Discussion related to the musculoskeletal system - injuries, post-op, lameness, extremity issues (joint, muscle, tenon, fascia...), axial skeleton issues, etc., as it relates to canine rehabilitation.
I've got a complicated case that I could use your help with. It's my first case since getting my CCRT of course
3yo MN Boxer mix that was diagnosed with hip dysplasia and had a THR 1 yr ago on the Right hip. The pet has been NWB ever since. He's been back to the surgeon several times. They cultured the hardware to see if it was infected. Culture was negative but they treated with antibiotics anyway. The client says the dog received PT after the surgery but there is no indication of that in the medical records. Last time he was at the surgeon's was on 6/18/18 and explant surgery was discussesd. Client came to my hospital for acupuncture consult. I just received my CCRT and we have no PT program in place yet, but advised owner that PT is recommended to help p heal.
On my exam: NWB lame RR, the dog cries out in pain on abduction and minor extension of the right hip. There is moderate muscle atrophy of the hams and quads on the RR. No neurologic abnormalities. Iliopsoas (R) palpation elicits pain, (L) does not. Very tight LS epaxial muscles.
Client is extremely short on finances and has mentioned euthanasia if pain cannot be controlled. (I will not euthanize this dog as I feel he can be treated.)
We did perform acupuncture for pain, as well as laser 8J/CM2 (chronic) on the right iliopsoas, hip and LS area. I took him off carprofen to re-initiate the inflammatory response to assist in remodeling of the tendon fibers and put him on Methocarbamol, gabapentin and amantadine.
Any guidance and insight you can give me would be greatly appreciated!! Thank you so much!
What a kick in the teeth that your first case after your CCRT is a complicated one! Oi!
Okay, so I have a few thoughts, and most of them centre around surgical error and/or immed post-op mismanagement.
1. The angles of the hip / socket aren’t correct, thus leaving tissues to be pinched.
2. Iliopsoas was compromised during Sx (I remember back in my early days of teaching and hearing a surgeon tell a story of accidentally ‘nicking’ the iliopsoas during a THR, and they thought it would do okay if they left it. The entire class of physiotherapists gasped. To which he replied, “yah, he didn’t do well.”). So perhaps a nicking of it, or some other damage, perhaps ischemia to the iliopsoas.
3. Inadequate post-op pain management, thus leading to ‘wind up pain’ (central sensitization), and postural compensations.
4. And of course now you have some compensations being primary issues. It is known in human and animal that THR implant failure is often associated with tight muscles and weak muscles… both of which you have!
5. And just to throw it out there, but be sure to check for SIJ and L-S pain. (I’ve seen problems here with long surgeries with a dog on it’s back… not specifically THR, but I have seen it with neutering of large dogs! It’s not top of my list in your case, but I’d be remiss if I didn’t mention to check there!)
So, treatment wise…. I’d try rehab before explant or euthanasia!!
Just be sure that pain is managed. Your list of meds is dandy, but at this point in time, I’m not sure you’re looking to re-start inflammation for proper tendon healing. At this point, you are needing to slowly stretch tight fibres and scar tissue. So, if you’re not getting adequate pain control with your combo-meds, but there was some with the carprophen, then I don’t think there is harm with using carprophen (and likely in addition to the other or combo of the others you have selected).
I believe your goals need to be pain management followed by easy ther-ex and tissue extensibility. Given that cost is a factor… whatever you can help the owner to manage at home would be great! Hot or cold before exercise, heat before stretching, perhaps purchasing of a portable PEMF - HealFast Loops are very economical, and/or Assisi Loops which are a bit more costly, but have some research behind them. Teach the owner stretches, massage, and stress that tissues should be taken to a point of resistance but not outright crying pain. Discomfort is okay.
Now, to get the dog to use the leg will be a whole other uphill battle. This is now a learned non-use, confirmed by ‘pain’… which means you’ll have a heck of a time getting the dog to buy into using the leg, even if you get rid of the pain. So, I’d try to simple weight bearing exercises, after whatever you / the owner uses for pain, and after some soft tissue work (i.e. within a session). With this much ‘stuff’ going on, I think you’ll get a set back if you push to hard or too fast to get ‘normal’ use. It happens in people too! People with back pain need slow, easy, non-painful, successful movements in order to change the pain signalling coming from the back. (i.e. easy swaying +/- arm swinging, or pelvic tilts in a chair, then in standing… and so on.) Think about ‘positive experiences with what you are working with… but with that said, everything can’t be passive. Which is where you’d end a session with trying to get active use and WB on the limb.
Well, I think that gives you enough to get started with and start thinking about. Please update if/when you can!
(I’m also going to post this to the forum and hopefully we might get others to chime in…)
Thank you so much for your expert input. Unfortunately, this owner is looking for a quick fix and went back to the surgeon for explant. I have no idea if he will seek rehab afterwards. Kind of frustrating as I feel I can help the dog but the client is unwilling to do the work.
