Iliopsoas strain

[Guest guest]

I am presently treating a border collie with strained Iliopsoas. I have started

with some Low Level Laser and will see the patient again today, I would like to

start having them do some exercises at home. I was wondering what people would

suggest as their favorite exercises for treating this ailment.

[Guest guest]

,

One of my favorite muscles! I examine and treat the m. psoas major with the

patient in lateral recumbency and usually place a noodle or rolled up towel on

the downside to create lateral flexion of the lumbar spine and giving more room

to access the muscle in the mid to caudal lumbar area. This position can also

be used for musculoskeletal ultrasound examination. I often find this muscle to

be very painful in both acute injury and the chronic presentation we see in so

many of our rehab patients. My treatments include trigger point dry needling

and therapeutic laser focused on the palpable areas of pain. I think both

examination and therapy is much easier with very low doses of dexdomitor, 0.1 to

0.3cc IV in a lab, like your patient. This enables me to still localize pain

and better evaluate the muscle manually or w/ musculoskeletal u/s. In addition,

the sedated patient is more relaxed for therapy, especially when TrP-DN is

performed. Following therapy we stretch but you have to be careful not to

overstretch in the sedated patient (personal experience). During sedation we

usually administer O2 and monitor SpO2 and then we reverse. If only using a

therapeutic laser then you may not always need to sedate but in the acutely

injured patient like yours it can really help. I usually treat the acute

patient 3 to 6 times but my reevaluation and u/s findings can tell me that.

Very controlled exercise, no explosive activity for sometime, for certain

several weeks after pain and if muscle is torn much longer.

From a pharmaceutical prospective consider gabapentin 5-10mg/kg q8-12h and

amitriptyline 0.25-0.5mg q12h.

I uploaded some clips to vimeo. The first patient was not sedated however the

second patient required it.

Hope this helps.

http://vimeo.com/34053133

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

[Guest guest]

Hi Rick.

Happy holidays to all.

I'm a little startled by your mention of sedating your patient for examination

and therapy. Are you not concerned that you won't get adequate feedback from

your patient during your therapy?

Amie

Amie Lamoreaux Hesbach, MSPT, CCRP, CCRT

Physical Therapist

Massachusetts Veterinary Referral Hospital

20 Cabot Road

Woburn, MA 01801

Phone:

Fax:

E-mail: ahesbach@...

Website: www.IVGMassVet.com

> ,

>

> One of my favorite muscles! I examine and treat the m. psoas major with the

patient in lateral recumbency and usually place a noodle or rolled up towel on

the downside to create lateral flexion of the lumbar spine and giving more room

to access the muscle in the mid to caudal lumbar area. This position can also

be used for musculoskeletal ultrasound examination. I often find this muscle to

be very painful in both acute injury and the chronic presentation we see in so

many of our rehab patients. My treatments include trigger point dry needling

and therapeutic laser focused on the palpable areas of pain. I think both

examination and therapy is much easier with very low doses of dexdomitor, 0.1 to

0.3cc IV in a lab, like your patient. This enables me to still localize pain

and better evaluate the muscle manually or w/ musculoskeletal u/s. In addition,

the sedated patient is more relaxed for therapy, especially when TrP-DN is

performed. Following therapy we stretch but you have to be careful not to

overstretch in the sedated patient (personal experience). During sedation we

usually administer O2 and monitor SpO2 and then we reverse. If only using a

therapeutic laser then you may not always need to sedate but in the acutely

injured patient like yours it can really help. I usually treat the acute

patient 3 to 6 times but my reevaluation and u/s findings can tell me that.

> Very controlled exercise, no explosive activity for sometime, for certain

several weeks after pain and if muscle is torn much longer.

>

> From a pharmaceutical prospective consider gabapentin 5-10mg/kg q8-12h and

amitriptyline 0.25-0.5mg q12h.

>

> I uploaded some clips to vimeo. The first patient was not sedated however the

second patient required it.

>

> Hope this helps.

>

>

> http://vimeo.com/34053133

>

>

>

> 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

>

>

>

>

>

> ------------------------------------

>

>

[Guest guest]

Amy,

Sure did not mean to startle you, maybe I need to explain myself better. I have

just found that in painful patients and even sometimes in patients with a low

tolerance of pain, I can examine painful muscles much better and then treat

them easier with very minute doses of Dexdomitor (60 to 200 mcg/m2). Now I

have already determined areas of myalgia before the closer examination for taut

bands and MTrPs. In the m. psoas major that lies ventromedial to the m.

iliocostalis lumborum and lumbar transverse process It is critical to have a

relaxed patient to palpate changes in the muscle. With invasive therapy near

the caudal vena cava and abdominal aorta I prefer a relaxed patient.

I also question, and would like discussion, regarding passive stretching of a

myalgic muscle that is shortened due to the presence of taut bands. If the

canine patient resists gentle stretching and manipulation are we accomplishing

anything? The attached .pdf is a series of pictures of a patient that

maintained a non-weight bearing state for considerable time postop CCL excap.

Some what unusual is that NWB posture was maintained by constant flexion of the

stifle rather than more common coxofemoral flexion. Since the caudal thigh

muscles never were able to relax numerous taut bands and MTrPs were formed in

stifle flexors (Cinderella Hypothesis). Initial stifle extension 106 degrees,

after 0.1cc (60 mcg/m2)Dexdomitor - stifle extension 119 degrees and then

following TrP-DN and before any stretching 131 degrees. My feedback is the

palpable feel of the muscle, the changes in resistance as the needle enters the

taut band and the local twitch response(s) from the needle entering MTrP.

- once open scroll down to see first picture.

In this same patient video of LTR observed by movement of a needle within same

taut band as the invasive therapy is performed distally in the same band. In

the m. psoas major I can only appreciate LTRs in a very relaxed animal.

Treatment was performed under sedation.

http://vimeo.com/34093639

One additional video using musculoskeletal ultrasound to visualize LTR.

http://vimeo.com/33599630

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

1 of 1 Photo(s)

[Guest guest]

Hello all, sorry to be late to the party. Severe pain with bilateral hip extension, no identifiable mechanism of injury, hunched (flexed?) lumbar posture....Make sure you aren't missing a lumbar issue (e.g. disc herniation or other). Spontaneous bilateral "psoas" pain likely points to secondary guarding.....Sent from my iPad Hi Rick.Happy holidays to all.I'm a little startled by your mention of sedating your patient for examination and therapy. Are you not concerned that you won't get adequate feedback from your patient during your therapy?AmieAmie Lamoreaux Hesbach, MSPT, CCRP, CCRTPhysical TherapistMassachusetts Veterinary Referral Hospital20 Cabot RoadWoburn, MA 01801Phone: Fax: E-mail: ahesbach@...Website: www.IVGMassVet.comOn Dec 21, 2011, at 7:05 PM, Rick Wall, DVM wrote:> ,> > One of my favorite muscles! I examine and treat the m. psoas major with the patient in lateral recumbency and usually place a noodle or rolled up towel on the downside to create lateral flexion of the lumbar spine and giving more room to access the muscle in the mid to caudal lumbar area. This position can also be used for musculoskeletal ultrasound examination. I often find this muscle to be very painful in both acute injury and the chronic presentation we see in so many of our rehab patients. My treatments include trigger point dry needling and therapeutic laser focused on the palpable areas of pain. I think both examination and therapy is much easier with very low doses of dexdomitor, 0.1 to 0.3cc IV in a lab, like your patient. This enables me to still localize pain and better evaluate the muscle manually or w/ musculoskeletal u/s. In addition, the sedated patient is more relaxed for therapy, especially when TrP-DN is performed. Following therapy we stretch but you have to be careful not to overstretch in the sedated patient (personal experience). During sedation we usually administer O2 and monitor SpO2 and then we reverse. If only using a therapeutic laser then you may not always need to sedate but in the acutely injured patient like yours it can really help. I usually treat the acute patient 3 to 6 times but my reevaluation and u/s findings can tell me that. > Very controlled exercise, no explosive activity for sometime, for certain several weeks after pain and if muscle is torn much longer. > > From a pharmaceutical prospective consider gabapentin 5-10mg/kg q8-12h and amitriptyline 0.25-0.5mg q12h. > > I uploaded some clips to vimeo. The first patient was not sedated however the second patient required it.> > Hope this helps.> > > http://vimeo.com/34053133> > > > 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> > > > > > ------------------------------------> >

[Guest guest]

Christie,

I just sent it to you directly from vimeo, let me know if that helps.

Rick

[Guest guest]

Liz,

I very much enjoy the multidiscipline environment of this discussion group. I

sincerely believe that veterinary rehabilitation has and will continue to

benefit from discussions, and sometimes debates, between DVMs, PTs, and RVTs. I

will always be very respectful of the skills that PTs bring to this discipline

and I remain excited about the future of rehabilitation due to cooperation.

Perhaps I am completely misinterpreting your comments but I find them somewhat

condescending. I am mistaken please accept my apology in advance and if not I

am fairly thick skinned and would still appreciate a discussion.

The original question that sparked this discussion concerned a 2 year old Lab

with acute onset pain and kyphotic posture. While under sedation for

radiographs Dr. Falch localized pain to the area of the m. psoas major. I

attempted to answer her questions which led to questioning by Amie regarding my

use of sedation in similar cases. It is absolutely fair to question anyone's

comments, this is a discussion group! I attempted to support my statements with

comments, personal opinions, and videos. Those are for you to accept or decline

but I would prefer that they stimulate an open discussion.

I am the only DVM who responded to Dr. Falch's questions, while 3 PTs

participated in this discussion. Amie had specific question for me,

raised question concerning the Dr. Falch's conclusions and you questioned the

diagnosis and my statements. Again, all fair, but could you additionally answer

at least some of Dr. Falch's questions and could you support the statements you

make?

I am always amazed when discussing muscle stretching how the golgi tendon organ

and reflex predominate the discussion with little if any mention of all the

other muscle components and reflexes.

My questions:

1.

-------- " I have never had a dog that, over time, and with a skilled hand, would

not eventually allow a gradual lengthening, manually, of the muscle. In this

way, the golgi tendon organs can return to a more normal response pattern, and

help to return normal tone to the muscle. " ---------------

So are you saying that the increased tone within a painful muscle is the result

of improper Golgi Tendon firing resulting in decreased alpha-motor neuron

inhibition? Could you discuss further?

2.

---------- " Many humans have acute pain in the iliopsoas when the lumbar

spine/disc are in a state of injury and inflammation. The neuro response of the

muscle is upset when there is any compression of the nearby nerve root...and

there is the protective reaction of the muscle as well. " -------------

Do you commonly find intervertebral disc disease in 2 year old labs? Could you

explain the neuro response of the muscle you describe due to nerve root

compression. I am familiar with the formation of MTrPs, thought to be due to

the antidromic neuronal activity and the release of endogenous substance with

vascular and cellular action " Neurogenic Inflammation " . Is this what you are

referring to?

3.

---------- " Again...it seems that this dog should be assessed for a lumbar spine

issue. " -----------

So if you are of the opinion that the pain localized by Dr. Falch's in the m.

psoas major is secondary to another lumbar spine issue could you please list

some of your differential considerations for acute lumbar pain in a 2 year old

lab?

Sincerely and with all professional respect,

Rick Wall

[Guest guest]

Hi Rick and Liz,Just to make the conversation more juicy! I believe if you take this lab of the grains, especially the gluten grains of "wheat, barley, rye and oats" this dog will do much better with his psoas strain (food and snacks included!). Most labs are highly grain sensitive, and a common musculo-skeletal compensation pattern happens around an inflamed right kidney, ureter and bladder over time. Left follows later. The dog will get an kyphotic posture because of inflammation of the pancreas/kidney area on the right, a flat diaphragm, a common spinal compensation of side bend right, rotated left spine from L1 to L7. What can pinch the L3 - L4 nerve roots (neurogenic inflammation) and can give a limp on the right rear, and limited extension because of spams of the ilio-psoas muscle (ureter runs right in front of psoas!), and last but not least, an pelvis rotation of right ventral and left dorsal rotated combined with a descended sacrum. This might be hard to follow if you haven't studied chiropractic or osteopathy, but I see this a common musculo-skeletal compensation around a gluten impaction. If you are more interested, I will be gladly explain more, but as a PT I couldn't stay out of this fun conversation.Happy Holidays, Kortekaas PTwww.fullspectrumcaninetherapy.com> To: VetRehab > Date: Tue, 27 Dec 2011 17:49:14 -0600> Subject: Re: Iliopsoas strain> > > Liz,> > I very much enjoy the multidiscipline environment of this discussion group. I sincerely believe that veterinary rehabilitation has and will continue to benefit from discussions, and sometimes debates, between DVMs, PTs, and RVTs. I will always be very respectful of the skills that PTs bring to this discipline and I remain excited about the future of rehabilitation due to cooperation. Perhaps I am completely misinterpreting your comments but I find them somewhat condescending. I am mistaken please accept my apology in advance and if not I am fairly thick skinned and would still appreciate a discussion.> > The original question that sparked this discussion concerned a 2 year old Lab with acute onset pain and kyphotic posture. While under sedation for radiographs Dr. Falch localized pain to the area of the m. psoas major. I attempted to answer her questions which led to questioning by Amie regarding my use of sedation in similar cases. It is absolutely fair to question anyone's comments, this is a discussion group! I attempted to support my statements with comments, personal opinions, and videos. Those are for you to accept or decline but I would prefer that they stimulate an open discussion. > > I am the only DVM who responded to Dr. Falch's questions, while 3 PTs participated in this discussion. Amie had specific question for me, raised question concerning the Dr. Falch's conclusions and you questioned the diagnosis and my statements. Again, all fair, but could you additionally answer at least some of Dr. Falch's questions and could you support the statements you make?> > I am always amazed when discussing muscle stretching how the golgi tendon organ and reflex predominate the discussion with little if any mention of all the other muscle components and reflexes. > > My questions:> > 1.> > --------"I have never had a dog that, over time, and with a skilled hand, would not eventually allow a gradual lengthening, manually, of the muscle. In this way, the golgi tendon organs can return to a more normal response pattern, and help to return normal tone to the muscle."---------------> > So are you saying that the increased tone within a painful muscle is the result of improper Golgi Tendon firing resulting in decreased alpha-motor neuron inhibition? Could you discuss further?> > 2.> > ----------"Many humans have acute pain in the iliopsoas when the lumbar spine/disc are in a state of injury and inflammation. The neuro response of the muscle is upset when there is any compression of the nearby nerve root...and there is the protective reaction of the muscle as well."-------------> > Do you commonly find intervertebral disc disease in 2 year old labs? Could you explain the neuro response of the muscle you describe due to nerve root compression. I am familiar with the formation of MTrPs, thought to be due to the antidromic neuronal activity and the release of endogenous substance with vascular and cellular action "Neurogenic Inflammation". Is this what you are referring to?> > 3.> > ----------"Again...it seems that this dog should be assessed for a lumbar spine issue."-----------> > So if you are of the opinion that the pain localized by Dr. Falch's in the m. psoas major is secondary to another lumbar spine issue could you please list some of your differential considerations for acute lumbar pain in a 2 year old lab?> > Sincerely and with all professional respect,> > Rick Wall> > ------------------------------------> >

[Guest guest]

Hi all,I'm a bit of a lurker, as I am a beginner in rehab, having practiced emergency medicine for nigh on 20 years. But with this discussion I felt I had something to contribute.I've diagnosed intervertebral disc lesions (and sent to surgeons for myelograms and laminectomies) labradors as young as 2 years. And they weren't severe traumas, either. One I remember was just taking off after a tennis ball. he was an exceptionally muscular boy, though. My own labradors (active field trial dogs all), when X-rayed, (usually for gi issues and not lameness or pain) have had spondylosis lesions as young as 2 years of age. It is my impression that the sort of conformation and life we breed labs for: very muscular, sprint and jumping, rapid take offs, may predispose them for intervertebral disc disease. Nothing to back it up but my own experience, but I'd love to throw it out there and see what comes back. cheers. MillsVeterinarian and Science Writer5080 Riordan Hill RoadHood River, Oregon 97031 cynthmills@...Author of The Theory of Evolution: What it is, Where it came from, and Why it works; and articles for Discover, Health, Scientific American, Conservation and the Boston Globe. Liz,I very much enjoy the multidiscipline environment of this discussion group. I sincerely believe that veterinary rehabilitation has and will continue to benefit from discussions, and sometimes debates, between DVMs, PTs, and RVTs. I will always be very respectful of the skills that PTs bring to this discipline and I remain excited about the future of rehabilitation due to cooperation. Perhaps I am completely misinterpreting your comments but I find them somewhat condescending. I am mistaken please accept my apology in advance and if not I am fairly thick skinned and would still appreciate a discussion.The original question that sparked this discussion concerned a 2 year old Lab with acute onset pain and kyphotic posture. While under sedation for radiographs Dr. Falch localized pain to the area of the m. psoas major. I attempted to answer her questions which led to questioning by Amie regarding my use of sedation in similar cases. It is absolutely fair to question anyone's comments, this is a discussion group! I attempted to support my statements with comments, personal opinions, and videos. Those are for you to accept or decline but I would prefer that they stimulate an open discussion. I am the only DVM who responded to Dr. Falch's questions, while 3 PTs participated in this discussion. Amie had specific question for me, raised question concerning the Dr. Falch's conclusions and you questioned the diagnosis and my statements. Again, all fair, but could you additionally answer at least some of Dr. Falch's questions and could you support the statements you make?I am always amazed when discussing muscle stretching how the golgi tendon organ and reflex predominate the discussion with little if any mention of all the other muscle components and reflexes. My questions:1.--------"I have never had a dog that, over time, and with a skilled hand, would not eventually allow a gradual lengthening, manually, of the muscle. In this way, the golgi tendon organs can return to a more normal response pattern, and help to return normal tone to the muscle."---------------So are you saying that the increased tone within a painful muscle is the result of improper Golgi Tendon firing resulting in decreased alpha-motor neuron inhibition? Could you discuss further?2.----------"Many humans have acute pain in the iliopsoas when the lumbar spine/disc are in a state of injury and inflammation. The neuro response of the muscle is upset when there is any compression of the nearby nerve root...and there is the protective reaction of the muscle as well."-------------Do you commonly find intervertebral disc disease in 2 year old labs? Could you explain the neuro response of the muscle you describe due to nerve root compression. I am familiar with the formation of MTrPs, thought to be due to the antidromic neuronal activity and the release of endogenous substance with vascular and cellular action "Neurogenic Inflammation". Is this what you are referring to?3.----------"Again...it seems that this dog should be assessed for a lumbar spine issue."-----------So if you are of the opinion that the pain localized by Dr. Falch's in the m. psoas major is secondary to another lumbar spine issue could you please list some of your differential considerations for acute lumbar pain in a 2 year old lab?Sincerely and with all professional respect,Rick Wall------------------------------------

[Guest guest]

,

I am glad to have your experienced input. There is no question that Dr. Falch's

patient should have a differential of IVDD, labs are one of the breeds that can

have both Hansen Type I and II. Either of these IVDD types could create myalgia

in the paraspinals due to neurogenic inflammation as well as the associated

neuropathic pain. I would probably expect to see a pain response in the dorsal

paraspinals along the spinal cord segment(s) involved but not always. Dr. Falch

did not mention neuro examination findings, I assume it was normal. However,

there is no contraindication to reducing the pain burden by treating the myalgia

even in suspected IVDD.

In the patient you mention did you refer for advanced imaging based on neuro

findings and pain are were your patients just painful?

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

[Guest guest]

,

1.

---------- " but I see this a common musculo-skeletal compensation around a gluten

impaction. If you are more interested " ------------------

The floor is yours!

2.

--------- " Most labs are highly grain sensitive, " -----------------

What is your evidence to support this statement. There is a breed related

gluten enteropathy reported in Irish Setters but I have not heard of any reports

in labs.

3.

--------- " kyphotic posture because of inflammation of the pancreas/kidney area

on the right " --------------

Do you have abnormal cPLI and/or TLI to support pancreatitis in these patients?

Have you measured cobalamin and folate?

4.

----------- " What can pinch the L3 - L4 nerve roots (neurogenic inflammation) and

can give a limp on the right rear, " -------------

Why just L3-L4? If you truly have visceral issues associated with gluten

impaction, as you have mentioned, how do you discern the myalgia related to

visceral-somatic pain vs. neurogenic inflammation related to radiculopathy?

Interesting statements, I look forward to your response!

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

[Guest guest]

Well, this was a few years ago and advanced imaging such as MRI and CT scans were not commonly available. The one I mentioned also presented with acute paresis--he was down in the rear, so I contacted the one surgeon I could depend on to be available to do an emergent surgical decompression. He performed a myelogram and surgery that night. In those days being presented with an acute disc could be tense--finding a qualified surgeon wasn't a slam dunk.c MillsVeterinarian and Science Writer5080 Riordan Hill RoadHood River, Oregon 97031 cynthmills@...Author of The Theory of Evolution: What it is, Where it came from, and Why it works; and articles for Discover, Health, Scientific American, Conservation and the Boston Globe. ,I am glad to have your experienced input. There is no question that Dr. Falch's patient should have a differential of IVDD, labs are one of the breeds that can have both Hansen Type I and II. Either of these IVDD types could create myalgia in the paraspinals due to neurogenic inflammation as well as the associated neuropathic pain. I would probably expect to see a pain response in the dorsal paraspinals along the spinal cord segment(s) involved but not always. Dr. Falch did not mention neuro examination findings, I assume it was normal. However, there is no contraindication to reducing the pain burden by treating the myalgia even in suspected IVDD. In the patient you mention did you refer for advanced imaging based on neuro findings and pain are were your patients just painful?Rick Wall, DVMCertified Canine Rehabilitation PractitionerDiplomate, American Academy of Pain ManagementCertified Myofascial Trigger Point TherapistCenter for Veterinary Pain Management and RehabilitationThe Woodlands, TXwww.vetrehabcenter.com------------------------------------

[Guest guest]

Hi Rick,

1) What I was trying to say is that with a muscle " strain " there is a different

message given to the golgi tendon organs than with a contracture due to

persistently holding the leg up due to another issue, or due to nerve root

compression/disc compression and protective holding of the muscle.

2) What is known as " intervertebral disc disease " in the veterinary world is

often diagnosed after the fact, after the disc has already been injured, and is

in the process of degeneration. Yes I have found disc injuries even in puppies,

in fact, more commonly seen than I would have expected. Usually I can trace it

back to an acute injury (being pounced upon, or a fall), but I would not negate

the power of a dog's diet to affect discs as well.

3) My offsite, and therefore, not clinical, thought about the lab comes from the

original post, which states:

" 2 y.o. lab...who acutely became painful with a hunched posture yesterday night.

He's so painful he does not want to eat. On exam in the clinic he did not allow

me to extend hips and was extremely guarded in the back. Direct back palpation

did not seem to ellicit much pain. He walks with his back end tucked and with a

'stiff' gait more pronounced on the left. " It goes on to state that he was

painful in the iliopsoas under sedation....?

At any rate, my first thought, given the above, is the spine. If the iliopsoas

is the only problem, I would expect perhaps unweighting of the leg, but not a

hunched posture and refusal to eat.

>

>

> Liz,

>

> I very much enjoy the multidiscipline environment of this discussion group. I

sincerely believe that veterinary rehabilitation has and will continue to

benefit from discussions, and sometimes debates, between DVMs, PTs, and RVTs. I

will always be very respectful of the skills that PTs bring to this discipline

and I remain excited about the future of rehabilitation due to cooperation.

Perhaps I am completely misinterpreting your comments but I find them somewhat

condescending. I am mistaken please accept my apology in advance and if not I

am fairly thick skinned and would still appreciate a discussion.

>

> The original question that sparked this discussion concerned a 2 year old Lab

with acute onset pain and kyphotic posture. While under sedation for

radiographs Dr. Falch localized pain to the area of the m. psoas major. I

attempted to answer her questions which led to questioning by Amie regarding my

use of sedation in similar cases. It is absolutely fair to question anyone's

comments, this is a discussion group! I attempted to support my statements with

comments, personal opinions, and videos. Those are for you to accept or decline

but I would prefer that they stimulate an open discussion.

>

> I am the only DVM who responded to Dr. Falch's questions, while 3 PTs

participated in this discussion. Amie had specific question for me,

raised question concerning the Dr. Falch's conclusions and you questioned the

diagnosis and my statements. Again, all fair, but could you additionally answer

at least some of Dr. Falch's questions and could you support the statements you

make?

>

> I am always amazed when discussing muscle stretching how the golgi tendon

organ and reflex predominate the discussion with little if any mention of all

the other muscle components and reflexes.

>

> My questions:

>

> 1.

>

> -------- " I have never had a dog that, over time, and with a skilled hand,

would not eventually allow a gradual lengthening, manually, of the muscle. In

this way, the golgi tendon organs can return to a more normal response pattern,

and help to return normal tone to the muscle. " ---------------

>

> So are you saying that the increased tone within a painful muscle is the

result of improper Golgi Tendon firing resulting in decreased alpha-motor

neuron inhibition? Could you discuss further?

>

> 2.

>

> ---------- " Many humans have acute pain in the iliopsoas when the lumbar

spine/disc are in a state of injury and inflammation. The neuro response of the

muscle is upset when there is any compression of the nearby nerve root...and

there is the protective reaction of the muscle as well. " -------------

>

> Do you commonly find intervertebral disc disease in 2 year old labs? Could

you explain the neuro response of the muscle you describe due to nerve root

compression. I am familiar with the formation of MTrPs, thought to be due to

the antidromic neuronal activity and the release of endogenous substance with

vascular and cellular action " Neurogenic Inflammation " . Is this what you are

referring to?

>

> 3.

>

> ---------- " Again...it seems that this dog should be assessed for a lumbar

spine issue. " -----------

>

> So if you are of the opinion that the pain localized by Dr. Falch's in the m.

psoas major is secondary to another lumbar spine issue could you please list

some of your differential considerations for acute lumbar pain in a 2 year old

lab?

>

> Sincerely and with all professional respect,

>

> Rick Wall

>

[Guest guest]

I'm sorry I've not been able to chime in on this due to the timing of a wonderful vacation.  This particular patient had lumbar radiographs that were normal.  Under sedation the pain was strong when I palpated a tight band on the left iliopsoas muscle.  He did not show pain on lumbar back palpation as I typically see with IVD.  He did resist extension of either hip when unsedated.  The owners of this dog were leaving for vacation and could not come back in for a week so I placed him on rest and Rimadyl after treating with laser and gentle stretch at the clinic.  He should be coming back this Friday for follow up.

Questions:  If it's an acute iliopsoas injury wouldn't extending either hip stretch the painful muscle causing him to guard both?  If not please explain as I really want to be accurate in diagnosing so I can treat effectively.

 Other than x-rays and palpation of back how else due you differentiate iliopsoas injury from IVD.  Please note he had absolutely no pain response on the other side when extending that hip or palpating the iliopsoas under sedation. 

This is a very athletic dog young dog and I think IVD would be uncommon with normal neuro. exam, x-rays, and lack of response on lumbar palpation. I love all the discussion from all parties and am fascinated to learn more about how different disciplines assess a patient.  It would be helpful though if some of the questions asked are answered as well. 

Liz,

I very much enjoy the multidiscipline environment of this discussion group.  I sincerely believe that veterinary rehabilitation has and will continue to benefit from discussions, and sometimes debates, between DVMs, PTs, and RVTs.  I will always be very respectful of the skills that PTs bring to this discipline and I remain excited about the future of rehabilitation due to cooperation.  Perhaps I am completely misinterpreting your comments but I find them somewhat condescending.  I am mistaken please accept my apology in advance and if not I am fairly thick skinned and would still appreciate a discussion.

The original question that sparked this discussion concerned a 2 year old Lab with acute onset pain and kyphotic posture.  While under sedation for radiographs Dr. Falch localized pain to the area of the m. psoas major.  I attempted to answer her questions which led to questioning by Amie regarding my use of sedation in similar cases.  It is absolutely fair to question anyone's comments, this is a discussion group!  I attempted to support my statements with comments, personal opinions, and videos.  Those are for you to accept or decline but I would prefer that they stimulate an open discussion.

I am the only DVM who responded to Dr. Falch's questions, while 3 PTs participated in this discussion.  Amie had specific question for me, raised question concerning the Dr. Falch's conclusions and you questioned the diagnosis and my statements.  Again, all fair, but could you additionally answer at least some of Dr. Falch's questions and could you support the statements you make?

I am always amazed when discussing muscle stretching how the golgi tendon organ and reflex predominate the discussion with little if any mention of all the other muscle components and reflexes.

My questions:

1.

-------- " I have never had a dog that, over time, and with a skilled hand, would not eventually allow a gradual lengthening, manually, of the muscle. In this way, the golgi tendon organs can return to a more normal response pattern, and help to return normal tone to the muscle. " ---------------

So are you saying that the increased tone within a painful muscle is the result of improper Golgi Tendon firing  resulting in decreased alpha-motor neuron inhibition?  Could you discuss further?

2.

---------- " Many humans have acute pain in the iliopsoas when the lumbar spine/disc are in a state of injury and inflammation. The neuro response of the muscle is upset when there is any compression of the nearby nerve root...and there is the protective reaction of the muscle as well. " -------------

Do you commonly find intervertebral disc disease in 2 year old labs?  Could you explain the neuro response of the muscle you describe due to nerve root compression.  I am familiar with the formation of MTrPs, thought to be due to the antidromic neuronal activity and the release of endogenous substance with vascular and cellular action " Neurogenic Inflammation " .  Is this what you are referring to?

3.

---------- " Again...it seems that this dog should be assessed for a lumbar spine issue. " -----------

So if you are of the opinion that the pain localized by Dr. Falch's in the m. psoas major is secondary to another lumbar spine issue could you please list some of your differential considerations for acute lumbar pain in a 2 year old lab?

Sincerely and with all professional respect,

Rick Wall

------------------------------------

[Guest guest]

,

Wow, you start this discussion and then disappear, on vacation no less! (Hope

you had a good time).

--------- " Under sedation the pain was strong when I palpated a tight band on the

left iliopsoas muscle. " ------------------

--------- " Please note he had absolutely no pain response on the other side when

extending that hip or palpating the iliopsoas under sedation. " --------------

Is one of these a TYPO?

Rick Wall

>

[Guest guest]

Sorry if I was unclear.  The first statement was the pain I found on the LEFT side under sedation.  On the RIGHT side I found none under sedation.  My thought was that the refusal to extend either hip while awake might be guarding while under sedation (dxdomitor/torb) I was possibly better able to localize the pain.

,

Wow, you start this discussion and then disappear, on vacation no less! (Hope you had a good time).

--------- " Under sedation the pain was strong when I palpated a tight band on the left iliopsoas muscle. " ------------------

--------- " Please note he had absolutely no pain response on the other side when extending that hip or palpating the iliopsoas under sedation. " --------------

Is one of these a TYPO?

Rick Wall

>

------------------------------------

[Guest guest]

,

Unless I read the posts wrong (they are a little tough to follow) you used

Dexmeditomidine (an alpha -2 agonist) and butorphanol (an opiod

agonist/antagonist). The combination offers mild to moderate analgesic effects

as well as sedative. It is interesting that you got pain from a strain with this

combination. On the other hand, I would expect pain on manipulation with this

drug combination with a disc issue.

ph A. DeLucia DVM, CCRP

Director of Rehabilitation Services- Valley Animal Hospital

1171 Valley Road

Clifton, New Jersey 07013

ext. 303

drd@...

Veterinary MRI and RT Center of NJ

1071 ison Avenue

CLifton, New Jersey 07011

drd@...

[Guest guest]

I admit I have not ruled out a disc in this dog but am having trouble figuring out the best way to differentiate these two conditions, especially when I got no pain on back palpation.  The only other case of iliopsoas strain I saw was in a world class agility dog who was a little off at times.  This dog was also painful when palpated in the area of pain under sedation with dxdomitor/torb and definitely did not have a disc.  Are strains of this muscle usually not painful under this sedation?  I only have an N of 1 to compare too.

Also under sedation this dog had the largest pain response on palpation of the left iliopsoas muscle.  I also got pain with extension of the hip and internal rotation but not as great as on direct palpation. Review of exam  -

2 year old M/N 70# athletic labrador retriever.  Presented with acute pain and decreased appetite starting the night before I saw him.   No known episode of trauma or yelping when running outside but not always watched when outside.  On exam he had a hunched posture in the lumbar spine with a tucked tail position.  He did not like manipulation of his tail but no swelling or pain noticed at the base.  No pain noted on back palpation.  Anal glands - empty.  CPs were normal.  He resisted any extension of either hip.  When watching him walk he was stiffer on the left HL with a shortened stride.

Sedation was performed with 0.3 ml of dxdomitor and 0.3 ml of torb IV.  Under sedation x-rays were done and looked normal of hips and lumbar spine. Under sedation he had marked pain on palpation of the left iliopsoas with a MTrP felt.  When palpating the MTrP he was painful and would flinch all the way down to prepuce.  He was painful on extension of the left hip under sedation as well.  He did not show pain on extension of the right hip or palpation of the right iliopsoas under sedation. 

Questions:If this is a disc should I have seen pain on extension of both hips under sedation?Are iliopsoas muscle strains usually not painful with sedation I used?  (as I mentioned above I only have an N of 1 to compare to)

Can you see reluctance to extend both hips with a one sided acute strain?  (if this is uncommon this already makes a disc more likely)What kind of gait to you tend to see with an acute painful strain vs a disc? 

I would really love to improve my skills at differentiating these two conditions.  Thanks again for any help. Falch, DVM

 

,

Unless I read the posts wrong (they are a little tough to follow) you used Dexmeditomidine (an alpha -2 agonist) and butorphanol (an opiod agonist/antagonist). The combination offers mild to moderate analgesic effects as well as sedative. It is interesting that you got pain from a strain with this combination. On the other hand, I would expect pain on manipulation with this drug combination with a disc issue.

ph A. DeLucia DVM, CCRP

Director of Rehabilitation Services- Valley Animal Hospital

1171 Valley Road

Clifton, New Jersey 07013

ext. 303

drd@...

Veterinary MRI and RT Center of NJ

1071 ison Avenue

CLifton, New Jersey 07011

drd@...

[Guest guest]

,

Sorry, my mistake, I misread your post.

----------- " If it's an acute iliopsoas injury wouldn't extending either hip

stretch the painful muscle causing him to guard both? " ------------

Potentially because it is hard to extend the coxofemoral joint without creating

some degree of hyperextension of the lumbar and lumbosacral spine, but I can

usually appreciate a difference in the painful side. I don't use coxofemoral

extension much as a diagnostic tool because it simply can elicit a pain response

for several different issues and is just not specific.

While I know that their have been varying opinions I think that acute injury to

the iliopsoas must be at the top of the list of differentials in your patient

due to age, history, clinical findings, etc. It is never wrong to treat pain,

it appears that you have adequately localized it and directed therapy in that

area. It will be interesting to see how your patient is doing after a period of

rest. Regarding how to more accurately diagnose acute injury in the iliopsoas

complex - it is my opinion that musculoskeletal u/s will probably become the

standard in years to come. Alterations in size and muscle architecture will

discern strain from tears and MTrPs will be identified as well. MSKUS will also

enable the accurate delivery of things like platelet rich plasma to injured

tissues to hasten the healing process. MSKUS does require a really good machine

with features that aide in musculoskeletal work. CT scan has been used but do

to costs and availability I do not see this becoming a widely accepted tool for

diagnosis of iliopsoas injury. I am attaching 3 articles that you might be of

interest.

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

3 of 3 File(s)

CT features of suspect trauma to iliopsoas.pdf

Ultrasonographic Eval of Iliopsoas.pdf

U:S Sonoelastic.pdf

[Guest guest]

> If this is a disc should I have seen pain on extension of both hips under

> sedation?

Does not necessarily have to be a disc. There are other disease processes that

occur in the L-S area.

> Are iliopsoas muscle strains usually not painful with sedation I used? (as

> I mentioned above I only have an N of 1 to compare to)

I would not expect a pain response unless you have severe strain. That said, one

of my professors told me that absence of evidence is not evidence of absence.

> Can you see reluctance to extend both hips with a one sided acute strain?

I would expect not unless you are inadvertently pulling while cranking hard

without good immobilization of the affected side.

> What kind of gait to you tend to see with an acute painful strain vs a

> disc?

As I said, may not be a disc.

The IS (iliopsoas) is a fusion of the Psoas Major and Iliacus The IS muscle has

diverse actions. When the femur is fixed in normal position, you obtain flexion

and fixation of the vertebral column. When the leg is extended backward, the

trunk is drawn backwards. I would therefore expect reluctance to movement of

these specific actions in a strain (history should also indicate a per acute

onset). I like to place the limb in both these positions (w/o NSAIDs and pain

modulation) and observe if there is any compromise in the aforementioned actions

(observation first). Palpation-wise, I would expect to get pain either at the

trochanter minor (lesser) of the femur or pain on aggressive palpation of the of

the area of the arcuate line of the ilium and/or the transverse processes of

lumbar vertebrae 2 through 7 without movement. I would also expect a firm muscle

mass due to spasm from guarding (the muscle is fairly easy to isolate).

I would not expect any neurological symptoms (disc). If one has pain with a

disc, I would also expect neuro compromise in performing your neuro exam.

>

> I would really love to improve my skills at differentiating these two

> conditions. Thanks again for any help.

Ultimately , cross sectional imaging would aid in not only differentiating

these two conditions (you can see muscle strain quite nicely on a T2 weighted MR

scan) , but also include ruling out the other disease processes of the area.

Hope that helps a little.

>

> Falch, DVM

> > ph A. DeLucia DVM, CCRP

> > Director of Rehabilitation Services- Valley Animal Hospital

> > 1171 Valley Road

> > Clifton, New Jersey 07013

> > ext. 303

> > drd@...

> > Veterinary MRI and RT Center of NJ

> > 1071 ison Avenue

> > CLifton, New Jersey 07011

> >

> > drd@...

[Guest guest]

How do you diagnose iliopsoas problems? Musculoskeletal ultrasound allows us to

look at and inside the muscle. This is a sagital view of the m. psoas major.

In this view measurements can be made and color flow doppler can be used to

determine increase blood flow. Following localization of pain, ultrasound

findings can help to localize pathology

Rick Wall

1 of 1 File(s)

PastedGraphic-1.pdf

[Guest guest]

Have you tried/had any success with therapeutic ultrasound for these primary iliopsoas strains? (MRI ruled out other causes)

n Shuler Holladay, DVM, CCRP

From: "VetRehab " <VetRehab >To: VetRehab Sent: Monday, January 2, 2012 4:58 AMSubject: Digest Number 1630

Vet Rehab Professionals

Messages In This Digest (1 Message)

1.1.

Re: Iliopsoas strain [1 Attachment] From: Rick Wall, DVM

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1.1.

Re: Iliopsoas strain [1 Attachment]

Posted by: "Rick Wall, DVM" drwall@... drwallrwall

Sun Jan 1, 2012 6:37 pm (PST)

Correction, the u/s image on my previous post is a transverse view not sagittal forgot to change heading from a previous powerpoint slide.Rick Wall

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[Guest guest]

n,

We have not used therapeutic u/s for these problems, perhaps others have.

Rick Wall