Yorkie with persistent skipping

[Guest guest]

I have been treating a 6 year old, 7 pound Yorkie for an intermittent to

continuous left hind limb non-weight bearing lameness AND an intermittent right

hind limb lameness at the trot with no improvement and no ideas. If anything it

is getting worse.

Q started skipping intermittently at about 6 months of age. He was diagnosed

with Microvascular Dysplasia at 1 1/2 years of age and is well controlled with

conservative management. He also has a history of a collapsing trachea. He

started having trouble jumping and was skipping more in April 2008 and was

diagnosed with a Grade III/IV left MPL and Grade I/IV right MPL. The owner also

noted he was becoming more pigeon toed. He had bilateral MPLs repaired in 5/08

and the tibital pins removed in 10/2010. The owner does not thinking the surgery

has helped, although pin removal seemed to help temporarily.

He has also had a workup for Iliopsoas injury (as a possible cause of the

lameness) and a tendinopathy was verified by ultrasound. The iliopsoas was

treated with Shockwave therapy. Repeat ultrasound 4 weeks post Shockwave showed

significant improvement of the lesion, and Q was no longer painful on hip

extension with internal or external rotation.

Q has been receiving acupuncture and chiropractics for the last 6 months with no

improvement. He has trigger points at the T-L junction and L3, L4. He has done

underwater treadmill, swimming, therapeutic exercises, laser treatment of the

hips and spine, and electroacupuncture at the trigger points.

The owner notices that he is now NWB on the left hind limb walking around the

house. Cold weather makes the skipping worse. He is now snapping at the owner

when she tries to move him on her lap. He has always snapped and growled when

grooming around his hips/hind limbs since he was < 1yr of age. He is very

difficult to examine as he is aggressive towards most anyone at the clinic,

which didn't begin until just before the MPL repairs. I have gained his trust so

he will allow me to examine him, but consultations with any other services is a

real circus even with a muzzle.

He just had an MRI of the thoracolumbar spine and distal extremities from the

hips to stifles. There were no abnormalities noted in the spine, hips or

Iliopsoas. There was mild DJD in both stifles. Nerve roots were WNL, facets WNL,

no muscle tears, hips WNL. No abnormalities are noted on radiography other than

mild stifle DJD bilaterally. He has been examined by the neurologist and three

separate orthopedists. The only physical exam finding in the last 18 months was

pain on hip extension with internal rotation and palpation of the insertion of

the iliopsoas muscle (see above for tx).

He is currently on Denamarin, Adequan, Deramaxx (6.25 mg once daily), Gabapentin

(25 mg BID) and SQ Buprenorphine (0.03 mg BID). The owner notes that he wants to

play more with his toys and is not as grouchy with the buprenorphine on board,

but gets a little sleepy about 45 minutes after injection.

He's a real enigma. The owner is considering euthanasia, likely out of

frustration and worry that he is in constant pain. I'm not entirely sold that he

is constantly in pain, but I have no idea how to explain the skipping. I do

believe that the owner underestimates his behavior issues, but he recently

jumped out of her arms onto the ground (this happened prior to the MRI, and was

part of the impetus for the MRI). He has been REALLY grouchy and NWB LH 95% of

the time at the trot now. I'm happy to expand on anything thus far if anyone

needs more details.

Marti Drum, DVM, PhD

University of Tennessee

Small Animal Physical Rehabilitation

[Guest guest]

Hey Marti! This might be a silly question, but is he still luxating patellas? Pam NicholsSent from my Verizon Wireless BlackBerryDate: Wed, 31 Mar 2010 21:04:34 -0000To: <VetRehab >Subject: Yorkie with persistent skipping I have been treating a 6 year old, 7 pound Yorkie for an intermittent to continuous left hind limb non-weight bearing lameness AND an intermittent right hind limb lameness at the trot with no improvement and no ideas. If anything it is getting worse.Q started skipping intermittently at about 6 months of age. He was diagnosed with Microvascular Dysplasia at 1 1/2 years of age and is well controlled with conservative management. He also has a history of a collapsing trachea. He started having trouble jumping and was skipping more in April 2008 and was diagnosed with a Grade III/IV left MPL and Grade I/IV right MPL. The owner also noted he was becoming more pigeon toed. He had bilateral MPLs repaired in 5/08 and the tibital pins removed in 10/2010. The owner does not thinking the surgery has helped, although pin removal seemed to help temporarily. He has also had a workup for Iliopsoas injury (as a possible cause of the lameness) and a tendinopathy was verified by ultrasound. The iliopsoas was treated with Shockwave therapy. Repeat ultrasound 4 weeks post Shockwave showed significant improvement of the lesion, and Q was no longer painful on hip extension with internal or external rotation. Q has been receiving acupuncture and chiropractics for the last 6 months with no improvement. He has trigger points at the T-L junction and L3, L4. He has done underwater treadmill, swimming, therapeutic exercises, laser treatment of the hips and spine, and electroacupuncture at the trigger points.The owner notices that he is now NWB on the left hind limb walking around the house. Cold weather makes the skipping worse. He is now snapping at the owner when she tries to move him on her lap. He has always snapped and growled when grooming around his hips/hind limbs since he was < 1yr of age. He is very difficult to examine as he is aggressive towards most anyone at the clinic, which didn't begin until just before the MPL repairs. I have gained his trust so he will allow me to examine him, but consultations with any other services is a real circus even with a muzzle. He just had an MRI of the thoracolumbar spine and distal extremities from the hips to stifles. There were no abnormalities noted in the spine, hips or Iliopsoas. There was mild DJD in both stifles. Nerve roots were WNL, facets WNL, no muscle tears, hips WNL. No abnormalities are noted on radiography other than mild stifle DJD bilaterally. He has been examined by the neurologist and three separate orthopedists. The only physical exam finding in the last 18 months was pain on hip extension with internal rotation and palpation of the insertion of the iliopsoas muscle (see above for tx). He is currently on Denamarin, Adequan, Deramaxx (6.25 mg once daily), Gabapentin (25 mg BID) and SQ Buprenorphine (0.03 mg BID). The owner notes that he wants to play more with his toys and is not as grouchy with the buprenorphine on board, but gets a little sleepy about 45 minutes after injection.He's a real enigma. The owner is considering euthanasia, likely out of frustration and worry that he is in constant pain. I'm not entirely sold that he is constantly in pain, but I have no idea how to explain the skipping. I do believe that the owner underestimates his behavior issues, but he recently jumped out of her arms onto the ground (this happened prior to the MRI, and was part of the impetus for the MRI). He has been REALLY grouchy and NWB LH 95% of the time at the trot now. I'm happy to expand on anything thus far if anyone needs more details. Marti Drum, DVM, PhDUniversity of TennesseeSmall Animal Physical Rehabilitation

[Guest guest]

Patellas cannot be luxated and are in a normal position both on palpation and on

MRI.

>

> Hey Marti! This might be a silly question, but is he still luxating patellas?

Pam Nichols

> Sent from my Verizon Wireless BlackBerry

>

[Guest guest]

Marti,

Wow! I am jealous of the extensive workup we usually don't get this much

information.

In patients with chronic pain, especially those that are difficult to examine we

must use decreasing function and/or decrease in ability to perform daily

activities as and assessment of pain. Thus a decrease in function is an

increase in pain. If this is recognized by the owner then chronic pain is

always a consideration. So with that said some reactions that owners recognize

at home can be behavioral or a combination of acquired behavior due to chronic

pain (i.e. attempting to bite when picking up).

I think that the most common problem that creates skipping or periodic

non-weight bearing followed by a relatively normal gait is articular dysfunction

of the stifle. Your diagnostics indicate OA of the stifle and you are using an

NSAID and Adequan which is great! I might consider titration upward of the

gabapentin and addition of amitriptyline 0.25-0.5mg/kg (the later seems to help

with the descending pain inhibition pathway by increasing serotonin and

norepinephrine). With stifle dysfunction I often find MTrPs in the functional

muscles of the stifle - m. sartorius, m. tensor fascial latae, m. rectus

femoris, vastus group and to a less degree m. biceps femoris, m. semitendinosus

and m. semimembranosus. These muscles can be overload and become painful due

the stifle dysfunction. In some the functional muscles of the coxofemoral

joint, mainly flexors, will be overload in that the hip joint becomes more

active in ambulation due to the decrease function of the stifle. This could

possibly explain you finding of MTrPs in the dorsal m. psoas major and even

possibly in the dorsal paraspinals (both of these groups can be more active in

ambulation and sometimes in the maintenance of a kyphotic posture associated

with hind limb disorders).

Just some thoughts on an extremely well handled case you are to be commended!

Rick Wall, DVM

Certified Canine Rehabilitation Practitioner

Diplomate, American Academy of Pain Management

Certified Myofascial Trigger Point Therapist

Center for Veterinary Pain Management and Rehabilitation

The Woodlands, TX

www.vetrehabcenter.com