Discussion related to the musculoskeletal system - injuries, post-op, lameness, extremity issues (joint, muscle, tenon, fascia...), axial skeleton issues, etc., as it relates to canine rehabilitation.
Hi there,
I have a patient (10yo M/N huntaway x mastiff) who was originally referred by his vet for severe OA in the right elbow. At the time of referral the vet biopsied a subcutaneous soft tissue lump on the plantar aspect of the left metacarpals. This lump was not causing the dog any issues but the vet was suspicious of neoplasm. At the time of biopsy there was a significant bleed noted but the bleeding stopped and the wound was closed. Histology results showed that the mass was primarily fibrous tissue and no neoplasm identified. Since this biopsy the size of the mass has increased and the dog developed lameness on the left forelimb. The stitches were removed 10 days later and the lameness increased to the point where the dog was having extreme difficulty mobilising on the affected limb. He presented at 2 weeks post biopsy. I have attached some pics which are stills from a video I cant upload. He has minimal carpal and MCP extension in the stance phase of gait and seems to be weightbearing most on this lateral 2 toes. On assessment he has some pain at end of range shoulder flexion but no pain to palpation of the biceps or supraspinatus tendon, elbow clear, carpus flexion is limited by soft tissue approximation of the mass but it is not painful, he actually has slightly increased carpal extension on the left compared to the right with a softer end feel, but no pain. No tenderness or trigger points in the carpal/ digital flexors identified. There was pain to dorsal glide the 3rd and 4th MCP joints and the 4rd PIP joint with heat and mild swelling at these joints also. Possibly some adverse neural tension - didn't really know how to assess it properly at the time ( have since watched the video presentations!) but the reason If felt there may have been was that his leg shuddered a bit when I extended the forelimb and carpus in slight abduction. At the time of assessment he was on antibiotics (just in case) NSAIDs, paracetamol and tramadol. I performed some traction of the MCPS which improved the pain free passive range of motion of these joints but did not change his weight bearing or gait. I'm not really sure what else to do for this guy, as I'm not entirely sure I know exactly what is going on, obviously his MCPS are sore but I'm not entirely sure if this is the driver, or if it is secondary to 2 weeks of altered gait. I'd be grateful for anyone's thoughts or experience with anything similar. Thanks in advance.
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Interesting case. I've not seen or heard of anything quite like it. But, I'm happy to run through some thought processing with you.
So, the shoulder signs you describe... like some OA in the glenohumeral joint.
Great that the elbow is clear, and reduced carpal flexion could be OA or just breed related.
Which takes us to the toes and foot in general. So lets say that there is / was OA in the foot.
Now perhaps the bleed caused other soft tissue troubles (stickiness in and around the joints and tendons).
Or, could be that it set off a peripheral sensitization (which increased pain with all things foot related).
With all of the foot issues, you could treat with modalities for pain and better blood flow (i.e. laser), you could do contrast baths (hot and cold - 30 seconds of each) to improve blood flow and help desensitize the area, and you could do some manual therapy (joint mobilizations and effleurage) to help with pain and movement of any stagnation of fluids.
But... in the back of my head I've have soft tissue sarcoma or nerve sheath tumour in my differentials.
However, treating the foot and the lameness isn't a bad measure. At this point, you don't really know the reason for the original lameness, you do know that the biopsy and potentially excessive bleeding exacerbated the issue. Treat that and see what's left after a couple of treatments, then re-evaluate.
Hi Laurie, Thanks so much for your reply. I treated him basically with effluerage and joint mobilisations, and got his owners to do some effluerage and ice packs after activity and joint tracions at home and he did really well! Much better than I expected based on his initial presentation!He had 3 treatments over a few weeks and by the last treatment was fully weight bearing and wanting to run around with the other dogs again and only had slight tenderness to end range glides of one of the MCPs.