Grade 4 Medially luxated patella

[WendyRobinson]

I recently started seeing a 5 #, 16 year old, male/neutered Chihuahua who has a grade 4 MPL on his left hind and a grade 2 MPL on his right hind leg. Before I started seeing him he was initially classified as a grade 3 MPL on left hind which then progressed to a grade 4. He also has a heart murmur, is under treatment for Cushing's disease and hypothyroidism.
Fortunately, this little guy loves to walk and is treat motivated and is willing to peform exercises.
He is severely weight shifted forward and walks with both pelvic limbs severely bow-legged with his leg severely internally rotated as well as tarsal hyperextension. Left patellar ligament and sartorius muscle are tight and shifted medially. He stands and sits with his pelvic limbs in extension but can bring his legs through PROM and stifle flexion and patient seems comfortable.
He is currently getting weekly laser treatments, massage and rehab and the owners are great at doing recommended exercises between sessions.
He was perfoming front paw, elevated hip flexor stretches, cookie stretches and lateral stepping. He seems to perform these better with his front paws elevated prior to my first visit.
On my first visit, I added in supported 3-legged standing with glute and quad tapping making sure owner correct his leg posture when possible (stands with leg internally rotated). This is a difficult exercise for him to perform due to weakness. And 1/4 squats while keeping legs in a proper posture.
On the second visit, He showed improvement in strength, walking posture and ability to perform exercises. I did not add in any other exercises but increased reps.
Today I add in step overs (just enough to pick up leg and step over) for coordination and proprioception and planking to try and bring his back legs into a more normal square stance.

My questions are:
*If he remains comfortable and willing am I able to continue to increase his challenge by adding in things like 3-legged squat or step ups.

*Is there any advantage to trying to go to 1/2 sit to stands and then full at some time as long as his leg posture is correct.

* Would shockwave therapy on the tight tendon and muscle help loosen these structures in hopes of reducing the patellar luxation.

*Are there any other treatmens or exercises that may benefit this little ole man.

Thank you in advance and all your hard work on this site. I have found it very helpful for many cases and for enhancing my learning

Sincerely,
Wendy

[lehughes]

Hi Wendy!

Great question AND good case for discussion. I like that you are approaching this case with practicality.
I've had a case like this just a couple of years ago. That little one did well with pool (swimming) as and exercise, and she's come to me for laser therapy and some stretching, myofascial release, and spinal mobilizations. We also utilized a cart so that the dog could go for longer walks.

I would still with exercise therapies and progressing the challenges as able. I wouldn't worry about shockwave at this point - it's not likely to give you any sort of advantage. Maybe think about a little cart. The Walkin Wheels ones are nice, light, very adjustable, owner friendly, and economical for this size of dog.

Otherwise keep on doing what you're doing!

All the best!

Laurie

[WendyRobinson]

Thank you so much for your thoughts and help Laurie
I really appreciate your insight

Sincerely,
Wendy

[lehughes]

My pleasure! Best of luck!
L