Hi Laurie,
I am a new fourleg member and so excited and appreciative. I have been reading your weekly newsletters for a while now.
I am wondering if you have any references or information on chronic carpal hyperextenion. Like from excess forward weight bearing. I seem to only find information on acute/traumatic injuries.
Here's the back story... I am seeing a 6 year old Husky with a recent history of right forelimb lameness after hard play and a long standing history of not wanting to go up stairs and hoping/limping on a hindleg.
On exam, she has a mild head bob that would alternate between sides. She has bilateral carpal hyperextension in standing, and with decreased flexion and discomfort and grade 2 cranial glides of both her radio carpal and ulnar carpal bones initially. The carpal hyperextension was also noted by a previous vet in 2017. She also has decreased hip extension bilaterally with dec flexibility of her hamstrings.
So my assessment is that she has chronic hyperextension of her carpi from excess forelimb weight bearing from a chronic hindlimb issue. Or possibly, since it was noted a couple years ago, maybe something traumatic did happen that didn't get treated at the time/
Mom is limited on funds but we started some laser of her hips and carpi, some isometric strengthening exercises of her forelimb, and ordered her a custom brace from Thera-Paw. With the brace, we added some sidestepping, Just one to see how it worked out- Although after seeing it and reading some of your other posts, I wish I had stuck with the Carpo-flex -X. I think may be too heavy for her.
However, she just went back for an annual exam at her rDVM and he told the owner that he "does not believe" in chronic carpal hyperextension, only traumatic. And now she is And because she is no longer painful on her wrist, he is not even sure that is the issue at all and instead, wants to exercise restict her completely. Ugh!
The other vet is a friend, so I really hope we can get on the same page.
Thank you for all your help!
Jenna Hauck DVM, CVA, CCRT, VMMP
Chronic Carpal Hyperextension
Re: Chronic Carpal Hyperextension
Hey Jenna!
Welcome to FourLeg! So happy to have you on board!
Okay, now as for your case! I have a few different thoughts.
Let's start with 'root of the problem' (i.e. offloading of the rears). Hip extension issues. Could be hips. But could also be related to lumbosacral disc disease. Or the dog could have both.
Hamstring flexibility issues. After 27+ years in practice, I'm thinking I am prepared to say with confidence, that this is never a primary hamstring issue. I'd bet you that the problem is actually sciatic nerve mobility restriction secondary to an impingement / restriction at the lumbosacral junction. Dogs do too many things that stretch their hamstrings in the activities of daily living. Walking stretches the hamstrings, scratching their head stretches hamstrings. Unless the dog is confined to a cage where it can't stand up fully and move around, there's no reason for the hamstrings to tighten / shorten. However, an impingement or restriction of the L7 nerve root could impede the ability for the sciatic nerve to glide.
Here's the test I made up to prove my theory and/or this diagnosis. Try doing the 'hamstring stretch' (which is also a sciatic nerve root glide / dural mobility test) with the dog in side lying as you likely did when you first assess this to be a trouble. See how far the leg moves forward (i.e. how close to the front legs you can move the back leg). Then have someone do a tail pull traction (pull the tail firmly while stabilizing the rump - just so as to not move the dog) then retest the 'hamstring stretch'. You will likely find that you can get more movement. If so, this is your test as well as a treatment technique. (PS. If this is what you find, then also treat the L-S junction with your laser, manual therapy, traction, and home therapies - prescription of tail pull traction, etc.)
Secondly, the carpi. I think you are completely right on track with your thought processing in regards to chronic laxity due to over-loading of the forelimbs as a compensation for a rear end issue. I've seen this before... and you're not crazy! ANYTHING that is put into abnormal use / excessive loading has the potential to breakdown. Why not the carpal joint ligaments?
So, I would do as you have done. Support the carpal joints. Rest is not going to change the problem. The good thing about the custom supports is that you can likely modify them as well. Remove a strip or two of support to make them less rigid. But until the rear end issues are improved the front end issues (carpal laxity) will continue to decline... Albeit slowly, but it'll still decline. So try modifying the supports to make them less rigid, but still a bit of a support.
And if need be... 'everyone can be right'. We don't know, maybe there was a trauma in the past that has led to carpal hyperextension. Sometimes you 'throw that out there', so that everyone can be right, and it's not 'you versus the other vet'. Then you point out that the other vet isn't seeing the joint when it's sore, like you did. And you might think the same way as the other vet if you had only seen this dog now and not when it was sore. (See, everyone is right when you frame it the right way!) So, you may need to write a letter or call your friend - the vet - to explain all of your findings and thinking, and frame stuff just as I've explained above. And maybe make it a bit of a "here's how I learned to assess things in this way..." - (from your rehab training). It can be mind-blowing for a vet that has never been trained to think any differently from how vet school trained them to think. Rehab is not just new assessment & treatment techniques, but a whole different way of thinking. (You've likely experienced that!)
Okay, so that gives you a few different places to go from here and/or at least get started with.
Best of luck on all issues!!!
Cheers,
Laurie
Welcome to FourLeg! So happy to have you on board!
Okay, now as for your case! I have a few different thoughts.
Let's start with 'root of the problem' (i.e. offloading of the rears). Hip extension issues. Could be hips. But could also be related to lumbosacral disc disease. Or the dog could have both.
Hamstring flexibility issues. After 27+ years in practice, I'm thinking I am prepared to say with confidence, that this is never a primary hamstring issue. I'd bet you that the problem is actually sciatic nerve mobility restriction secondary to an impingement / restriction at the lumbosacral junction. Dogs do too many things that stretch their hamstrings in the activities of daily living. Walking stretches the hamstrings, scratching their head stretches hamstrings. Unless the dog is confined to a cage where it can't stand up fully and move around, there's no reason for the hamstrings to tighten / shorten. However, an impingement or restriction of the L7 nerve root could impede the ability for the sciatic nerve to glide.
Here's the test I made up to prove my theory and/or this diagnosis. Try doing the 'hamstring stretch' (which is also a sciatic nerve root glide / dural mobility test) with the dog in side lying as you likely did when you first assess this to be a trouble. See how far the leg moves forward (i.e. how close to the front legs you can move the back leg). Then have someone do a tail pull traction (pull the tail firmly while stabilizing the rump - just so as to not move the dog) then retest the 'hamstring stretch'. You will likely find that you can get more movement. If so, this is your test as well as a treatment technique. (PS. If this is what you find, then also treat the L-S junction with your laser, manual therapy, traction, and home therapies - prescription of tail pull traction, etc.)
Secondly, the carpi. I think you are completely right on track with your thought processing in regards to chronic laxity due to over-loading of the forelimbs as a compensation for a rear end issue. I've seen this before... and you're not crazy! ANYTHING that is put into abnormal use / excessive loading has the potential to breakdown. Why not the carpal joint ligaments?
So, I would do as you have done. Support the carpal joints. Rest is not going to change the problem. The good thing about the custom supports is that you can likely modify them as well. Remove a strip or two of support to make them less rigid. But until the rear end issues are improved the front end issues (carpal laxity) will continue to decline... Albeit slowly, but it'll still decline. So try modifying the supports to make them less rigid, but still a bit of a support.
And if need be... 'everyone can be right'. We don't know, maybe there was a trauma in the past that has led to carpal hyperextension. Sometimes you 'throw that out there', so that everyone can be right, and it's not 'you versus the other vet'. Then you point out that the other vet isn't seeing the joint when it's sore, like you did. And you might think the same way as the other vet if you had only seen this dog now and not when it was sore. (See, everyone is right when you frame it the right way!) So, you may need to write a letter or call your friend - the vet - to explain all of your findings and thinking, and frame stuff just as I've explained above. And maybe make it a bit of a "here's how I learned to assess things in this way..." - (from your rehab training). It can be mind-blowing for a vet that has never been trained to think any differently from how vet school trained them to think. Rehab is not just new assessment & treatment techniques, but a whole different way of thinking. (You've likely experienced that!)
Okay, so that gives you a few different places to go from here and/or at least get started with.
Best of luck on all issues!!!
Cheers,
Laurie
LAURIE EDGE-HUGHES
-
JHauckUF2003
- Posts: 2
- Joined: Sat Nov 02, 2019 5:47 pm
Re: Chronic Carpal Hyperextension
Laurie,
Thank you so much for your insight. I love the new thought( or at least new to me!) on the tight hamstrings and the test of sciatic nerve mobility - What a gem that I know I will incorporate into practice, not just this one, but in the future as well.
And also the personal insight into how to deal with my colleague - I do see how it is a difference in perspective and love how you framed it so everyone can "be right."
Can't wait to delve into the website even more.
Thank you,
Jenna
Thank you so much for your insight. I love the new thought( or at least new to me!) on the tight hamstrings and the test of sciatic nerve mobility - What a gem that I know I will incorporate into practice, not just this one, but in the future as well.
And also the personal insight into how to deal with my colleague - I do see how it is a difference in perspective and love how you framed it so everyone can "be right."
Can't wait to delve into the website even more.
Thank you,
Jenna