RF lameness agility dog

[Kriszty]

Hi,
Was wondering if people might have some thoughts on my own dog. We are very limited in the number of people we have here in Perth Australia, and I am very new to rehab (just qualified).
She is an 18month old border collie unsterilzed. She has had a consistent reluctance to hyperextend her shoulders (figits back) for maybe 6+ months, and on Saturday she pulled up very lame on her RF with not wanting to extend her shoulder at all. I could not localise any other pain on the leg. She has never had any pain on shoulder flexion, including with elbow extension (biceps). She is a crouchy stalky BC who does spend a lot of time with her head down in herding position and does seem to have tight neck muscles. She is a bit straight in the front end. Is being trained as an agility dog, is well conditioned.
When I mobilise her shoulders caudally she will let me hyperextend them with no reluctance. Radiographs yesterday on shoulders, elbows, neck, hips all clear. She regularly has her trigger points treated by a vet who is very experienced in myofascial pain and is always tight in her neck muscles (I assumed due to her postural crouchy position)?
I have (tried) to check 1st rib and she doesnt seem to have any pain, and have been doing the myofascial hold with the neck stretched up and turned laterally. My questions are:
1) Is it possible to have 'tight' shoulder joint capsules in a young dog, that just need mobilising, with no pathology?
2) would 'tight' neck muscles contribute to this?
3) Would this cause an actual lameness like she had on Sat (responded to 1 dose of NSAID) or do I need to look further for pathology (CT, orthopedic consult etc).
Thanks very much for any replies, I really love this site and I am learning HEAPS!

[lehughes]

Hi Kriszty!

So the only thing I don't see you having checked for are:
Medial Shoulder Instability / Hypermobility (extension + abduction)
Teres Major strain (although less likely by your description... but maybe)

I'm going to bet that the issue is likely shoulder...
but NOT tight capsule & NOT related to tight neck muscles

So, your homework is to check Training Videos 7 & 5 (Medial Shoulder) & in ARTICLEs under Athlete Considerations: Soft Tissue Injuries of the Shoulder in the Canine Athlete

I don't know that you need an MRI or ortho consult just yet. You just need to test the right thing / put your 'finger' in the right place!

Give these two differentials a whirl first! Good luck!

Laurie

[Kriszty]

Thank you so much for your reply, Laurie!
Nothing on medial shoulder or teres, took her to trigger point vet who said lots of pain in infraspinatus and lats (incl at origin which she said is unusual). She is on light duties for a week then recheck, is there anything apart from heat and stretching I should be doing? Both dogs were tight in their biceps, bit concerned it might be due to the new arena, the sand is softer than I would like until retic, rolling + soiltex settles.
Kriszty

[lehughes]

I understand that the inclination is to treat... but at this point, you don't know what.
I believe strongly (as do many / most physios) that trigger points are secondary - not primary pathologies. In fact, modern research is pointing to spinal dysfunctions as being the triggerpoint generator in many 'insidious' trigger points. So, I would suggest putting the triggerpoints as the primary cause to the side. I am quite concerned to hear vets (who are now taking trigger point courses) start hammering on triggerpoints and not look for the root of the problem. A trigger point might cause an ache or a nagging, but never enough discomfort to create a lameness. There is always more to the picture than just a trigger point. The current triggerpoint education on the veterinary side is misleading vets to believe that it's a primary condition. It isn't! I know I could piss off people by saying this... but it's the truth.

So... you are still searching for your lameness generator.

Describe to me your endfeel for the abduction (and /or take a video) - same goes for the shoulder hyperextension. When the problem has been going on for 6 months (i.e. you say she's avoided shoulder hyperextension), I think MSI. And then they get good at putting a low grade tone in their muscles to avoid going into full position / showing pain. In fact, when I feel apprehension at all with abduction (especially in a chronic case) I KNOW they are hiding an MSI.

Check Ribs 1 - 4 and T 1 - 4. Ribs you can push on with a regular force. T/S you need to push on the side of the spinous process - grade 4 pressure to find pains in this region.

Distal biceps tendon?

Could you film yourself assessing her? I wish my hands could extend across the ocean to help you more!

Laurie

[Kriszty]

Hi Laurie,
Thank you very much for your reply and yes your hands would be great, please!!
I watched your (very informative) vids on tendonopathies, supraspinatus/biceps lesions and how to assess for MSI and did those tests on her yesterday and got absolutely no pain. She has a fair amount of laxity in abduction, but it is equal bilaterally and had the normal 'clunk' end feel you were describing.
I pressed on all her ribs (ventrally) and all her thoracic spinous processes (laterally) and also got nothing. She has not been lame again since her one off episode on Saturday. I backed her training down and am running her on 20cm instead of 50 and she is pulling up from this fine. I wonder if her toes are bothering her, she consistently doesnt like them being handled (but then so do lots of dogs..) and she is hyperextended in the carpuses and hare footed.
Her shoulders have had normal extension since she had her trigger points treated last week (and yes I completely understand what you are concerned about, it concerns me too as I don't find it a diagnosis).
I can't tell if she is broken or not, find it very difficult with my own dogs!
Thanks,
Kriszty

[lehughes]

Is there someone else (with rehab background) near you to be able to assess her? (If this reappears).

ONLY from the perspective that she's your dog, as you say. I once had to take my own dog in to be looked at by my general practice vet. I was worried it was a prox. humerus OSA. My dog cried with all palpation of the shoulder when I did it. However, when I took her to the vet, she didn't squeak at anything until he hit one specific point. He said, "It's Biceps tendon!" (but his finger was on supraspinatus). I didn't care! I needed someone else's fingers to find the true pain point, and he did just that! I then treated supraspinatus and my dog got better.

Now however, if your dog is doing better... then maybe just slowly build up her exercise tolerance and see where you get.

Good luck!!

Laurie

[David Lane]

I would image that shoulder. There is too much going on in that area for some sort of tendinopathy or low grade MSI to not be on the list. Over the years I've had multiple dogs that despite repeated and meticulous shoulder exams, I could not come up with a Dx, and then we ultrasounded (I personally prefer ultrasound to MRI, but you want someone experienced as not all ACVR's are equal in this area) and found the shoulder to be a war zone. Sometimes these guys can hide severe pathology from detection through physical exam (either that or I sporadically suck at physical exams). There is usually more than one issue going on that imaging reveals, and shoulders are RARELY unilateral.

MSI is never off the list until that abduction angle and end feel has been palpated under sedation (similar to those cruciate cases where there is no drawer in an awake dog, but a raging one once sedated).

As a side note, I have a "three strikes" rule for 1st rib issues. There are primary 1st rib lamenesses, but if it recurs a 3rd time, I ultrasound the shoulder. In doing so, I have yet to find a shoulder without advanced pathology.

David Lane DVM
ACVSMR

[Kriszty]

Thanks for the replies, Laurie and David! I have just got back from taking her to my orthopedic specialist. He found quite a lot going on:
1) pain on medial shoulder palpation RF (no instability)
2) pain on L psoas (mild, he thought it was unlikely any fibres are torn)
3) pain on L faballae palp (?gastroc disease)

HELP. How do I rehab all that? I had started a psoas rehab program as I had found the psoas pain myself but how do I treat everything else all together? Also- do either of you have any comments on gastroc disease, this is thd 3rd BC I have had with it.

Thanks!!
Kriszty

[Kriszty]

So I have been doing a lot of reading on MSS and am now super concerned.
We dont have anyone in Perth that can ultrasound her, we only have one musculoskeletal U/S person and she won't do this. I *might* be able to get an MRI but it is going to be difficult. We have arthroscopy people, but only the large arthroscopes, not the needle width scopes I understand they are using in the U.S for this now. I am not keen on cutting her muscle to put a large scope in.
We also dont have anyone who does the radiofrequency treatment/shrinkage. Is there any point scoping her if we cant treat it?
I am not sure I understand when hobbles should be fitted, either. The orthopod that examined her said she had no instability/laxity, just pain on medial shoulder palp, but she wasnt examined under sedation.He doesnt believe in the disease. I have put them on her, ( my husband made them as I cant find anyone in Australia that stock them). I tried the bandage, but I found it kept stretching (tried telfa and coflex). He made them out of nylon collar material following the doglegs 'shoulder stabilisation' design (not the vest). I am not sure if they are quite tight enough though, I cant get much/any lateral movement of her shoulder/elbow but she seems to be able to turn her paw laterally and does so (plus puts it forwards slightly which I understand is an indication of disease).
I have been reading up on how to rehab this, and after reading an article written by Dr Canapp it looks like for the 1st 4 weeks (phase 1) I should be restricting all activity and doing PROM plus grade 1 and 2 joint mobilisations (cranial and caudal, I assume?) (as she has not been treated by radiofrequency). PROM in all other joints on the front legs as well.
I dont have therapeutic U/S (I do have an equissage and have been using this on her). No therapeutic exercises are mentioned at all.
Phase 2 (4-7 weeks) grade 3 joint mobes , short leash walks and UWTM recommended. Again no TherEx
Hobbles removed at 12 weeks then return to activity , therex free running gradually etc.
Thanks for any help,
Kriszty

[lehughes]

Okay... so I'm opening up a can of worms here...

1) An orthopaedic specialist that doesn't believe in Medial Shoulder instability / syndrome is behind the times.
2) You don't necessarily need arthroscopy or radiofrequency shrinkage to treat MSI. It has been argued (by other surgeons mind you...) that the dogs that do well with radiofrequency shrinkage are dogs that would do equally well with conservative management. And I happen to buy into that as well.
3) The Canapp's post op protocol for their MSI cases is far far too conservative and slow (and what I'd call 'old school' from a human PT perspective).
4) I'd only use hobbles if it was an acute case with instability (to allow static shoulder positioning and scar tissue formation in a shortened position) OR in an old dog without good muscle tone. Anything else I PREFER a stretchy fabric, which is why I like to use a bandage. It is there as a reminder, a mild blocking, and proprioception, but it allows muscle use and muscle retraining.
5) I think laser and shockwave can go a long way in helping to regenerate / heal cartilage & labrum issues... shockwave especially in these cases!

Gastroc disease... I think we should open up a new discussion on this. I know we had discussed it somewhere, elsewhere. I've not seen it... (and at this point, am not certain I believe in it... but I know that's just because I've never seen it or witnessed it yet!)

Laurie