Rosie is an 8 yr old Wheaton (F/S). She has a history of limping (LF) starting in mid September, 2019. She was initially sent home with a trial of Deramaxx for 1 week. There was no improvement with the Rx. She was radiographed by a colleague after the lack of response to the NSAID.
She will start to limp about 10-15 minutes in on a walk. She will offload slightly when standing. When gaited outside at the clinic, she is slightly kyphotic and short strided. The owner said that on occasion, she will be lame upon rising after laying down for a period of time.
On palpation, there is a palpable difference between the L and R scapular mm (on the L, the infra and supra spinatous mm’s are decreased relative to the RF). She resents ghj flexion and extension on the LF. Abduction angles on the LF ghj was greater than the RF ghj (40 vs about 30 degrees)
She did not seem to resent the ROM at her elbows but her measurements are slightly reduced on the LF.
The measurements are as follows:
Elbow- RF 165/40, LF 158/30
GHJ- RF 145/78, LF 130/90-92
Her cervical ROM was good. Both her iliopsoas’ were tight and there was a slight reaction with palpation. There were restrictions at the LS and L5.
The u/s observations were:
RF- that there was mild inflammation and mild enlargement at the bicep tendon and a small enthesiophyte at the bicipital origin. SS winl’s.
LF- Enlarged CSA with mild fluid in bursa. Enthesiophytes at the bicipital tendon origin and moderate hypoechoic lesion at the origin. Mild osteophytes at the ghj margin. SS mild hypoechoic lesion at insertion, with some impingement to the bicep
There is evidence that this has been a more chronic process. I feel that she is more uncomfortable at her L shoulder but her elbows are a concern. They are willing to pursue Shockwave =/- PRP (both shoulders and elbows), but I’m concerned about the laxity in the L shoulder. Should we avoid any form of shoulder wrap? Any other pearls you would add?
Rita
msi and elbow oa
Re: msi and elbow oa
Well, I have to say that this combo is quite the conundrum. The elbow-shoulder dilemma!
Argh!
So, I believe I read a paper (somewhere/sometime) that looked at patients that have both, where the elbow is what is/was the primary. But that being said... it comes down to assessment.
If I look at what you've provided. I would say that the shoulder seems to be the primary. As in, when you do the evaluation of each joint, the shoulder is painful whereas the elbow is not. So, let's assume that the shoulder is the primary and the elbow is your red-herring and/or incidental finding.
Okay. Shoulder.
So the abduction angle of 40degrees isn't crazy. Usually, 20degrees more than the average 32degrees is what you'd see. However, in chronic cases, I find that the dogs outsmart the maneuver and resist letting themselves go into their end range of abduction. So she may very well have more abduction than that.
The lack or ROM into flexion and extension however indicates that there is capsular tightening and/or inflammation. If the problem were just supraspinatus, then you'd have pain with flexion... but not extension. The biceps findings could be as a result of shoulder inflammation, the cause of shoulder inflammation, and/or an attempt to stabilize the shoulder because of MSI. However, if the biceps was the only or primary issue, then it shouldn't have that significant of an impact on the shoulder flex & extension ranges. So, something more joint related needs to be going on.
First thought, chronic MSI with capsulitis. The radiographs don't look that terrible to me.
So, I'm going to throw one wrench into the thought processing - cancer. Synovial cancer?
The other thing I'd think about is nerve sheath tumour... but for no other reason than the scapular muscle atrophy.
Okay, so while I'd have the above differentials in the back of my mind, I'd proceed with treating the shoulder. And before I'd go down the path of PRP, I'd just treat the shoulder. Laser, shockwave, mobilizations, stabilization exercises, biceps exercises, acupuncture...
Given that you have restrictions in flexion and extension, I don't think it's an overall hypermobility / instability at fault, but more of a total joint reaction. So, I don't know if you need to worry much about a shoulder wrap. BUT, you could try the tensor bandage (ace bandage) wrap as a test to see if it reduces lameness on a walk.
Okay... that's what I've got on this with my first pass of the brain!
I hope this helps.
Laurie
Argh!
So, I believe I read a paper (somewhere/sometime) that looked at patients that have both, where the elbow is what is/was the primary. But that being said... it comes down to assessment.
If I look at what you've provided. I would say that the shoulder seems to be the primary. As in, when you do the evaluation of each joint, the shoulder is painful whereas the elbow is not. So, let's assume that the shoulder is the primary and the elbow is your red-herring and/or incidental finding.
Okay. Shoulder.
So the abduction angle of 40degrees isn't crazy. Usually, 20degrees more than the average 32degrees is what you'd see. However, in chronic cases, I find that the dogs outsmart the maneuver and resist letting themselves go into their end range of abduction. So she may very well have more abduction than that.
The lack or ROM into flexion and extension however indicates that there is capsular tightening and/or inflammation. If the problem were just supraspinatus, then you'd have pain with flexion... but not extension. The biceps findings could be as a result of shoulder inflammation, the cause of shoulder inflammation, and/or an attempt to stabilize the shoulder because of MSI. However, if the biceps was the only or primary issue, then it shouldn't have that significant of an impact on the shoulder flex & extension ranges. So, something more joint related needs to be going on.
First thought, chronic MSI with capsulitis. The radiographs don't look that terrible to me.
So, I'm going to throw one wrench into the thought processing - cancer. Synovial cancer?
The other thing I'd think about is nerve sheath tumour... but for no other reason than the scapular muscle atrophy.
Okay, so while I'd have the above differentials in the back of my mind, I'd proceed with treating the shoulder. And before I'd go down the path of PRP, I'd just treat the shoulder. Laser, shockwave, mobilizations, stabilization exercises, biceps exercises, acupuncture...
Given that you have restrictions in flexion and extension, I don't think it's an overall hypermobility / instability at fault, but more of a total joint reaction. So, I don't know if you need to worry much about a shoulder wrap. BUT, you could try the tensor bandage (ace bandage) wrap as a test to see if it reduces lameness on a walk.
Okay... that's what I've got on this with my first pass of the brain!
I hope this helps.
Laurie
LAURIE EDGE-HUGHES
Re: msi and elbow oa
Thanks! I'll let you know how it goes. I appreciate your help!
Rita
Rita