Hello Laurie,
I was wondering if you could help me out with a case. I’m a vet and this is my third case since being certified. Already I seem to be specializing in lateral luxations, my first case was a grade one Frisbee dog and I have been following your exercises for medial lunation-I’m assuming the treatment is the same for lateral. The case that is really challenging me is Punkin a 23 kg slightly pudgy SF 6 year old Huskey mix. She was a rescued as a young dog and has always been lame on her right rear leg, which had never been worked up until last spring as the lameness was becoming more pronounced. She was brought to a boarded surgeon who examined her and reviewed her radiographs. Her assessment, was the femur was abnormally shortened most likely due to a fracture at 2 locations when Punkin was a puppy which healed incorrectly. Her patella is permanently luxated laterally. She does not have a cruciate drawer. The rads showed moderate arthritis of the stifle and there was some possibility of there being less bone density in her distal femur. The greater trochanter appeared stunted and rotated. The surgeon did not consider surgery a viable option.
On her assessment with me, she had a normal top line, was weight bearing on the affected leg but with some decreased strength. During the swing phase her stifle turns outward and when she flexes her stifle it turns inward with a slight pause before she extends, I’m assuming that the patella is catching. She obviously has a shortened stride on that leg. I was unable to measure the flexion of her stifle as it was too uncomfortable for her. The girth was about even with her contralateral limb but I’m guessing with the shortened leg its not all the informative. I could not find any trigger points but then again I’m a vet, I did find some discomfort when palpating her pirifomes region. Carprofen and rest appear to provide some relief but not completely.
So my thoughts are at least initially are to control pain, tweaking nutraceuticals, lasering, acupuncture, tPEMF massage, compressions and traction and perhaps some e-stim. I don’t have anything fancy ie ultrasound or UWTM. For exercises I was going to start simple and gentle, low caveletti’s, brief single leg stance, weaves, perturbations with front legs on unstable surface, tummy tucks.
Any other thoughts, should I try and move the patella into place and do the exercises. Other helpful exercises-I don’t want to make her more painful. If the exercises make sense, how should I advance them? Obviously, I can’t perform miracles but would like Pumpkin to continue to use that leg with a minimum amount of pain.
Your help is greatly appreciated, as is your web site, I have learned so much, but then have so much to learn. And I wonder how you get your dogs to be so cooperative.
Thank you
CC
Patellar Luxation Case
Re: Patellar Luxation Case
Hi C,
So, this sounds like a wonderful learning case!
Now, my first questions are: Why did the dog present? What were the owner’s concerns? You say that Carprofen and rest provide some relief - but relief of what? Lameness? Displays of pain?
Is there tenderness at the stifle / around the patella?
So, to boil it down from what you presented below: abnormal gait, pain with stifle flexion, and maybe SIJ dysfunction (as per the pain at the piriformis).
We don’t know where the pain is coming from - is it the patella or the moderate stifle OA? Perhaps you can figure that out with palpation (of the margins of the patella, as compared to the joint line & posteromedial joint line sulcus). I’m going to place my bet on the stifle itself.
What do to? Don’t worry about trying to get the patella back in alignment. That’ll prove futile - but you can try to glide it a little bit (medial-lateral and superior-inferior).
Try to mobilize the stifle joint itself (cranial-caudal glides, rotational glides, joint compressions).
Her gait pattern makes sense: Circumduction of the hip (what you are describing at ‘her stifle turns out’) is a way to avoid having to move the stifle much or bend it as much as would be required to clear the ground with forward motion. The inward turn with flexion is likely just a return to normal hip alignment (I’m assuming - without seeing a video).
Check the SIJ. Maybe do some gapping to treat - as something you can do proactively.
The rest of your tools and plan are perfect - so long as the owner has realistic expectations… and that you are treating the stifle OA and not just the patella. Laser is great, PEMF is great, acupuncture is great and the massage, compression-traction, and ther ex are great ideas as well. Not sure you need the EMS (or rather, if you need time for something else, then you can take that out of the lineup). Honestly, with just that, you should make a change.
Nutraceuticals would be good, and looking at pain med adjuncts would be good as well. I have one dog right now with terrible foot OA and a stomach that isn’t allowing for NSAIDs - he is night and day improved with the addition of codeine! Maybe also think about Hyaluronic Acid injections.
So while stifle flexion is limited… I would try to figure out how to prevent it from losing further flexion. Maybe sit to stands onto a platform / bench - or facing down hill. And perhaps a joint injection would allow for that. Try backing up. Maybe tug of war. - As ways to ’trick the dog’ into stifle flexion activities…. and depending on where you live, walking in shallow water, taller grass, or snow!
And for your last question about getting dogs to be cooperative… my best tricks are judicious use of cookies, instructing owners on what I need them to do, and calm but firm energy (i.e. I am the boss… but I don’t want to hurt you).
I hope this helps… but I think you are very much on track!
All the best,
Laurie
So, this sounds like a wonderful learning case!
Now, my first questions are: Why did the dog present? What were the owner’s concerns? You say that Carprofen and rest provide some relief - but relief of what? Lameness? Displays of pain?
Is there tenderness at the stifle / around the patella?
So, to boil it down from what you presented below: abnormal gait, pain with stifle flexion, and maybe SIJ dysfunction (as per the pain at the piriformis).
We don’t know where the pain is coming from - is it the patella or the moderate stifle OA? Perhaps you can figure that out with palpation (of the margins of the patella, as compared to the joint line & posteromedial joint line sulcus). I’m going to place my bet on the stifle itself.
What do to? Don’t worry about trying to get the patella back in alignment. That’ll prove futile - but you can try to glide it a little bit (medial-lateral and superior-inferior).
Try to mobilize the stifle joint itself (cranial-caudal glides, rotational glides, joint compressions).
Her gait pattern makes sense: Circumduction of the hip (what you are describing at ‘her stifle turns out’) is a way to avoid having to move the stifle much or bend it as much as would be required to clear the ground with forward motion. The inward turn with flexion is likely just a return to normal hip alignment (I’m assuming - without seeing a video).
Check the SIJ. Maybe do some gapping to treat - as something you can do proactively.
The rest of your tools and plan are perfect - so long as the owner has realistic expectations… and that you are treating the stifle OA and not just the patella. Laser is great, PEMF is great, acupuncture is great and the massage, compression-traction, and ther ex are great ideas as well. Not sure you need the EMS (or rather, if you need time for something else, then you can take that out of the lineup). Honestly, with just that, you should make a change.
Nutraceuticals would be good, and looking at pain med adjuncts would be good as well. I have one dog right now with terrible foot OA and a stomach that isn’t allowing for NSAIDs - he is night and day improved with the addition of codeine! Maybe also think about Hyaluronic Acid injections.
So while stifle flexion is limited… I would try to figure out how to prevent it from losing further flexion. Maybe sit to stands onto a platform / bench - or facing down hill. And perhaps a joint injection would allow for that. Try backing up. Maybe tug of war. - As ways to ’trick the dog’ into stifle flexion activities…. and depending on where you live, walking in shallow water, taller grass, or snow!
And for your last question about getting dogs to be cooperative… my best tricks are judicious use of cookies, instructing owners on what I need them to do, and calm but firm energy (i.e. I am the boss… but I don’t want to hurt you).
I hope this helps… but I think you are very much on track!
All the best,
Laurie
LAURIE EDGE-HUGHES
Re: Patellar Luxation Case
Laurie,
Thank you so much for getting back to me-and so quickly. Your response was reassuring and helpful. I saw the dog yesterday for treatment. She practically bit me several times after placing needles around her hip and stifle and this is one of sweetest dogs I know. So clearly I need to not just focus on the stifle but hip/SIJ as well. And as you said don’t worry too much about the patella.
C
Thank you so much for getting back to me-and so quickly. Your response was reassuring and helpful. I saw the dog yesterday for treatment. She practically bit me several times after placing needles around her hip and stifle and this is one of sweetest dogs I know. So clearly I need to not just focus on the stifle but hip/SIJ as well. And as you said don’t worry too much about the patella.
C