Hi!
I have a 6.5 week post op FHO that has been coming once weekly for there-ex, laser and UWTM for the past 5 weeks. She was NWB at all times at presentation and now she is PWB at all times but she has this frustrating internal rotation that I can’t seem to figure out!
She’s about the most hyper pup ever so exams are always challenging but overall she seems comfortable. She does resist when I check for drawer on that stifle but I don’t get laxity or pain with stifle extension.
I feel like for almost 7 weeks post op we should be doing better. Her owners have a very hard time with her HEP at home because she’s so hyper but they are trying.
Any thoughts or suggestions are always appreciated!
Thanks!
SB
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FHO Question
FHO Question
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Re: FHO Question
Hey S!
So the first thing that jumped out what the huge amount of atrophy of the biceps femoris!
I have more questions than answers to begin with:
1. What is her pain like? Do you think it’s well managed?
2. What is her hip extension like? Any pain with that?
3. What land exercises have been prescribed? And what in-clinic exercises have been done?
At this stage post op, especially with doing exercises and laser, I would expect better than this. I’d request an x-ray to look for a bone spur left behind.
That would be my first differential. Second would be that she requires more pain management… perhaps it was withdrawn too soon and now she has some windup pain.
Third, look for something else as the root of the problem (lumbosacral issue affecting L7 nerve root, or SIJ dysfunction… but they are lower on my list as possibilities)
Okay… I hope this helps!
Cheers,
Laurie
So the first thing that jumped out what the huge amount of atrophy of the biceps femoris!
I have more questions than answers to begin with:
1. What is her pain like? Do you think it’s well managed?
2. What is her hip extension like? Any pain with that?
3. What land exercises have been prescribed? And what in-clinic exercises have been done?
At this stage post op, especially with doing exercises and laser, I would expect better than this. I’d request an x-ray to look for a bone spur left behind.
That would be my first differential. Second would be that she requires more pain management… perhaps it was withdrawn too soon and now she has some windup pain.
Third, look for something else as the root of the problem (lumbosacral issue affecting L7 nerve root, or SIJ dysfunction… but they are lower on my list as possibilities)
Okay… I hope this helps!
Cheers,
Laurie
LAURIE EDGE-HUGHES
Re: FHO Question
Stephanie Badge <sbadge@gmail.com>
May 21, 2021, 7:54 AM (5 days ago)
to Laurie
Thank you for your reply!
She’s a bit hard to evaluate for pain because she is all over the place but she does seem uncomfortable with hip extension. Originally she had a lot of pain and spasm along her medial thigh but that seems to have resolved. She is on Methocarbamol (o is only giving SID but was prescribed BID-TID) and Galliprant SID. She has pain on palpation of her left Piriformis but no LS pain noted. She has intermittent discomfort with hyperextension of her right stifle and has a strange internal rotation of her tibia. I'm not getting drawer or stifle effusion but her stifle joint just doesn't seem quite right to me.
Owner declined sedation for further stifle eval or radiographs at this time
For exercises the owners are having a hard time at home so I’m not sure what they’re actually accomplishing but I’ve recommended leash walks through sand and inclines, front limbs on a low box and hold/weight shifting, cavaletti poles and sit to stands.
In the clinic we are doing incline/decline walking, step ups/step downs, figure 8’s, curb work, sit to stands and UWTM. She’s only at 12 minutes 0.5 mph before she gets too hard to control.
We've recently added side stepping which is going well but she's a bit impossible for backwards walking so far....we're working on it
Should I be doing something different for exercises? She is making consistent improvements so perhaps I should just be patient and she may just be a bit slower in the recovery process, but I had hoped for more by now.
Thanks again!
May 21, 2021, 7:54 AM (5 days ago)
to Laurie
Thank you for your reply!
She’s a bit hard to evaluate for pain because she is all over the place but she does seem uncomfortable with hip extension. Originally she had a lot of pain and spasm along her medial thigh but that seems to have resolved. She is on Methocarbamol (o is only giving SID but was prescribed BID-TID) and Galliprant SID. She has pain on palpation of her left Piriformis but no LS pain noted. She has intermittent discomfort with hyperextension of her right stifle and has a strange internal rotation of her tibia. I'm not getting drawer or stifle effusion but her stifle joint just doesn't seem quite right to me.
Owner declined sedation for further stifle eval or radiographs at this time
For exercises the owners are having a hard time at home so I’m not sure what they’re actually accomplishing but I’ve recommended leash walks through sand and inclines, front limbs on a low box and hold/weight shifting, cavaletti poles and sit to stands.
In the clinic we are doing incline/decline walking, step ups/step downs, figure 8’s, curb work, sit to stands and UWTM. She’s only at 12 minutes 0.5 mph before she gets too hard to control.
We've recently added side stepping which is going well but she's a bit impossible for backwards walking so far....we're working on it
Should I be doing something different for exercises? She is making consistent improvements so perhaps I should just be patient and she may just be a bit slower in the recovery process, but I had hoped for more by now.
Thanks again!
Re: FHO Question
Hey Stephanie,
Apologies for my tardy reply!
Okay, so the more I think about the internal rotation piece you are bringing up, the more I think it might be biomechanical as compared to pathologic in the stifle.
So, I'd suggest trying to stretch the hamstrings and gracilis (in standing if that's easier with this dog). Stifle extension + hip flexion and varying degrees of abduction. This will target Semi-Memb, Semi-Tend, and Gracilis, all of which attach to the medial side of the proximal tibia and could be responsible for the internal rotation you are seeing.
If piriformis is tender, think SIJ. Now, since you don't have a femoral head, you might want to try treating that with either sacral mobilizations (push on the sacrum - on whichever side seems 'higher'/more dorsal) and or gapping (side lie if able... if not then compress both ilial wings simultaneously).
It sounds like you are on the right track with your exercise line up. In difficult cases such as thing, I sometimes like to simplify it further and might suggest putting a bootie, or weight, or vetwrap / tape, plastic bag... or something of the like onto the good leg and then do functional exercises slowly (i.e. hills, stairs, and/or any of the other exercises the dog is already doing.)
Okay... that's what I've got for this round of questions!
Best of luck!
Laurie
Apologies for my tardy reply!
Okay, so the more I think about the internal rotation piece you are bringing up, the more I think it might be biomechanical as compared to pathologic in the stifle.
So, I'd suggest trying to stretch the hamstrings and gracilis (in standing if that's easier with this dog). Stifle extension + hip flexion and varying degrees of abduction. This will target Semi-Memb, Semi-Tend, and Gracilis, all of which attach to the medial side of the proximal tibia and could be responsible for the internal rotation you are seeing.
If piriformis is tender, think SIJ. Now, since you don't have a femoral head, you might want to try treating that with either sacral mobilizations (push on the sacrum - on whichever side seems 'higher'/more dorsal) and or gapping (side lie if able... if not then compress both ilial wings simultaneously).
It sounds like you are on the right track with your exercise line up. In difficult cases such as thing, I sometimes like to simplify it further and might suggest putting a bootie, or weight, or vetwrap / tape, plastic bag... or something of the like onto the good leg and then do functional exercises slowly (i.e. hills, stairs, and/or any of the other exercises the dog is already doing.)
Okay... that's what I've got for this round of questions!
Best of luck!
Laurie
LAURIE EDGE-HUGHES