexion. I will be uploading a video for Laurie shortly that has some great home exercises for this..
Basically uphill backwards, sqats, Sit to stand, and lots of work on balance equipment (hind limb focused)
I hope this helps
Tania