Chronic shoulders - to brace or not to brace?!

[K9Rehab]

Hi everyone,
I seem to have a steady caseload of chronic shoulder lameness (>6-12 months) these days. Most start out with the vets recommending rest and Nsaids (which doesn't typically work) and once they come to me I start on modified activity, manual therapy and strengthening. There have been some successes (usually with compliant owners who are also willing to avoid off leash/playing for at least 2-3 months or longer) but those that don't (or have set backs as soon as they start running off-leash again) are being referred to a surgeon who is recommending dogleggs - I have one in them currently and 2 more that are heading that way. My question is - she currently recommends they use the brace 24/7 for 3 months with only flat leash walks and then progressively loosen and progress exercises for the next 2-3 (total of 6 months). Has anyone had true success following such a protocol? Just want to know what to expect..... Thanks so much

[lehughes]

I find some of these frustrating as well...
Of my sporting dogs... if the owner can be diligent with exercises and restricted activity, they don't seem to need hobbles.
Of my pet parents (most recently my Sister-in-law's dog), I think they are careless (or perhaps the kids are) with what they allow (i.e. jump off the bed, throwing a ball). So, I am ordering them hobbles (on Saturday). I think the Hobbles work for the extremely lax shoulders or the owners that can't or won't control their dog 24/7.

So, I would (and will) modify the protocol below to 24/7 Hobbles... but I'd allow any kind of leash walking. Why just flat? Uphill / Down hill aren't medial stressors. Monitor the time / distance however so as not to create too much joint inflammation / fatigue if it's a very lax joint. I'd also add in specific exercises (i.e. 3 leg stands, progressing to the same with perturbations or on unstable surfaces, plus the push ups).

I've had some go back to agility... and then others, like my sister-in-law's 'Mexican Rescue Terror' where I am pulling my hair out. I have RARELY ever needed hobbles. (I use the tensor bandage / ace bandage wrap)
So, other than this case, my only other one was a dog that we ordered them for post-operatively... she didn't do well conservatively pre-op because of a labrum tear... but we tried conservative first...
So, labrum tear is another factor for 'won't do well'.

I feel like I was talking in circles there! I hope pieces of it make sense!

Laurie

[K9Rehab]

Thank you Laurie... honestly it's nice to just know I'm not the only one who finds these cases frustrating. This is a relatively new surgeon who is all of a sudden referring a lot more to me so I want to be on board with what she is recommending. I actually did convince her to allow for low grade inclines, 3 leg stands etc exactly as you recommended into the phase 1 hobbling plan and she was on board so I'm glad you think the same. What would you say would be a reasonable timeline after the hobbles? I feel like I need to really have my pet parents know what to expect so that they don't just expect to take them off and let Dave the dog run free. Now what are your thoughts on cortisone.... because that's being recommended too, injection then hobbles.

[lehughes]

Hmmm...

So Hobbles - i'd tell the owners plan for 2 - 3 months. Then you can decide if they are clued in owners and maybe only 2 months is needed. OR if they are "whoops, we let her run around the yard and jump on and off the bed" kind of owners where they would need them for longer!

Cortisone I would only recommend for JOINT issue but not soft tissue. If you think the joint is irritated and inflamed and/or the labrum is the main issue... then sure, they can try cortisone. Of course we know from the human side that it causes joint deterioration.

So, here's how I look at it: If we want the hobbles to protect the soft tissues of the joint and allow some tightening of the medial joint capsule to helps stabilize the shoulder... then cortisone inhibits that process because we need that bit of inflammation to stimulate the response.
If we just want to settle down the joint and stop it from moving into problematic positions until the inflammation is gone, then cortisone makes sense... but you won't have a stronger joint.

It's a catch 22.

Sometimes you have to assess the owners as well. If they are pet parents just looking for a fix it now and not as bought into strengthening etc... then maybe cortisone to just 'shut up the joint'... and plan to repeat it periodically.

If they are owners that are looking for the best long term solution - then hobbles and rehab without the cortisone.

You also factor in your relationship with the surgeon. Maybe you let her do what she's wanting to do on a couple and watch and see... and then with future cases suggest more conservative approaches.

We always walk a fine line!

Laurie

[David Lane]

I would like to echo that there are 2 treatment paths here: rehab with the goal or repair, or corticosteroid injections... not both at once. If these are true MSS cases, we want to initiate healing of the subscap tendon, and corticosteroids will shut that process down... If the owner just wants to palliate pain and not return the dog to an active lifestyle, then perhaps corticosteroids is a reasonable option. I have never used corticosteroids for an MSS case for the above reasons, but have seen many cases that were treated that way, failed treatment, and then ended up on my plate (admittedly there is selection bias here because the cases where treatment went well, likely wouldn't have ended up on my plate).

I fully support the idea of injecting PRP into the joint to palliate pain while doing rehab. Or, even better, PRP plus "stem cells" to facilitate tendon healing. Can you redirect the surgeon into doing that?

[K9Rehab]

Yes Laurie... new surgeon just starting referring to me so it is a fine line. Cortisone and hobbles really didn't make sense to me, but thought maybe I was just missing something. In our human world cortisone often gives you enough of a reprieve from pain that you can start working on neuro-muscular retraining and strengthening! David I will certainly bring up PRP with her, she's in Calgary and I'm in Kimberley so I'm not certain if she is doing them, thank you for the suggestion! It's a 2 year old very active doodle, owners seem invested yet they have busy lives with young kids so I do think the hobbles for the next 3 months will perhaps give this dog the best chance. Fingers crossed.

[lehughes]

Question... are the surgeon's initials AR?

If so, refer to David Lane instead! If the surgeon were local to you, I'd tread more lightly... but in this case, advocate for the dog.



Laurie

[K9Rehab]

They are not. Wish I could refer to you David but it's quite a drive from Kimberley. Calgary is our main specialty referral source just because of the distance. This surgeon also does the majority of the TPLOs that I locally see.

[lehughes]

Well then... I guess you go down the path of discussing the detriments of cortisone and soft tissue healing...
Play the humble delivery of education card...

L.