MSI or Teres major? diagnosis, and treatment

[Guest guest]

Hi All, I am seeing a 5 year old very active Australian Shepherd who has an 8 mo history of intermittant forelimb lameness; I actually saw the dog a while ago for hip dysplasia and we did several months of  HL strengthening exercises and swimming. At that time he was occasionally slighly lame in front but I guess we did not think that much of it. A few months ago he worsened; rDVM took shoulder and elbow rads which were judged unremarkable then the dog was sent to a local surgeon, who diagnosed MSI and referred the dog to me telling the owner to try two months of rehab and if that did not work he would do surgery (for the MSI) consisting of stabilizing the shoulder with a figure 8 wire.

 I asked the surgeon what degree of abduction he had gotten (he had the dog sedated) so I could decide if this were a mild, moderate or severe MSI and thereby decide if the dog were a candidate for radiosurgery that Sherman Canapp does. The surgeon told me he did not use a goniometer but thought the abduction angle was about 60. The dog's limp is pretty mild, and intermittant (responds to rest) so I thought that sounded extreme. So myself and the PT I worked with examined the dog and, with both owners holding and two of us measuring, we got 50 degrees on the left (the affected limb) and 55 on the right. There is significant pain on the left at end range, none on the right. This led us to speculate that the dog simply has the very loose shoulders characteristic of herding breeds and we can't use shoulder abduction angle alone to diagnose  MSI. Of course the fact that the lame leg does not seem to have a greater angle than the good leg does not support MSI, does it? Then we were palpating the dog in standing and got a tremendous, and reproducible, pain response in the caudal proximal humerus region. Which led us to think this is a teres major strain, which we have heard of but never seen.

 So my question: is there anything else I can do or check to confirm this? If it's not MSI, I don't think the dog needs hobbles and he certainly doesn't need surgery. And if teres major, any tips on rehab protocol?

 Pam Mueller PhD DVM CCRT (one of these days)Animal Therapy Center, Bethlehem PA

[Guest guest]

Pam,

Great questions! It sounds like a teres major strain based on your description.

I would recommend a musculoskeletal ultrasound to confirm. I also agree hobbles

would not be indicated in this case. While the abduction angles described by

Cook et al. 2005 Vet Surg is a good starting point, it unfortunately does not

always correlate with the pathology found arthroscopically (Devitt, Vet Surg).

In other-words, you can have an abduction angle of 35 degrees with significant

disruption of the subscapularis, MGL, cranial capsule, labrum, etc…..you can

also have an abduction angle of 55 degrees with normal pathology (may be

increased due to atrophy or may just be normal for that particular dog). Most

sensitive finding, what is the angle compared to the contralateral (again we do

these awake and unsedated), and is there spasm or discomfort on abduction?

Rarely do we recognize a true subluxation or luxation…..these cases are not

truly " unstable " they have pathology (tendinopathies, sprain, disruption, labral

pathology, etc)……we have therefore been referring to these cases as a " medial

shoulder syndrome or MSS " vs medial shoulder instability or MSI. We are

currently in the process of writing up a series of over 500 cases (2005-2011)

for vet surg and redefining the condition, terminology, etc.

Hope that helps a bit.

Best,

Sherman

Sherman O. Canapp Jr., DVM, MS, CCRT

Diplomate, American College of Veterinary Surgeons

Diplomate, American College of Veterinary Sports Medicine & Rehabilitation

Chief of Staff

Veterinary Orthopedic &

Sports Medicine Group

10975 Guilford Road

polis Junction, MD 20701

Phone:

Fax:

http://www.vosm.com

>

> Hi All,

> I am seeing a 5 year old very active Australian Shepherd who has an 8 mo

> history of intermittant forelimb lameness; I actually saw the dog a while

> ago for hip dysplasia and we did several months of HL strengthening

> exercises and swimming. At that time he was occasionally slighly lame in

> front but I guess we did not think that much of it. A few months ago he

> worsened; rDVM took shoulder and elbow rads which were judged unremarkable

> then the dog was sent to a local surgeon, who diagnosed MSI and referred

> the dog to me telling the owner to try two months of rehab and if that did

> not work he would do surgery (for the MSI) consisting of stabilizing the

> shoulder with a figure 8 wire.

>

> I asked the surgeon what degree of abduction he had gotten (he had the dog

> sedated) so I could decide if this were a mild, moderate or severe MSI and

> thereby decide if the dog were a candidate for radiosurgery that Sherman

> Canapp does. The surgeon told me he did not use a goniometer but thought

> the abduction angle was about 60. The dog's limp is pretty mild, and

> intermittant (responds to rest) so I thought that sounded extreme. So

> myself and the PT I worked with examined the dog and, with both owners

> holding and two of us measuring, we got 50 degrees on the left (the

> affected limb) and 55 on the right. There is significant pain on the left

> at end range, none on the right. This led us to speculate that the dog

> simply has the very loose shoulders characteristic of herding breeds and we

> can't use shoulder abduction angle alone to diagnose MSI. Of course the

> fact that the lame leg does not seem to have a greater angle than the good

> leg does not support MSI, does it? Then we were palpating the dog in

> standing and got a tremendous, and reproducible, pain response in the

> caudal proximal humerus region. Which led us to think this is a teres major

> strain, which we have heard of but never seen.

>

> So my question: is there anything else I can do or check to confirm this?

> If it's not MSI, I don't think the dog needs hobbles and he certainly

> doesn't need surgery. And if teres major, any tips on rehab protocol?

>

> Pam Mueller PhD DVM CCRT (one of these days)

> Animal Therapy Center, Bethlehem PA

>

> >

> >

>

[Guest guest]

> >

> > Hi All,

> > I am seeing a 5 year old very active Australian Shepherd who has an 8 mo

> > history of intermittant forelimb lameness; I actually saw the dog a while

> > ago for hip dysplasia and we did several months of HL strengthening

> > exercises and swimming. At that time he was occasionally slighly lame in

> > front but I guess we did not think that much of it. A few months ago he

> > worsened; rDVM took shoulder and elbow rads which were judged unremarkable

> > then the dog was sent to a local surgeon, who diagnosed MSI and referred

> > the dog to me telling the owner to try two months of rehab and if that did

> > not work he would do surgery (for the MSI) consisting of stabilizing the

> > shoulder with a figure 8 wire.

> >

> > I asked the surgeon what degree of abduction he had gotten (he had the dog

> > sedated) so I could decide if this were a mild, moderate or severe MSI and

> > thereby decide if the dog were a candidate for radiosurgery that Sherman

> > Canapp does. The surgeon told me he did not use a goniometer but thought

> > the abduction angle was about 60. The dog's limp is pretty mild, and

> > intermittant (responds to rest) so I thought that sounded extreme. So

> > myself and the PT I worked with examined the dog and, with both owners

> > holding and two of us measuring, we got 50 degrees on the left (the

> > affected limb) and 55 on the right. There is significant pain on the left

> > at end range, none on the right. This led us to speculate that the dog

> > simply has the very loose shoulders characteristic of herding breeds and we

> > can't use shoulder abduction angle alone to diagnose MSI. Of course the

> > fact that the lame leg does not seem to have a greater angle than the good

> > leg does not support MSI, does it? Then we were palpating the dog in

> > standing and got a tremendous, and reproducible, pain response in the

> > caudal proximal humerus region. Which led us to think this is a teres major

> > strain, which we have heard of but never seen.

> >

> > So my question: is there anything else I can do or check to confirm this?

> > If it's not MSI, I don't think the dog needs hobbles and he certainly

> > doesn't need surgery. And if teres major, any tips on rehab protocol?

> >

> > Pam Mueller PhD DVM CCRT (one of these days)

> > Animal Therapy Center, Bethlehem PA

> >

> > >

> > >

> >Just an aside - I thought I learned somewhere along the way that dogs do not

have a labrum. Wrong information?

Sammi Flynn DVM, CVA, CVC, CVCH

>

[Guest guest]

With the question about the labrum of the dog, here is an article for all to enjoy. It's a big one because of pictures but is available free of charge and via pubmed central. For those of you who

don't know pubmed central is a search database that lists only articles that are available to the general public free of charge.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2771608/?tool=pubmed

The article is about the anatomic comparison between the human and canine glenoid labrum. Enjoy

, VMD, CCRP

Veterinary Orthopedic Sports Medicine Group

https://www.VOSM.com

From: VetRehab [VetRehab ] On Behalf Of onceagainfarm [live2ride@...]

Sent: Monday, November 14, 2011 7:33 PM

To: VetRehab

Subject: Re: MSI or Teres major? diagnosis, and treatment

> >

> > Hi All,

> > I am seeing a 5 year old very active Australian Shepherd who has an 8 mo

> > history of intermittant forelimb lameness; I actually saw the dog a while

> > ago for hip dysplasia and we did several months of HL strengthening

> > exercises and swimming. At that time he was occasionally slighly lame in

> > front but I guess we did not think that much of it. A few months ago he

> > worsened; rDVM took shoulder and elbow rads which were judged unremarkable

> > then the dog was sent to a local surgeon, who diagnosed MSI and referred

> > the dog to me telling the owner to try two months of rehab and if that did

> > not work he would do surgery (for the MSI) consisting of stabilizing the

> > shoulder with a figure 8 wire.

> >

> > I asked the surgeon what degree of abduction he had gotten (he had the dog

> > sedated) so I could decide if this were a mild, moderate or severe MSI and

> > thereby decide if the dog were a candidate for radiosurgery that Sherman

> > Canapp does. The surgeon told me he did not use a goniometer but thought

> > the abduction angle was about 60. The dog's limp is pretty mild, and

> > intermittant (responds to rest) so I thought that sounded extreme. So

> > myself and the PT I worked with examined the dog and, with both owners

> > holding and two of us measuring, we got 50 degrees on the left (the

> > affected limb) and 55 on the right. There is significant pain on the left

> > at end range, none on the right. This led us to speculate that the dog

> > simply has the very loose shoulders characteristic of herding breeds and we

> > can't use shoulder abduction angle alone to diagnose MSI. Of course the

> > fact that the lame leg does not seem to have a greater angle than the good

> > leg does not support MSI, does it? Then we were palpating the dog in

> > standing and got a tremendous, and reproducible, pain response in the

> > caudal proximal humerus region. Which led us to think this is a teres major

> > strain, which we have heard of but never seen.

> >

> > So my question: is there anything else I can do or check to confirm this?

> > If it's not MSI, I don't think the dog needs hobbles and he certainly

> > doesn't need surgery. And if teres major, any tips on rehab protocol?

> >

> > Pam Mueller PhD DVM CCRT (one of these days)

> > Animal Therapy Center, Bethlehem PA

> >

> > >

> > >

> >Just an aside - I thought I learned somewhere along the way that dogs do not have a labrum. Wrong information?

Sammi Flynn DVM, CVA, CVC, CVCH

>

[Guest guest]

> > >

> > > Hi All,

> > > I am seeing a 5 year old very active Australian Shepherd who has an 8 mo

> > > history of intermittant forelimb lameness; I actually saw the dog a while

> > > ago for hip dysplasia and we did several months of HL strengthening

> > > exercises and swimming. At that time he was occasionally slighly lame in

> > > front but I guess we did not think that much of it. A few months ago he

> > > worsened; rDVM took shoulder and elbow rads which were judged unremarkable

> > > then the dog was sent to a local surgeon, who diagnosed MSI and referred

> > > the dog to me telling the owner to try two months of rehab and if that did

> > > not work he would do surgery (for the MSI) consisting of stabilizing the

> > > shoulder with a figure 8 wire.

> > >

> > > I asked the surgeon what degree of abduction he had gotten (he had the dog

> > > sedated) so I could decide if this were a mild, moderate or severe MSI and

> > > thereby decide if the dog were a candidate for radiosurgery that Sherman

> > > Canapp does. The surgeon told me he did not use a goniometer but thought

> > > the abduction angle was about 60. The dog's limp is pretty mild, and

> > > intermittant (responds to rest) so I thought that sounded extreme. So

> > > myself and the PT I worked with examined the dog and, with both owners

> > > holding and two of us measuring, we got 50 degrees on the left (the

> > > affected limb) and 55 on the right. There is significant pain on the left

> > > at end range, none on the right. This led us to speculate that the dog

> > > simply has the very loose shoulders characteristic of herding breeds and

we

> > > can't use shoulder abduction angle alone to diagnose MSI. Of course the

> > > fact that the lame leg does not seem to have a greater angle than the good

> > > leg does not support MSI, does it? Then we were palpating the dog in

> > > standing and got a tremendous, and reproducible, pain response in the

> > > caudal proximal humerus region. Which led us to think this is a teres

major

> > > strain, which we have heard of but never seen.

> > >

> > > So my question: is there anything else I can do or check to confirm this?

> > > If it's not MSI, I don't think the dog needs hobbles and he certainly

> > > doesn't need surgery. And if teres major, any tips on rehab protocol?

> > >

> > > Pam Mueller PhD DVM CCRT (one of these days)

> > > Animal Therapy Center, Bethlehem PA

> > >

> > > >

> > > >

> > >Just an aside - I thought I learned somewhere along the way that dogs do

not have a labrum. Wrong information?

>

> Sammi Flynn DVM, CVA, CVC, CVCH

Hi ,

Thanks lots for the terrific article! I looked back in my intro to rehab class

notes and that was where it was mentioned in a table comparing the differences

between human and canine shoulder. One of the points was " canine shoulder-no

labrum " . Guess they didn't want to go into the details. Again, your article is

a great source of information.

Sammi Flynn

"

> >

>