Nerve Sheath Tumor? Any Type of Rehab?

[DeniseLaceyBaxter]

Hi, I have a patient, Black Lab M/N 7 years old with a consistent Left fore lameness/partial weight bearing. Painful upon manipulation of D4 & 5 and in his axillary region. Radiographs of carpus, elbow and shoulder are NSF. Diagnosis is open but the specialists are leaning towards a nerve sheath tumor.

I've checked his cervical & thoracic spine, ribs along with testing for muscle strain and proprioception. All are NSF. Treated him twice with laser and therapeutic ultrasound of teres major/Latisimuss dorsi with the first time a positive response and a second time no change.

The digits on his Left paw are beginning to hyper flex into a "claw-like" posture when he is lying down. The muscle tone in his Left fore is similar to his Right, appearing normal. Would you consider this a spasticity and would it be worth a try with NMES to reduce? And would you continue with the laser? Or is there something else that I am missing?
Thank you in advance for your time on this one!
Denise M Testa,
C Spot Run

[lehughes]

Hey Denise!

So, the most distinctive thing I have ever found in every nerve sheath tumour I've ever seen is a dramatic atrophy of the muscles that the affected nerve supplies. Not just disuse atrophy but DRAMATIC atrophy. In NONE of the cases, have I ever found pain to manipulate the distal joints or soft tissues. And I have not found the neck to be painful either (in the C/S cases).
I have found small soft tissue findings, that resolve with some treatment... but don't explain the degree of lameness.

So... I'm not sure what to tell you about this case. The 'claw toes' sound to be a bit of an oddity for a nerve sheath tumour diagnosis. Are they tighter / restricted to stretch the DDFT and SDFT on the affected side compared to the non affected side? Any pain to palpate the sesamoids?

No, I'd not both to e-stim for spasticity... Yes, I'd laser... but where? Yes, distally, likely not to the C/S if nerve sheath tumour is the prime suspect... but this case is missing some of the key elements of nerve sheath tumour.

Can you video the gait?

Still in 'mystery' mode, I'm afraid!

Laurie

[lehughes]

Oh, and if nerve sheath tumour... you just work with function. Therapeutic exercise for health. some pain management.
Laurie

[DeniseLaceyBaxter]

Hi, I have attached a photo comparing Left and Right forepaws so you can see what I mean by claw-like

Photo Fore paws

1.2.392.200046.100.14.49626839520223043573324228546425287549.jpg (309.18 KiB) Viewed 2821 times

Radiograph L Fore paw

1.2.392.200046.100.14.61694445210478775252813988274161727522.jpg (218.74 KiB) Viewed 2821 times

Radiograph L Fore Paw

LukeMurphy.JPG (1.85 MiB) Viewed 2821 times

[lehughes]

I'm trying to upload the video to my YouTube account so I can share it here.
https://youtu.be/USE10ZF_8wA

But essentially, I don't see anything 'tell-tale' for what is going on in the X-rays or with gait.

If we were to say that the Claw-Foot is part of the primary problem, then I'd look at antagonists to the flexor muscles (i.e. any loss of tone / tension / function of the Digital Extensors)? (Extend the Elbow and assess the 'tension in the system' as you try to flex each toe. Compare that to the other side.) Is there a difference in circumference of the forelimbs? (i.e. perhaps a soft tissue sarcoma causing pressure on the flexor muscle group, causing a passive tension... or conversely to the extensors causing an inhibition. If there is a difference in size and the 'affected' side is bigger, I throw these thoughts into the mix of potentials. If the affected forearm is smaller... it's likely just disuse. What is the tone of the extensor muscle group? Reflexes?

Now, if we were to say that the claw foot is a different issue, or even a non-issue in regards to the limping, then based on video, I'd check shoulder and elbow... despite radiographs showing nothing. Look for all of the soft tissue culprits.

I guess we're still at the drawing board with this case!

Laurie