Laurie's Blogs.

Hey Laurie,

Have been reading all of your MSI stuff and watching the videos.  I have client with an agility dog, 5 y/o,  44 lb lab, very fit and well-muscled, has been jumping  20 inches, that I think may have MSI.  She knocks bars and on recent video we were able to determine that she lands and experiences an issue with the front, then knocks the next bar as she can’t get her stride right before the next jump.  She has not allowed extension on the right shoulder for years! – then had bilateral iliopsoas which was injected with PRP and rehabbed  (shoulder ROM did not increase during this time off) – once back from that seemed ‘stiff in the front upon rising’ after increased activity with short strides.  Shoulders were diagnosed via MS US with biceps tendinosis, right with adhesions and worse than left (I knew that with palpation)– SST and ISS were clear on US.  She has NEVER shown lameness other than the stiff and short stride.

After laser, joint mobs, and UWTM I can get the left in position to check MSI and I think it was ~50 degrees (at home now, chart at work), but I cannot get the right in position to test, she simply will not allow glenohumeral extension.  She is uncomfortable when checking the subscapularis on the right but not on the left.  Do you have video of other testing I can do? 

She is doing the Tband resisted 3 leg stand with a large difference right to left and backward walking on the treadmill.  You said to ‘encourage extension’, would swimming be an ok activity?

How much backward walking on treadmill?  And what reps/frequency of Tband 3 legged stand?  We have not incorporated the ace wrap yet, but may next week.  Owner recently dropped to 16 inch jumps and gave NSAID for agility trial and she did well, did not knock bars and was not stiff following day.

So, we, (owner and I) feel like we don’t really have a diagnosis on the right.  Where do I go from here?  Do I try to have her sedated to check abduction angle?  Would CT or MRI give more information than the MS US?  I can find an equine vet that has ESWT

She is reluctant to return to the sports medicine specialist DVM as he will want to inject (in our opinion injections in both shoulders and iliopsoas were no more beneficial than rehab).

Her husband is a vet, and we have mentioned to him, if he would sedate, I would examine.  Her vet husband, called a surgeon (where I work) but surgery was her first option.  So we are feeling like I am the most thorough diagnostician and I feel very inadequate!

So, my questions are:

Videos of any other testing?

Reps/frequency of Tband exercise?

Time/frequency walking backward on treadmill?

Swimming?

ESWT – if so where specifically?  As I will have to direct the vet

Will sedating and examining give us the info we need (I know it will let test laxity of joint) but will it tell us anything else?

Would other diagnostics be beneficial?  MR/CT

Owner is willing to travel across the country for diagnosis and treatment but isn’t sure that a shoulder problem doesn’t just get the ‘diagnosis of the day’, and if surgery is the recommendation, she would have difficulty cutting on a dog that isn’t lame.

Any help greatly appreciated.

CS

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Hi CS,

So from what you describe, I think you're right on target with the Dx of MSI with a concurrent biceps tendinopathy.  Biceps is a stabilizer and intra-articular in it's insertion at the shoulder - so these two will commonly go hand in hand.  And I have found this as well, that the dog will avoid positioning to do the test when the joint is still problematic or the more chronic the condition.  So I'd bet that's what it is.  On an outside thought process, double check ribs 1 - 3... similar location and can cause this weightbearing pain / issue... but doesn't fit with some of the shoulder specific stuff.  Could be a missing puzzle piece however - so worth thinking about!  That's the only other thing I'd assess... oh, check elbow for fun too - just had one bite me in the butt lately - supraspinatus & flare of elbow OA.

So, I'd invest in a plan as follows:

•Keep the jump height lower for now (or forever if we can't get resolve)... but for now at least, we need no irritation to reverse the gains we'll make.

•If using NSAIDs, go LOW dose.  It's a catch 22 - they will help the shoulder joint inflammation, but could delay soft tissue healing (Subscap/ligs/Biceps).

•Modalities to the shoulder joint line, biceps, and medial joint line.  

•I wouldn't trust a non-rehab vet to be specific enough with shockwave to get either biceps tendon or the medial joint line (with the dog's shoulder externally rotated & scapula lifted off the chest wall).  So keep it in the back of you mind as a last resort.

•So, you've got two issues - irritation of the joint + biceps tendon AND a volitional postural 'holding back' of shoulder extension.  So, you can justify modalities.  You can justify manual therapies (to increase extension - caudal glides, & I'd do medial lateral glides too)  and show the owner joint compressions and joint distractions (for pain management & joint lubrication).  And of course you need the exercise bit.

•backwards walking on the treadmill - ideally inclined... so they are facing downwards (all 4 on... or rear legs on a platform and only front legs on).  But you need to play with the legs... hold the left leg back a bit, so that the right leg has to reach further.  I'd try to do it for 10 minutes per session.  If the owner is doing this, that's one thing, but I think the dog would do better coming to you twice a week to make gains.  If the owner has a treadmill then she can put the dog on it backwards as a way to try it out, and maybe maintain some gains... but YOU will be invaluable in getting the best possible reach from this exercise.

•The theraband exercise is not likely going to be enough as a static flat land exercise.  So in this case, I would play with it a bit by positioning the dog with the rear legs elevated.  Reps... I go by time - try for about 5 minutes or until the dog gets bored, tired, or starts to cheat.  I would also try doing it with the dog on the treadmill - rears on a platform, fronts on treadmill, backwards... loop the band around the front leg and see if you can pull on it while the dog is moving.  Do this for as long as it looks to be making the dog work (2 minutes... 7 minutes???)

•I'd then also prescribe down hill walking (for the biceps tendon) or down stairs, and or push ups for a cookie (rear legs up on a stair / stool and reach forwards and down for a cookie - bending shoulders / elbows to get the treat).  2 sets of 10 stairs twice a day.

•I'd scrap UWT... (unless you don't have a land treadmill and you're using the UWT to do the backwards walking) and I don't think that swimming will get you the extension in the shoulder that you're looking for.

•And... if worse comes to worse, I have seen cases where a shot of cortisone into the the G-H joint is what did wonders.  (Keep that in your hat as a last, last resort.  It totally goes against everything I stand for & believe... but sometimes it does the trick!)

I hope this helps!!!  I think I remembered everything that has come up in my head over the last few days.  I've seen cases like this... hang in there!

Cheers!

Laurie