I am treating a border collie who had right TPLO surgery eight weeks ago, and we are still really struggling to get him to use the leg.
Backstory - he is high level agility dog who became 3-leg lame in December. We tried rehab with him, but never achieved FWB on the right hind, and every time he did more than he was supposed to he was back on three legs again. So, his owner decided to go ahead with surgery.
He had TPLO surgery on early May. I first saw him two weeks after surgery (still on analgesic meds at that point) and he appeared to be doing ok, was putting the foot on the floor, although not FWB. A few days later, he came off the meds and was back on three legs. X-rays showed fibular head fracture and he was put back on a further four weeks strict rest by the surgeon. I saw him again after those four weeks and he was still hopping along on three legs, his owner reported that this had not changed in the four week period.
He has been back to the surgeon multiple times, they can't find anything abnormal and don't appear to be concerned. His owner is beside herself. He does not like to be carried, so can't do stairs and she is still sleeping on the couch downstairs with him (her husband isn't happy!!). Obviously, her end goal is to get back to agility, but if we can't get him to put his foot down, that is going to be a problem!
He has full range of motion throughout the right hind. I've checked his back, his hip, hock and foot trying to find a reason why he doesn't want to use the leg. Can dogs become centrally sensitized?? He is your typical intense border collie who doesn't know how to stand still. His owner has good skills and we have tried shaping him to put his right foot on an object, just to get his foot touching something (he has a strong rear foot target from contact training) but he is very reluctant.
He is a dog that lives to please his owner, and she is a skilled shaper, so I am finding it strange that he won't maintain his foot contact on anything. This makes me think that either he is centrally sensitized (if there is such a thing in dogs) or that he does have pain somewhere. Also concerning is that he appears to be 'getting used' to being on three legs, he hops along quite happily and is placing the left hind well under his body like a tripod dog would.
Any suggestions????? He hasn't been on pain meds since the initial post-surgery period. I'm wondering if it is worth trying to get the vet to prescribe a short course of pain meds just to see if he will start using the leg? If he does, at least this would confirm he does have pain somewhere??
Border Collie Still NWB Eight Weeks after TPLO - HELP!!!
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David Lane
- Posts: 164
- Joined: Mon Oct 24, 2016 10:51 pm
Re: Border Collie Still NWB Eight Weeks after TPLO - HELP!!!
Hello,
Are you able to elaborate further about what the surgeon has done to rule out complications? Specifically, what has been done to eliminate the possibility of a meniscal tear?
I too have had patients that I wonder about a maladaptive pain syndrome on. However, if that was the case, I would expect the presentation to be one of easily detected stifle pain without an underlying explanation of why that pain is there. If you are not able to elicit pain, then the history suggests more of an associative learning problem (perhaps facilitated by the dog being "pain sensitive" in the first place).
Having said that, I never want to attribute symptoms to behaviour if they are indeed of pain origin. To that end, I absolutely agree that putting this dog back on pain control while doing rehab is a good idea. This advice assumes that an underlying meniscal tear or any other surgical complications have been absolutely ruled out. If the pain control medication triggers rapid significant improvement, then there is real pain. If it does not, then again I'm thinking an associative learning issue.
If it is learned, then you need to slow down on the shaping plan for the desensitization program, and increase the value of the reward (if possible). If the dog gets too apprehensive during structured exercises, then perhaps they need to be done in a novel environment with many distractions (ie: go walk a wooded trail with roots, angled ground etc.), and see if use of the leg improves in that situation.
I hope that helps.
Are you able to elaborate further about what the surgeon has done to rule out complications? Specifically, what has been done to eliminate the possibility of a meniscal tear?
I too have had patients that I wonder about a maladaptive pain syndrome on. However, if that was the case, I would expect the presentation to be one of easily detected stifle pain without an underlying explanation of why that pain is there. If you are not able to elicit pain, then the history suggests more of an associative learning problem (perhaps facilitated by the dog being "pain sensitive" in the first place).
Having said that, I never want to attribute symptoms to behaviour if they are indeed of pain origin. To that end, I absolutely agree that putting this dog back on pain control while doing rehab is a good idea. This advice assumes that an underlying meniscal tear or any other surgical complications have been absolutely ruled out. If the pain control medication triggers rapid significant improvement, then there is real pain. If it does not, then again I'm thinking an associative learning issue.
If it is learned, then you need to slow down on the shaping plan for the desensitization program, and increase the value of the reward (if possible). If the dog gets too apprehensive during structured exercises, then perhaps they need to be done in a novel environment with many distractions (ie: go walk a wooded trail with roots, angled ground etc.), and see if use of the leg improves in that situation.
I hope that helps.
David Lane DVM
ACVSMR, CVA, CVSMT, CCRP
ACVSMR, CVA, CVSMT, CCRP
Re: Border Collie Still NWB Eight Weeks after TPLO - HELP!!!
Hey Stella,
I believe that dogs can absolutely get centralized pain. I've seen it a few times (and primarily with TPLOs with inadequate pain management.) Typically in the vet world, it's termed "Wind Up Pain"... but central sensitization is exactly what it is.
My most recent example was a high drive field trial dog with bilateral TPLO's. On pain meds for 2 weeks. When she came off the meds, up went one leg, and the whole rear end tucked under to avoid rear end weight bearing. Back on pain meds for another 3 - 4 weeks, and she's doing great.
Of interest, I found some swelling in the stifle(s), but the dog had full ROM, no signs of meniscus... just seemed to be apprehensive with stifle movement and use. Central sensitization doesn't have to make the stifles themselves 'painful'... which is part of the phenomenon. The periphery doesn't tell the correct story!
My secondary example was a marshmallow of a dog, with a single TPLO. Due to issues in his gut, was only put on Tramadol for 2 weeks post op. So at 4 weeks out, he walked like a dog who had just had surgery 5 days earlier. A course of anti-inflammatories did the trick with him as well.
Given the fact that there was an incident where the fibular head was fractured, I believe that puts the dog at a disadvantage from a pain management standpoint. It's a double whammy of pain on pain... and the typical spinal cord and supratentorial mechanisms were over loaded and unable to cope. Thus, pain!
In both of my cases, I was able to pass on my concerns to the vet, and additional pain meds were prescribed. One has to think NOW that they need to be on board LONGER to help dampen down the signalling - so perhaps a 3 - 4 week course, versus just another 2. In both cases, we held off doing any exercise therapies until pain management had begun, and helped in that regard with laser, TENS, and the like. One vet now tells clients "If Laurie says there's pain. Then there's pain! I have no doubt in her ability to know when there's pain!"
So, your next challenge (I think), is to get the owner to buy into the need for additional pain control AND the vet. Whether the surgeon is the regular vet, or not... you need someone on your side to do the actual prescribing! So it may require a note back AND a phone call. And have the owner call the vet as well.
I really enjoyed reading David's take on the Associative Learning problem. I have found this phenomenon to be the curse within the 'late stage' rehab (as compared to early). For example, those dogs that are doing all of your boot camp exercises, etc, but still can't achieve that last bit of 'normal use' or 'normal weight bearing' or 'equal thigh circumference'. Those are the guys, I suggest 'let them be a dog for a month'... don't worry about 'structured exercise'. And then come back and we'll re-evaluate. Which usually does the trick!
Best of luck Stella! Keep us posted!
Cheers,
Laurie
I believe that dogs can absolutely get centralized pain. I've seen it a few times (and primarily with TPLOs with inadequate pain management.) Typically in the vet world, it's termed "Wind Up Pain"... but central sensitization is exactly what it is.
My most recent example was a high drive field trial dog with bilateral TPLO's. On pain meds for 2 weeks. When she came off the meds, up went one leg, and the whole rear end tucked under to avoid rear end weight bearing. Back on pain meds for another 3 - 4 weeks, and she's doing great.
Of interest, I found some swelling in the stifle(s), but the dog had full ROM, no signs of meniscus... just seemed to be apprehensive with stifle movement and use. Central sensitization doesn't have to make the stifles themselves 'painful'... which is part of the phenomenon. The periphery doesn't tell the correct story!
My secondary example was a marshmallow of a dog, with a single TPLO. Due to issues in his gut, was only put on Tramadol for 2 weeks post op. So at 4 weeks out, he walked like a dog who had just had surgery 5 days earlier. A course of anti-inflammatories did the trick with him as well.
Given the fact that there was an incident where the fibular head was fractured, I believe that puts the dog at a disadvantage from a pain management standpoint. It's a double whammy of pain on pain... and the typical spinal cord and supratentorial mechanisms were over loaded and unable to cope. Thus, pain!
In both of my cases, I was able to pass on my concerns to the vet, and additional pain meds were prescribed. One has to think NOW that they need to be on board LONGER to help dampen down the signalling - so perhaps a 3 - 4 week course, versus just another 2. In both cases, we held off doing any exercise therapies until pain management had begun, and helped in that regard with laser, TENS, and the like. One vet now tells clients "If Laurie says there's pain. Then there's pain! I have no doubt in her ability to know when there's pain!"
So, your next challenge (I think), is to get the owner to buy into the need for additional pain control AND the vet. Whether the surgeon is the regular vet, or not... you need someone on your side to do the actual prescribing! So it may require a note back AND a phone call. And have the owner call the vet as well.
I really enjoyed reading David's take on the Associative Learning problem. I have found this phenomenon to be the curse within the 'late stage' rehab (as compared to early). For example, those dogs that are doing all of your boot camp exercises, etc, but still can't achieve that last bit of 'normal use' or 'normal weight bearing' or 'equal thigh circumference'. Those are the guys, I suggest 'let them be a dog for a month'... don't worry about 'structured exercise'. And then come back and we'll re-evaluate. Which usually does the trick!
Best of luck Stella! Keep us posted!
Cheers,
Laurie
LAURIE EDGE-HUGHES
Re: Border Collie Still NWB Eight Weeks after TPLO - HELP!!!
Chronic pain, central sensitization, wind up are all actually describing the same situation. This is a condition where there are physiochemical changes within the central nervous system brought about by continued and/or severe peripheral nociceptive input. The changes are especially in the dorsal horn of the spinal cord and the pain processing centers of the brain. This is where drugs such as gabapentin, amantadine and amitriptyline help NSAIDs in the management of pain. The initial 3 drugs work within the CNS while NSAIDs primary action is in the periphery. In some patients with chronic pain they can also have hyperalgesia (increased sensitivity to nociceptive input or enhanced intensity of input) and/or allodynia (when normally non-painful input creates nociceptive input). In your patient you must localize all ares of pain for treatments to be effective.
Fibular fractures are of concern to me because they are often the result of a too distal osteotomy that puts added stress on the fibula. The Fibula provides rotational stability so when it is not there there can be a shifting of the at the osteotomy sight that can result in a slight external rotation of the tibia and/or valgus deformity. Careful evaluation of current radiographs to immediate postoperative can reveal if that is occurring. Radiographs can also assess the integrity of screws. If the surgeon use locking plates and screws rotation with a fibular fracture is much less likely. I would also be concerned if there is a positive tibial compression and/or cranial drawer. The TPLO should eliminate tibial thrust. Of course as mentioned meniscal tears should always be considered with continued postoperative lameness. McMurry's Test may be helpful to evaluate the meniscus.
Your patient has had a dysfunctional joint for 8 months now so muscle dysfunction is very likely present in the functional unit muscles of the hip and stifle. Myalgia is probably present and contributing to the overall nociceptive input and in some instances muscle will be the main nociceptive input. Examine all those muscles closely.
Rick Wall
Fibular fractures are of concern to me because they are often the result of a too distal osteotomy that puts added stress on the fibula. The Fibula provides rotational stability so when it is not there there can be a shifting of the at the osteotomy sight that can result in a slight external rotation of the tibia and/or valgus deformity. Careful evaluation of current radiographs to immediate postoperative can reveal if that is occurring. Radiographs can also assess the integrity of screws. If the surgeon use locking plates and screws rotation with a fibular fracture is much less likely. I would also be concerned if there is a positive tibial compression and/or cranial drawer. The TPLO should eliminate tibial thrust. Of course as mentioned meniscal tears should always be considered with continued postoperative lameness. McMurry's Test may be helpful to evaluate the meniscus.
Your patient has had a dysfunctional joint for 8 months now so muscle dysfunction is very likely present in the functional unit muscles of the hip and stifle. Myalgia is probably present and contributing to the overall nociceptive input and in some instances muscle will be the main nociceptive input. Examine all those muscles closely.
Rick Wall
Re: Border Collie Still NWB Eight Weeks after TPLO - HELP!!!
Thanks guys for your responses, sorry I'm slow replying. I only have the password to get into the forum saved on my home computer, and never wrote it down, so can't log in from another device!!
I've tried McMurrays and couldn't elicit anything, the surgeon also reported that they had cleared the meniscus as a cause of ongoing dysfunction. Because I have been concerned about ongoing pain, we have been very conservative in our rehab, basically working on trying to get him to place his foot on anything - not necessarily weight bearing through it, just placing it flat on a surface - because when he does put it down on the floor he's usually resting it on his toes. I've been doing some work on his back because he's usually a bit twitchy up there, soft tissue massage, Gd II mobs for pain relief and also sensory input through his foot - stroking etc (I'm thinking of the things I'd do for a human with RSD / CRPS).
Ok, update and maybe a bit more back story! The surgeon did agree to try meds and put the dog on Metacam. He had maximum dose today with no effect. I'm a human physio too, and am wondering if the drugs have the same effects in dogs? Meloxicam (human version) is an NSAID, while I know NSAIDs have analgesic effect, this is not their primary role? So, I've always said if NSAID not working, there is no / little inflammation present. I was hoping the dog would be put on an actual painkiller and / or a drug that may affect the nervous system such as Gabapentin. The surgeon has said that because the Metacam hasn't done anything there is likely an issue with the metalwork (they think he is rejecting it) and they want to get him in ASAP for removal of the hardware. I know this is a possibility, but I have concerns about this dog having further surgery.
Backstory notes - the surgeon told the owner the fibular head fracture was from the dog doing too much post-op. I know she complied with post-op instructions to the letter, which is why eight weeks later she is still sleeping on the couch downstairs! Everything I found in my quick Google search suggested that surgical procedure / technique was more likely the cause of the fibular head fracture. He was not put back on meds after the fibular head fracture was diagnosed, he only had meds for the initial two week post-op period. I'm wondering if this could be contributing to his ongoing dysfunction.
I've tried McMurrays and couldn't elicit anything, the surgeon also reported that they had cleared the meniscus as a cause of ongoing dysfunction. Because I have been concerned about ongoing pain, we have been very conservative in our rehab, basically working on trying to get him to place his foot on anything - not necessarily weight bearing through it, just placing it flat on a surface - because when he does put it down on the floor he's usually resting it on his toes. I've been doing some work on his back because he's usually a bit twitchy up there, soft tissue massage, Gd II mobs for pain relief and also sensory input through his foot - stroking etc (I'm thinking of the things I'd do for a human with RSD / CRPS).
Ok, update and maybe a bit more back story! The surgeon did agree to try meds and put the dog on Metacam. He had maximum dose today with no effect. I'm a human physio too, and am wondering if the drugs have the same effects in dogs? Meloxicam (human version) is an NSAID, while I know NSAIDs have analgesic effect, this is not their primary role? So, I've always said if NSAID not working, there is no / little inflammation present. I was hoping the dog would be put on an actual painkiller and / or a drug that may affect the nervous system such as Gabapentin. The surgeon has said that because the Metacam hasn't done anything there is likely an issue with the metalwork (they think he is rejecting it) and they want to get him in ASAP for removal of the hardware. I know this is a possibility, but I have concerns about this dog having further surgery.
Backstory notes - the surgeon told the owner the fibular head fracture was from the dog doing too much post-op. I know she complied with post-op instructions to the letter, which is why eight weeks later she is still sleeping on the couch downstairs! Everything I found in my quick Google search suggested that surgical procedure / technique was more likely the cause of the fibular head fracture. He was not put back on meds after the fibular head fracture was diagnosed, he only had meds for the initial two week post-op period. I'm wondering if this could be contributing to his ongoing dysfunction.
Re: Border Collie Still NWB Eight Weeks after TPLO - HELP!!!
Okay... well, you then throw into the differentials Infection around the plate. I also saw one dog where the surgery stirred up an underlying synovial carcinoma (dog was owned by the vet who did the surgery, did the revision, went in checked a 3rd time... and on 4th inspection, the cancer was 'identifiable'. He was the 'sorest' looking post op CCL (tight rope) I had ever seen, with the most atrophy I have ever seen - two things that are now burned into my memory as guideposts moving forwards.
As for the # of the fibular head - yep, we'll always be the ones thrown under the bus. No it wasn't you! It was faulty surgical technique. I just had a rehab vet from Austria shadowing this past week. She put it most succinctly. "The person who had their hands on the dog last, will always take the blame - right or wrong!"
So... I would have hoped that Metacam would have done SOMETHING. Even if not a typical 'pain med'. Sometimes I will probe the owner to probe the vet about 'other meds' and give them names of those other meds to ask their vet about. i.e. Can my dog have tylenol? What would be the dose? OR, I was told about a drug called Gabapentin, could we try that as well before jumping into surgery? (We, the non-prescribers, have to be sort of careful... and this is one way I've worked around it.) OR, you could be the one that contacts the vet and states: "Mary is very leery about doing another surgery with Fido, would you be open to trying him on a 2-week course of adjunctive pain meds as well? Just to rule out 'pain' as the functional limiter?"
Rock and a hard place!
Laurie
As for the # of the fibular head - yep, we'll always be the ones thrown under the bus. No it wasn't you! It was faulty surgical technique. I just had a rehab vet from Austria shadowing this past week. She put it most succinctly. "The person who had their hands on the dog last, will always take the blame - right or wrong!"
So... I would have hoped that Metacam would have done SOMETHING. Even if not a typical 'pain med'. Sometimes I will probe the owner to probe the vet about 'other meds' and give them names of those other meds to ask their vet about. i.e. Can my dog have tylenol? What would be the dose? OR, I was told about a drug called Gabapentin, could we try that as well before jumping into surgery? (We, the non-prescribers, have to be sort of careful... and this is one way I've worked around it.) OR, you could be the one that contacts the vet and states: "Mary is very leery about doing another surgery with Fido, would you be open to trying him on a 2-week course of adjunctive pain meds as well? Just to rule out 'pain' as the functional limiter?"
Rock and a hard place!
Laurie
LAURIE EDGE-HUGHES
Re: Border Collie Still NWB Eight Weeks after TPLO - HELP!!!
Thanks Laurie. He goes back to see the surgeon today, his other appointments have been with the surgeons rehab vet (if you saw my FB post, you'll remember that this is the one that gave front feet up on the couch and backing up as homework when the dog was clearly on three legs). I'm sure they are going to go with further surgery, his owner is convinced that removing the hardware is going to 'fix' the problem. So, I can only wait and see what he looks like on the other side and hope for the best.
Re: Border Collie Still NWB Eight Weeks after TPLO - HELP!!!
Fingers crossed then!!!
Keep us posted... if they find something and/or if the dog begins WB post op!
Cheers,
Laurie
Keep us posted... if they find something and/or if the dog begins WB post op!
Cheers,
Laurie
LAURIE EDGE-HUGHES
Re: Border Collie Still NWB Eight Weeks after TPLO - HELP!!!
He is scheduled for surgery on Wednesday. I'll let you know!!
Re: Border Collie Still NWB Eight Weeks after TPLO - HELP!!!
Many months later, I thought I would update you guys this poor dog. He had surgery to remove the hardware, and they also (apparently) went in and checked his meniscus - told the owner meniscus was fine. Removing the hardware made no difference to his weight bearing status. We tried everything to improve his weight bearing, but it never improved. This week he went for a second opinion and arthroscopic surgery to check the meniscus again, the post-op report was not good. In his owners words "his knee is toast" - severe arthritis, meniscus damage, incorrect angle from the initial surgery (not a surprise seeing as he ended up with a fibular head fracture after the surgery). This surgeon is recommended total joint replacement as a pain relieving measure. His owner is trying to decide what to do 