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I was referred an 8yr old M Field Trial Dog with recent Dx of Infraspinatus Bursitus

The dog has a 6 mo Hx of intermittent R forelimb lameness-worse with high activity
The dog was treated previously by a Rehab vet. A steroid injection into the R shoulder joint
was performed 7 wks ago with some positive improvement. However lameness and soreness persisted.

An MRI was performed 2 wks ago and a Dx of Infraspinatus bursitus was made
(increased signal surrounding the Infraspinatus Tendon with focal involvement of the muscle consistent with Infraspinatus bursitus) Normal Biceps/Supraspinatus tendon and muscle.

An Ultrasound guided Triamcinilone injection (36 mg) was performed
The dog is in my area for the rest of the summer and was referred to me for Rehab Therapy

The referring Rehab vet wanted me to perform Shockwave therapy in addition to other modalities
On exam of the dog minimal RF lameness was noted, decreased shoulder extension with some discomfort, muscle restrictions Triceps, Pectoral and Biceps, mild atrophy

I am unsure of doing shockwave given the steroid injection-isn't the steroid going to cancel the inflammatory response of the shockwave??
I did some Ultrasound on the Infraspinatus muscle and some laser and started some soft tissue work

Does any one have an opinion on using Shockwave in this situation??
I wasn't aware of Infraspinatus bursitus or how this compares to a tendonopathy and its treatment

Would appreciate any input
A. Morgan DVM CCRT

NOTE:

Dr. Morgan had e-mailed me with the following information... I'm going to post her other questions here... and then answer everything in my next post. Laurie

Hi Laurie
I posted this on your forum and no one is replying
unless I am reading it wrong-first time posting

Please see post
The MRI report said the Infraspinatus tendon was N
I did a search on Infraspinatus bursitus-uncommon but seen in the Labrador-This dog has no Hx of trauma (traumatic bursitus)-but he is a lab

When I spoke to my PT friend they said in people can occur from Mid and Lower trap weakness, Teres Minor weakness
Serratus/Lat and posterior Deltoid weakenss
I am U/S and Lasering the Infraspinatus with STM
I don't want him to decondition so I have been walking him on land and UWTM-he intermittently short strides on that limb
in the UWTM but not on land

Question: Eccentric loading exercises for the Infraspinatus would not be adviseable right? if Bursa inflamed cause further pinching/irritation

Just wondering Thx exercise if any would be recommended? It has been 2 wks since steroid injection
I was thinking Theraband pulls, balance disc with weight shifting, He likes traction of the limb so I assume this is taking pressure off bursa

After speaking with PT wondering some ways to strengthen the above muscles? Not sure of the pathophysiology of how this happened
Excessive pounding of his forelimbs-running and jumping????

would appreciate your thoughts
Ann-Margret

Hi Ann-Margret,

I’ll reply to you here and then cut and paste onto the forum as well.

So, firstly, I’ve never seen an infraspinatus bursitis! Interesting indeed!
I’m not sure the human rationale can be transferred over to the dog in this case, simply because the dog weight bears on the forelimb and at 60% at that!
So, the likelihood of this being related to a weakness of the other muscles is slim.
To be honest, to try to grapple with ‘why’ could well be futile. Could be how the dog uses the limb, could an excessive round of exercise causing a flare up, could have been a trauma the owners didn’t witness, could be excessive muscle tension secondary to ??? (who knows what), and so on. So without worrying about the why, let’s go into what you can check and what you can do!

So your therapeutic goals would be:
1) Reduce inflammation in the bursa. Your laser & ultrasound would do this. As well, this is the kind of case that I would be happy to see get a steroid injection into the bursa. So, I’m glad that’s on board. Acupuncture could also be part of the regimen. I also think that perhaps the limb distraction / traction may be helping in this regard as well.
2) Evaluate muscular tension in and around the shoulder joint. This might be secondary or primary. Doesn’t matter. Check scalenes & rhomboids as your primary muscles that could be affected. Then go through all the rest: TMaj & Lats, Biceps & Supraspinatus, LH Triceps, and Supf Pecs. Compare all of these to the other side. If you find a restriction, add it to your stretching protocol.
3) Myofascial glides / extensibility. So, you could look at the muscles listed above, but I’m thinking of infraspinatus itself. So I’d see about doing some slow dragging / muscle separation (along the length of the muscle). You can avoid the tendon itself, so as not to compress or irritate the bursa. Direction over the infraspinatus tendon / caudal shoulder joint, you could do some skin lifting, cupping, or K-Taping to try and get a lift as well. This is purely fascial… but it might help.
4) Maintaining strength. A bursa is different than a tendon. A tendon you want to push. A bursa is temperamental… it won’t like that. So you’re right, you’d not do an exercise (eccentric or concentric) specific to the infraspinatus… however, no such exercise exists!! So you’re perhaps in luck on that!! I would prefer this guy moving without a limp if/when possible. So, I wouldn’t put this guy in the UWT given your description. I’d advise the owner on leash walks… and to increase time and distance so long as no lameness occurs and/or it does not get worse during or after the walk. As the steroid injection is doing it’s job, you can try for some specific therapeutic exercise for forelimbs (biceps & supraspinatus mostly… as they are the prime shoulder stabilizers, and may be the two that need strengthening if there was indeed a strength imbalance of the shoulder muscles.) So try your 3-leg stands, Diagonal leg stands, Push ups…

5) ROM: My new favourite for this is the exercise of Rear Legs elevated and then guide the dog to take a treat from under it's chest / between it's elbows. This get active shoulder extension quite nicely. Beyond that, some glenohumeral glides to facilitate extension would be useful, as well as the stretching.

6) Shockwave: Your gut instincts would be mine as well. Shockwave would have the potential to flare up the bursa. Bursa's don't like to be pounded, poked, or shaken up. So, I would also steer clear of that!

Okay, I think I touched on all of the points and questions. This would be my plan of attack!

I hope this helps!

All the best!

Laurie