Joint mice in the biceps tendon sheath

[Kay Webb]

Hello there, I have a male neutered 2year old border collie who had bilateral OCD lesions pre 1yr old. Treated with arthroscopic removal of flap and fragments and curettage. Slow to recover and contemplated synthetic Syncart plug in the left shoulder with the larger lesion. Did eventually become sound in comparison to pre surgery but always retained a swaying awkward looking gait. Bearing in mind his lack of motor learning experience and long periods of rest with consequent weakness last year have just been focussing on improving that. Last year I got a stance analyser and strted to try and plot our progress towards a more balanced dog. However consistently significantly offloading the right forelimb and the left hind. Time to have another look at structure I thought so he went for scans which show 2 little joint mice lodged in the biceps tendon sheath and compressing the tendon. Tiny osteophytes on the edge of the biceps groove too. Also a large one in the caudal pouch of the left shoulder that seems not to be causing problems mechanically but surely will be causing ongoing synovitis. It is unclear whether he has pain ( nightmare to examine)so initially we are doing a pain relief trial but treatment options I have been presented with are steroid injection and biceps tenotomy. Im not keen on either. steroids seems like a temporary fix at best and I feel he needs his biceps! We have always intended to do agility and do very low level training but if at all possible would like to progress. What other treatment options are out there and what pros and cons might there be. Im lasering it ++ for now whilst exploring options. Any suggestions??

[Kay Webb]

I would love to have the surgeons perspective on a case like this alongside physios rehabbers who have dealt with . There might be so many good reasons why what seems logical to me might very well not be. Are there any shoulder specialists out there who could give me the benefit of their experience.

[lehughes]

Hi Kay!

Well, I'm not a surgeon, nor do I have any experience with this exact type of case.

I would agree with you that a steroid injection isn't a good long term fix, and indeed I too believe that the biceps tendon has an important function at the shoulder. (Okay, more than belief - research papers show that it is a major stabilizer.)

So, I also hope that a surgeon will pipe up.

However should a surgical option be elusive or not a guarantee of improved function or performance, then my suggestion would be to attempt therapies that would stimulate the body to resorb the 'foreign material'.

As such, anything that stimulates blood flow would be good. (Laser, Shockwave, U/S, PEMF, Acupuncture). Stretching and eccentric loading could also fit into this category... but since they also cause movement / rubbing of the tendon against the foreign substance, they also have the potential to stimulate inflammation. So, they're a crap shoot. (Not to say, 'do nothing', but just to rationalize what might be going on if you notice that activity of any kind sparks pain or lameness).

That would be my plan anyways. Beyond that, you could look into administration of a homeopathic remedy - Silicea. It is used for removal of foreign substances. Not my area of expertise, but I did have a client try it with positive results (tiny sliver of metal in the calcaneal tendon). I've tucked it away in the back of my head ever since!

Best of luck!

Laurie

[David Lane]

Also not a surgeon (at least one who drives a scope), but I doubt you can get too much of an answer without having a scope driver see the dog and images first hand. Cutting the biceps is easy, but cleaning the groove is much more difficult. Depending on the location of the fragments, they might not be accessible by scope, and it could require a full arthrotomy. If the surgeon you talked to won't consider anything besides a tenotomy, then find someone else willing to take on the challenge of attempting of cleaning up the joint.

[Kay Webb]

Thanks Laurie and David for your advice. I think we are all singing from the same hymn sheet and Ill pursue options for the least invasive surgical route and see where we get to. In my imagination it wouldn't seem that difficult to slip a tiny hook or suction down the sheath and hook the little b******s out. How come some seemingly simple things are difficult and yet we can do neuro surgery on an in-utero foetus. Well not me obviously but you know what I mean. I shall keep lasering as per Laurie's protocol until we have another vet appt and Ill let you know how we get on.

[Kay Webb]

Just a little update. Two weeks ago Joe went for removal of the joint mice. Could not be accessed arthroscopically but surgery was minimally invasive and the transvers humeral ligament was not cut. The biceps tendon looked grossly normal. I have the little offenders in a specimen pot and they look like 2 pearls, about 3-4mm across, with a tiny sharp point on each. They certainly look as if they'd be an irritant so we will see how he does now he is without them. Fingers crossed.

[lehughes]

Thank you for the update Kay! Fingers crossed for the pup as well!

Cheers,

Laurie