Hi Laurie,
Firstly I want to thank you for your incredible online resource! I am relatively new to the canine physio world and also I'm the only one in my region so having access to your education is just fantastic. Secondly I want to thank you for your replies to my questions on the forum - very helpful!!!!
I just have a quick question. I was reading you blog on "FHOs - the good the bad and the ugly" as I have a very bad and ugly one at the moment, miniature poodle 3 weeks post surgery (following multiple coxofemoral dislocations) has not put weigh through the leg at all, holding the hip in maximal flexion and internal rotation.
Anyway in you blog you said you're feeling for a clunk when you go through the hip ROM - what is the significance of this - This little dog has a major clunk as I move is hip from flexion to extension and back again - however it does not seem painful, yet it feels terrible. The other thing to note is even when I can fully extend the stifle and tarsus and get his leg into a normal weight bearing position he now appears to have a significant leg length discrepancy as the femur is riding very high, you can palpate it adjacent to the SIJ.
I've tried every trick in the book and just cant get this little guy to put his foot down!! The vet who performed the surgery is concerned but is hoping that rehab will be the answer - I'm not so sure!!!
Thanks so much!
KH
FHO Leg Length Discrepancy
Re: FHO Leg Length Discrepancy
Hey Kristie,
My apologies for this very tardy reply! October was utter chaos!
Okay, so this does sound like a tricky case! I would guess that since you have full ROM and there isn’t pain with the clunk you feel, that it is not a bone spur.
I’d guess that it might be soft tissue flicking over something (maybe the greater trochanter?), because if it were a spur creating the clunking anywhere in there, I think you’d have pain.
I have heard of some surgeons advising no / minimal weight bearing for several weeks, hoping that the scar tissue with solidify and no stretch out dorsally with weight bearing (thus creating a short leg), but it sounds like your case never used the foot anyways. So, that isn’t what happened!
The leg length discrepancy is tricky… you can’t really change that much. The only thing coming to mind would be slow gentle long leg tractions to see if you can slowly draw the femur back down and stretch out any dorsal scar tissue that might have ‘pulled’ the femur dorsally.
It also reminds me of a case I saw when doing my Master Degree in Australia about 12 years ago. It was a medium sized dog, similar history to your dog, and just wouldn’t weight bear. The hip evaluated to be non-painful, but he wouldn’t put it down. After trying many things statically, one student just walked beside the dog and pressed down on his rump. Low and behold he would weight bear on it. So that became the exercise.
Other tricky cases, we’ve had to get very creative. One of our favourite & most successful tricks is going fast-slow-fast-slow arbitrarily using the UWT. Make is such a disturbance that the dog will want to use all 4 legs for balance. I think backing up could also be helpful.
But if there really is a substantial leg length discrepancy and the leg is legitimately non-functionally short… then that’s a problem.
I’d try all of the things above, and if you are still banging your head against the wall, then request a re-X-ray.
Best of luck (and again, I’m sorry for my late reply!)
Cheers,
Laurie
PS in our FHO case that I discussed in the blog 2 weeks ago. My therapist sent an note back to the referring vet, who said "We thought that too!" And last we heard the dog was scheduled back to see the surgeon.
My apologies for this very tardy reply! October was utter chaos!
Okay, so this does sound like a tricky case! I would guess that since you have full ROM and there isn’t pain with the clunk you feel, that it is not a bone spur.
I’d guess that it might be soft tissue flicking over something (maybe the greater trochanter?), because if it were a spur creating the clunking anywhere in there, I think you’d have pain.
I have heard of some surgeons advising no / minimal weight bearing for several weeks, hoping that the scar tissue with solidify and no stretch out dorsally with weight bearing (thus creating a short leg), but it sounds like your case never used the foot anyways. So, that isn’t what happened!
The leg length discrepancy is tricky… you can’t really change that much. The only thing coming to mind would be slow gentle long leg tractions to see if you can slowly draw the femur back down and stretch out any dorsal scar tissue that might have ‘pulled’ the femur dorsally.
It also reminds me of a case I saw when doing my Master Degree in Australia about 12 years ago. It was a medium sized dog, similar history to your dog, and just wouldn’t weight bear. The hip evaluated to be non-painful, but he wouldn’t put it down. After trying many things statically, one student just walked beside the dog and pressed down on his rump. Low and behold he would weight bear on it. So that became the exercise.
Other tricky cases, we’ve had to get very creative. One of our favourite & most successful tricks is going fast-slow-fast-slow arbitrarily using the UWT. Make is such a disturbance that the dog will want to use all 4 legs for balance. I think backing up could also be helpful.
But if there really is a substantial leg length discrepancy and the leg is legitimately non-functionally short… then that’s a problem.
I’d try all of the things above, and if you are still banging your head against the wall, then request a re-X-ray.
Best of luck (and again, I’m sorry for my late reply!)
Cheers,
Laurie
PS in our FHO case that I discussed in the blog 2 weeks ago. My therapist sent an note back to the referring vet, who said "We thought that too!" And last we heard the dog was scheduled back to see the surgeon.
LAURIE EDGE-HUGHES
Re: FHO Leg Length Discrepancy
Hi Laurie,
Thanks so much for your reply.
Within that time this little dog had his leg amputated.
It was a real learning experience for me.
Immediately after assessing this dog I called the vet who performed the surgery as I felt he needed a follow up X-ray as there seemed to be bone on bone contact. She agreed but then spoke to the senior vet surgeon who felt an xray would not be of value but to continue with rehab and pain relief for another 3 weeks.
When I talked to this senior surgeon, and he reviewed the dog with me, he pretty much talked me into believing that this dogs progress was still within the normal range (despite everything I'd learned telling me otherwise).
I put my concerns down to a lack of experience and let it go.
When I saw the dog next the owners said they still wanted an xray so I suggested they ask the operating vet again, which they did.
She obliged and it turns out it there was not enough femoral neck removed and there was bone on bone contact.
The vet clinic paid for an independent surgeon to operate to remove the remaining bone but when he got in there he felt he could not salvage the leg and had to amputate.
I wish I had advocated more strongly for this little dog. I let self doubt and fear of upsetting the vet interfere in my decisions and I really regret it. Although I doubt the outcome would have been any different for the dog maybe the owners would have felt more supported. They are very upset and angry at the operating surgeon and the vet clinic's management of their dog.
Anyway I hope November is a bit more relaxing for you than it seems October was!
Thanks again,
KH
Thanks so much for your reply.
Within that time this little dog had his leg amputated.
It was a real learning experience for me.
Immediately after assessing this dog I called the vet who performed the surgery as I felt he needed a follow up X-ray as there seemed to be bone on bone contact. She agreed but then spoke to the senior vet surgeon who felt an xray would not be of value but to continue with rehab and pain relief for another 3 weeks.
When I talked to this senior surgeon, and he reviewed the dog with me, he pretty much talked me into believing that this dogs progress was still within the normal range (despite everything I'd learned telling me otherwise).
I put my concerns down to a lack of experience and let it go.
When I saw the dog next the owners said they still wanted an xray so I suggested they ask the operating vet again, which they did.
She obliged and it turns out it there was not enough femoral neck removed and there was bone on bone contact.
The vet clinic paid for an independent surgeon to operate to remove the remaining bone but when he got in there he felt he could not salvage the leg and had to amputate.
I wish I had advocated more strongly for this little dog. I let self doubt and fear of upsetting the vet interfere in my decisions and I really regret it. Although I doubt the outcome would have been any different for the dog maybe the owners would have felt more supported. They are very upset and angry at the operating surgeon and the vet clinic's management of their dog.
Anyway I hope November is a bit more relaxing for you than it seems October was!
Thanks again,
KH
Re: FHO Leg Length Discrepancy
Ugh! What a case!
When a scenario like this plays out, you just have to chalk it up to the universe delivering you (all) a learning experience.
Lots of lessons to be had with this:
Clinically - you’ll never forget this scenario and when things don’t seem right, they’re likely not right!!! The short leg, the clunk you felt, the inability to trick the dog in any way to weight bear. You’ll never forget those things.
Professionally - You know that when your gut and clinical experience hands you the things you described / felt, to advocate for a follow up (write / call the surgeon with your concerns) and coach the clients to request a follow-up radiograph (in a scenario such as this).
It’s tricky… but in the human healthcare world, this is one of the reasons that there is a push for ‘Patient Centred Care’, where ever play is a spoke in a wheel and the patient is at the centre. It’s not hierarchal… which vet medicine still is. (As demonstrated by your concern of upsetting the surgeon and deferring.) This case shows how every player in the team should be able to raise a concern and be listened to, and valued for their knowledge and what they bring to the team. (But I digress.)
Don’t beat yourself up. I believe things happen for a reason. This ‘reason’ appears to be for learning some big lessons.
"Thank you universe." Lick your wounds. Carry on better than you were before!
All the best,
Laurie
When a scenario like this plays out, you just have to chalk it up to the universe delivering you (all) a learning experience.
Lots of lessons to be had with this:
Clinically - you’ll never forget this scenario and when things don’t seem right, they’re likely not right!!! The short leg, the clunk you felt, the inability to trick the dog in any way to weight bear. You’ll never forget those things.
Professionally - You know that when your gut and clinical experience hands you the things you described / felt, to advocate for a follow up (write / call the surgeon with your concerns) and coach the clients to request a follow-up radiograph (in a scenario such as this).
It’s tricky… but in the human healthcare world, this is one of the reasons that there is a push for ‘Patient Centred Care’, where ever play is a spoke in a wheel and the patient is at the centre. It’s not hierarchal… which vet medicine still is. (As demonstrated by your concern of upsetting the surgeon and deferring.) This case shows how every player in the team should be able to raise a concern and be listened to, and valued for their knowledge and what they bring to the team. (But I digress.)
Don’t beat yourself up. I believe things happen for a reason. This ‘reason’ appears to be for learning some big lessons.
"Thank you universe." Lick your wounds. Carry on better than you were before!
All the best,
Laurie
LAURIE EDGE-HUGHES