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Companion animal practice

Investigation of lameness in dogs

2. Hindlimb

Philip Witte and Harry Scott

Hindlimb lameness is seen significantly more frequently than forelimb

lameness at the authors’ clinic. Lameness in the hindlimb is commonly
associated with the stifle (cranial cruciate ligament disease) and the hip
Philip Witte graduated from (hip dysplasia). Due to the predominance of certain conditions, it is easy
Bristol in 2005. He spent two to become complacent when diagnosing hindlimb lameness. A thorough
years working in mixed general investigation must be performed to avoid incorrect diagnosis, even in cases
practice in Herefordshire followed where radiographic signs are suggestive of a specific condition. For example,
by six months working with radiographic signs indicative of osteoarthritis of the hip correlate poorly
Cape buffaloes in South Africa. with clinical signs and should be treated as an incidental finding in the
He subsequently completed an absence of other signs of hip joint pain. This article describes an approach
internship in surgery at Southern to investigating hindlimb lameness in dogs. An article in the January issue
Counties Veterinary Specialists, of In Practice (volume 33, pp 20-27) discussed how to investigate lameness
where he is now an orthopaedic in the forelimb.
resident. He is currently working
towards the RCVS certificate in
advanced veterinary practice
(small animal surgery). Signalment injury, such as cranial cruciate ligament rupture and/
or meniscal injury. Severe lameness is unlikely to be
As discussed in Part 1, signalment can help to formu- seen in a dog with more chronic disorders, including
late a list of differential diagnoses. However, it can osteoarthritis (OA), secondary to hip dysplasia. Dogs
also suggest the priority in which particular condi- with hip dysplasia and mild subluxation may be more
tions should be considered in the investigation. For comfortable standing with the feet apart in a wide-
example, in a young small breed dog presented with based stance, while animals with severe subluxation
hindlimb lameness and resentment of hip extension, will be more comfortable with the feet placed together
Legg-Calvé-Perthes disease would be a likely diagno- in a narrow-based stance. Following initial observa-
sis, but in a large breed dog of a similar age hip dyspla- tion, the dog should also be made to perform some
sia may be a more likely cause. simple manoeuvres in the consulting room such as
sit-to-stand and lie-to-stand. Dogs with hip dysplasia
Harry Scott graduated from
and lumbosacral disease will typically have difficulty
Liverpool in 1977. He worked
in small animal general practice
History rising from a sitting or lying position. Dogs with stifle
and, to a lesser extent, hock pathology may display a
and completed certificates in
dermatology and orthopaedics
As with forelimb lameness, the progression of hind- positive ‘sit test’ (see Box 1).
followed by a fellowship by limb lameness will also influence how the list of dif- The purpose of gait analysis is to determine the
examination in canine spinal ferential diagnoses is formulated. affected limb and the severity of lameness. Gait analy-
surgery. Since 1999, he has sis is performed at a walk and a trot until the exam-
worked in referral practice both in iner is satisfied that the lame limb has been identified.
the UK and abroad, and is currently Gait examination Initial observation of the patient at a slow walk is
head of orthopaedics at Southern preferable because it is easier to evaluate each limb
Counties Veterinary Specialists. He Following a thorough general examination, initial individually. By placing the hands over the dog’s hips
holds the RCVS diploma in small orthopaedic assessment should include observation of during walking (Fig 1), it may be possible to palpate
animal surgery (orthopaedics) the dog’s gait and stance (orthopaedic examination of the ‘clunking’ that occurs with subluxation and reduc-
and is an RCVS specialist in small the hindlimb in dogs will be discussed in more detail
animal surgery (orthopaedics). He in an article to be published in the April 2011 issue
has recently become a certified of In Practice). Dogs with bilateral hindlimb lameness Box 1: Sit test
canine rehabilitation practitioner. will shift their centre of gravity cranially to transfer Dogs with stifle joint pain and, to a lesser extent, hock
weight to the forelimbs by standing with the hind- joint pathology will be unwilling to sit squarely on their
limbs tucked under the body and arching the back. In haunches with the affected stifle and hock joints fully
severe cases, the degree of kyphosis in dogs with bilat- flexed and will typically either sit in a raised position or
eral hindlimb lameness may mimic the appearance of adopt a posture whereby they sit on one hip with the
affected stifle/hock in a more comfortable extended
a dog with thoracolumbar spinal pain. Unilateral toe
position.
doi:10.1136/inp.d453 touching lameness is more typical of an acute/subacute

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Companion animal practice

Table 1: Grading lameness at a walk and trot

Grade Description
0 (None) No lameness is observed at a walk or trot
1 (Mild) Lameness is present, but may only be consistently apparent at a trot
2 (Mild to moderate) Mild lameness is obviously present at a walk and is worse at a trot
3 (Moderate) Obvious lameness is present at both gaits
4 (Moderate to severe) Obvious lameness is present at both gaits and may be intermittently
non-weightbearing
5 (Severe) Lameness is non-weightbearing most or all of the time
Grading lameness can be useful for monitoring changes in the severity of lameness over time,
and may also be indicative of the condition involved

bosacral disc disease and the location of ascending

Fig 1: By walking behind the dog with the hands on its neurological tracts. If hindlimb ataxia is suspected,
hips during gait analysis, the observer should be able
to palpate any subluxation and reduction of dysplastic a thorough neurological assessment should be per-
hips formed. History-taking should involve questions relat-
ing to urination and defecation, as well as hindlimb
tion of an unstable dysplastic hip during the stance coordination, especially scuffing of the claws or cross-
and swing phases of each step. When performing this ing of the legs when walking or trotting. It is worth
test, it is important to distinguish between ‘clunking’ noting that, although dogs may vocalise in other ways,
originating in the hip joints and crepitus, which may yelping is not a feature that is usually seen in cases
be referred along the femora from abnormal stifles. with OA. Unprovoked yelping generally indicates pain
Mild lameness cannot always be detected when a of neurological origin, and warrants thorough and
dog is walking but may become more apparent when prompt neurological investigation.
it is made to trot, as more force is placed on the limbs
at greater velocity. However, differentiation between
fore- and hindlimb lameness may be more difficult at Physical examination
a trot. In contrast to the head movement seen in dogs
with forelimb lameness, although less marked, the Following gait examination, the examiner should
head will tend to nod down when the affected hindlimb know which limb(s) is/are affected. Physical exami-
contacts the ground as the dog attempts to redistribute nation of the affected limb should be performed in
weight to the forequarters using the head and neck as conjunction with examination of the contralateral
a counterbalance. In more severe cases, particularly limb (but beware of bilateral lameness). Examination
at greater speed, lameness may manifest as a ‘bunny should be performed in a systematic and consistent
hopping’ gait in which animals move both hindlimbs manner (eg, from distal to proximal) to make sure that
simultaneously in adduction. This gait, which reduces nothing is missed. The contralateral limb should be
weightbearing by each individual hindlimb and also palpated first so that the dog becomes accustomed to
reduces extension of the hip joints, is often associ- being handled before any painful areas are touched.
ated with severe hip dysplasia. Observation at faster The purpose of the physical examination is to localise
gaits (canter and gallop) may be performed in selected the affected area of the joint or long bone.
cases but is less useful because the speed of movement
makes it difficult to assess the motion of individual Palpation of musculature
limbs. Following gait analysis, the severity of the lame- Palpation for muscle atrophy should always include
ness should be graded (see Part 1, and Table 1, above the gluteal muscles, the quadriceps and the hamstrings
right). (biceps femoris, semimembranosus and semitendino-
Neurological deficits are seen more commonly in sus muscles). Disuse (or reduced use) atrophy will pro-
the hindlimbs than the forelimbs, largely as a conse- duce a palpable asymmetry in the musculature within a
quence of the frequency of thoracolumbar and lum- few weeks. Muscle mass is generally slower to recover,
and apparently normal animals will frequently show
atrophy for a number of months following apparent
Box 2: Key visual signs of hindlimb resolution of lameness as muscle bulk returns. In gen-
lameness eral, the muscles that are most vulnerable to atrophy
are antigravity muscles that cross a single joint such
■■ Stride/step alterations as the quadriceps (excluding the rectus femoris which
●● Short-stepping (‘limp’)
crosses the hip and stifle joints). Muscles that are least
●● Ratio of stance to swing portion
vulnerable to atrophy are flexor muscles that cross
■■ Gluteal musculature
●● Jerking upward during weightbearing
more than one joint such as the hamstrings.
■■ Altered limb movement
●● Circumduction Palpation of bones
●● High-stepping versus claw scuffing An attempt should always be made to differentiate
■■ Altered limb placement bone pain from surrounding soft tissue or adjacent
●● External rotation
joint pain. Bone conformation should be assessed visu-
●● Internal rotation
ally and by palpation, although imaging, particularly

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computed tomography (CT), is more useful for inves- pain as well as those with hip pain, while hindlimb
tigating angular deformity or torsion. Femoral confor- abduction will generally not be resented by a dog with
mation is significant in the aetiology of medial patellar lumbosacral disease (unless there is concurrent hip OA).
luxation (genu varum) and lateral patellar luxation Many dogs appear to function reasonably well despite
(genu valgum). Although other sites can be affected, relatively advanced coxofemoral joint OA, but show
swelling and discomfort at the distal femur or proxi- severe resentment to attempted hip joint extension. It
mal tibia in an adult dog warrants further assessment is therefore prudent to perform hip joint manipulation
for bone neoplasia. A marked pain response on palpa- slowly and gently. Three manoeuvres commonly used
tion of bone is a feature of panosteitis, which is seen for assessing laxity of the hip joint in young dogs are
predominantly in juvenile German shepherd dogs. the Barden sign (‘hip-lift test’), Barlow sign and the
Ortolani sign (see Boxes 3, 4, 5). Sedation or general
Palpation of joints anaesthesia is usually required to perform these tests
Effusion may be palpable, obscuring the definition adequately as pain and muscle spasm will detract from
of the straight patellar ligament in the stifle and cir- their value in the conscious animal. These tests are of
cumferentially at all levels of the tarsal joints. In con- limited value in dogs with complete luxation of the hip
trast, hip joint effusion is not appreciable by palpation. joints or in dogs with advanced OA.
Harder thickenings indicative of chronic conditions Consideration of iliopsoas strain should be made in
may be apparent at, for example, the proximal medial dogs that resent hip extension, abduction and internal
tibia in cases of long-standing cranial cruciate liga-
ment disease (‘medial buttress’). Avulsion fractures
of the medial or lateral malleolus may be associated Box 3: Barden sign
with substantial firm swelling, often accompanied
by crepitus and discomfort on palpation. Firm dig- With the dog in lateral recumbency, the uppermost
ital palpation should be repeated to consistently elicit thigh should be grasped with one hand and lifted
laterally without abduction, while the thumb or
resentment until the examiner is satisfied that the
forefinger of the other hand is placed on the greater
location of the source of discomfort has been correctly trochanter. A positive Barden sign is elicited when the
identified. thumb or forefinger is elevated more than 4 to 6 mm.

Manipulation of joints
Joint manipulation is likely to be the most uncom- Box 4: Barlow sign
fortable part of the physical examination and should
therefore be performed last. All joints should be tested This test is essentially the first part of the Ortolani sign
involving subluxation of the femoral head. The hip is
in flexion and extension, internal and external rota-
placed in an abducted starting position and slowly
tion, and adduction and abduction, where indicated.
adducted. In dogs with joint laxity, a distinct click may
The range of motion possible, resentment to manipu- be felt as the femoral head subluxates and leaves the
lation, the presence of crepitus and end-feel should be acetabulum, which constitutes a positive Barlow sign.
noted (see Part 1, and Table 2 below).

Box 5: Ortolani sign

Examination of specific joints
The Ortolani sign is elicited with the dog in
Hip dorsal recumbency and both femora positioned
perpendicular to the table top. In dogs with joint laxity,
Hip joint manipulation should isolate flexion–exten-
firm pressure applied to the stifles along the axis of
sion from adduction–abduction and should also assess the femora towards the hips results in subluxation
internal and external rotation. Even in the absence of of the joints. With the stifles still held firmly, the limbs
hindlimb proprioceptive deficits, physical examina- are then slowly abducted. In dogs with joint laxity, a
tion should be aimed at differentiating between cau- distinct click is felt as the femoral head returns to the
dal lumbar/lumbosacral pain and hindlimb pain. Hip acetabulum, which constitutes a positive Ortolani sign.
The test can also be performed with the dog in lateral
extension inevitably results in lumbosacral extension,
recumbency with the limb in question uppermost.
which will be resented in dogs with lumbosacral spinal

Table 2: Variation in end-feel*

Name Description Significance
Bony/hard Bone approximates bone, resulting in an abrupt stop Always pathological. May be indicative of excessive
as two hard surfaces engage periarticular osteophytosis
Capsular/firm A firm but slightly yielding end-feel associated with Abnormal if associated with reduced range of
tension in the joint capsule motion. Pathological capsular end-feel is generally
harder than normal capsular end-feel
Tissue Motion is stopped by compression of soft tissues or Abnormal if occurs too early in the range of motion
approximation/ fluid resulting in a reduction in the range of motion or in a joint normally having a capsular end-feel.
soft with a soft end-feel May be seen in joints with substantial joint effusion
or periarticular oedema
Empty The end point is not felt due to the patient resisting Pain
full range of motion before resistance is reached
*End-feel is defined as the sensation at the ends of passive range of joint motion

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rotation (Breur and Blevins 1997). Specific palpation

of the iliopsoas muscle belly, the iliopsoas tendon and Box 7: Cranial tibial thrust
the point of tendon insertion on the lesser trochanter With the stifle joint held at a normal standing angle
will elicit significant discomfort in cases of iliopsoas (120°), the thumb of one hand should be placed
strain. on the lateral fabella and the index finger of the
same hand on the tibial tuberosity. Then, with the
metatarsus grasped in the other hand, flexion of the
Stifle
hock should be forced with the stifle fixed in position.
Manipulation of the stifle joint should always include This compresses the tibia, resulting in a cranial force
attempts at medial and lateral luxation of the patella on the proximal tibia. In the absence of a functional
with the joint held in both flexion and extension. The cranial cruciate ligament, there will be cranial tibial
examiner should be satisfied that the patella is seated translation (ie, the gap between the thumb and index
firmly within the femoral trochlea, and that it glides finger will increase). Tibial thrust is well tolerated
smoothly as the joint is flexed and extended. The sti- and can often be performed without sedation
or anaesthesia even in the larger breeds. Once a
fle joint should be stable in the transverse plane. Any
positive test has been elicited, it is worth initiating
laxity in this plane is indicative of collateral ligament tibial compression with the stifle joint extended and
injury. Cranial drawer (Box 6) and cranial tibial thrust allowing the joint to flex and extend while maintaining
(Box 7) are commonly used manoeuvres to assess compression. This action may precipitate displacement
the cranial translation of the tibia with regard to the and replacement of the caudal horn of the medial
femur. This is a diagnostic feature of cranial cruciate meniscus, sometimes palpable as a ‘click’. Absence of
this finding does not rule out meniscal disease.
ligament rupture.

Box 6: Cranial drawer

This test involves placing the thumb of one hand on
the lateral fabella, with the index finger on the patella,
and placing the thumb of the other hand on the
caudal tibial plateau, and the index finger on the tibial
tuberosity. The tibia should then be moved cranially
with respect to the femur. More than a few millimetres
of movement with a poorly defined end point
represents a positive result. A false negative result may
be seen in some dogs with chronic cranial cruciate
ligament disease where there is extensive periarticular
fibrosis with or without meniscal injury blocking cranial
tibial translation and also in dogs with partial cranial
cruciate ligament rupture. Animals with rupture of
the craniomedial band of the cranial cruciate ligament In the absence of a functional cranial cruciate
will only have a cranial drawer sign when the stifle is ligament, flexion of the hock (arrow) with the
partially flexed. It should be noted that increased laxity stifle in partial flexion results in cranial translation
is present in young large breed dogs, but the end point of the proximal tibia with regard to the distal
remains well defined. Sedation or anaesthesia may be femur
required to elicit laxity, especially in dogs with recent
rupture owing to pain and muscle spasm. In very large
breeds, the test is more difficult to perform unless the Hock
dog is anaesthetised. However, cranial tibial thrust can
The three components of the common calcanean (or
be elicited in the conscious animal.
Achilles) tendon (the superficial digital flexor tendon,
conjoined tendon of the biceps femoris, semitendino-
sus and gracilis muscles, and the gastrocnemius ten-
don) should be assessed. Swelling of the insertion of
the tendon of the gastrocnemius tendon on the tuber
calcis and resentment on palpation are seen with
Achilles tendinopathy. This may be associated with a
partially plantigrade stance with characteristic flex-
ing of the digits if the superficial digital flexor tendon
is intact. Common ligamentous injuries in this region
may involve the collateral ligaments of the tarsocrural
joint, including avulsion fractures of the medial (tibi-
al) or lateral (fibular) malleoli (Fig 2). Injury to these
ligaments is typically acute in onset, often resulting
in mild lameness for which the dog may not be imme-
With the distal femur grasped between thumb diately presented. Where medial or lateral instability
and forefinger of one hand and the proximal tibia
can be demonstrated on manipulation, it should be Fig 2: Avulsion fracture of
grasped between the thumb and forefinger of the
other hand, an attempt should be made to induce possible to accurately determine whether the instabil- the lateral fibular malleolus
cranial translation of the tibia with regard to the ity is more apparent with the hock in flexion (indica- (arrow) is often associated
femur (arrows). Increased movement and a poorly with varus instability owing
tive of injury to the short component of the collateral
defined end point are indicative of cranial cruciate to the attachment of the
ligament disease
ligament) or in extension (indicative of injury to the lateral collateral ligament
long part). Medial or, more commonly, lateral luxa- at this site

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tion of the superficial digital flexor tendon within the

tendon sheath as it courses over the proximal end of
the tuber calcis is an uncommon cause of hindlimb
lameness.
Damage to the plantar ligaments will result in
hyperextension of the tarsometatarsal or intertarsal
joints. Avulsion and other fractures of the bones of the
tarsus are generally presented as acute incidents due to
the greater level of discomfort usually apparent.

Metatarsus and pes

The interphalangeal joints are uncommon sources of
Fig 3: Positioning for lateral (above) and ventrodorsal
lameness. Chronic, fluctuating lameness as a sequela (below) radiography of the pelvis and hips. Note the
to OA of these joints or malunion/non-union of pre- use of a measuring aid and left/right markers in the
vious digital fractures is not seen very often. Foreign image above, which are used to aid measurement of
structures and to clarify left versus right positioning
bodies in pads and migrating interdigital foreign bod- in digital images
ies must not be omitted from the list of differential
diagnoses for chronic hindlimb lameness.

Radiography

Radiography is typically the primary imaging modal-

ity for the investigation of lameness. Orthogonal views
should be obtained for all investigations.

Pelvis and coxofemoral joint

Standard radiographic views of the pelvis are ventro- coxofemoral joints and to examine the joints for signs
dorsal (with the hindlimbs extended and placed in a of OA. Common signs of coxofemoral OA include a
frog-leg position) and lateral (see Box 8). curvilinear opacity at the site where the joint capsule
The lateral view of the pelvis (see Fig 3 for posi- attaches on the femoral neck (known as Morgan’s line,
tioning) may be used for determining the position of a Fig 4), remodelling of the cranial and caudal acetabu-
luxated hip and for evaluating pelvic symmetry where, lar rim, flattening of the femoral head and irregular
for example, there is a history of previous pelvic frac- widening of the femoral neck. Positioning is critical,
ture or sacroiliac luxation. Ventrodorsal views of the with obliquity appearing to open or close sacroiliac
pelvis and hips (see Fig 3 for positioning) are com- joints and increase or decrease acetabular femoral
monly viewed to determine the degree of laxity in the head coverage. If the pelvis is rotated, there will be

Box 8: Views of the pelvis

Lateral
■■ Patient in lateral PennHIP
recumbency The Pennsylvania Hip Improvement Program involves acquiring ventrodorsal
■■ Limb in question closest radiographs of the canine pelvis with the hindlimbs in three different positions
to the plate to quantify the degree of laxity in the hips. The three PennHIP views are:
■■ Neutral coxofemoral ■■ Ventrodorsal pelvis with the hindlimbs extended. In this view, the
joints with the femora coxofemoral joint capsule is twisted by the act of extending the hindlimbs,
parallel (as shown in Fig 3) and the resulting tension in the joint capsule pulls the femoral heads into
or the acetabula, artefactually improving coxofemoral approximation. This
■■ Dependent hip somewhat view is the standard for assessing the degree of bone change consistent
flexed and upper hip with OA;
somewhat extended, ■■ Ventrodorsal pelvis compression view. This view maximally reduces the
which gives more femoral heads into the acetabula;
information by splitting the ■■ Ventrodorsal pelvis distraction view. This view maximally subluxates the
femora in the radiograph femoral heads from the acetabula.
The distraction index (DI) is calculated from the last two views. DI is a direct
Ventrodorsal measurement that compares the location of the femoral head within the
■■ Patient in dorsal acetabulum in the compression and distraction views normalised for the femoral
recumbency head radius. The DI is an accurate measurement of hip laxity and, in young dogs,
■■ Hindlimbs extended with has been shown to correlate well with the development of OA in later life.
femora parallel, often held PennHIP was developed in the USA and is increasingly available in other
in position with tape parts of the world. PennHIP has been restricted in the UK by the need for
and/or manual positioning of the hindlimbs during radiography. A recently devised
■■ Hindlimbs abducted to technique for hands-free PennHIP has meant that some practitioners in the
give the ‘frog-leg’ view UK are now performing PennHIP on a regular basis. The PennHIP website
contains a complete list of all certified PennHIP practitioners in the world
PennHIP views
(www.pennhip.org).
See box on the right

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an apparent asymmetry in the sizes of the obturator

foramina and an increase in the width of the ilial wings
on the side furthest away from the plate and an appar-
ent increase in femoral head coverage on the contra­
lateral side (Fig 5).
Radiographic features of hip dysplasia tend to cor-
relate poorly with clinical signs, and dogs with severe
subluxation may show no clinical lameness. Therefore,
a finding of a wide coxofemoral joint space on a radio-
graph is not sufficient to diagnose hip dysplasia as the
cause of lameness.

Stifle and tibia

Caudocranial and mediolateral views are typically
acquired for examination of the stifle (Fig 6, Box 9).
In caudocranial views of the stifle, the fabellae should
be bisected by the femoral condylar cortices and the
patella should lie centrally. In the mediolateral view,
the femoral condyles should be superimposed over one
another, but should not overlie the tibial plateau. The Fig 4: Caudolateral curvilinear
triangular fat pad within the cranial stifle joint is com- osteophytes at the site where
the joint capsule attaches on
monly assessed to determine the presence or absence
the femoral neck (Morgan’s
of an effusion or soft tissue within the joint. Effusion line) is indicative of early
will also cause caudal displacement of the fascial plane coxofemoral osteoarthritis

Fig 5a (left): Satisfactory

ventrodorsal radiographic
view, with the hips extended.
Fig 5b (right): Rotation of the
pelvis in the same dog has
had the effect of apparently
worsening coxofemoral
conformation on the left
and improving coxofemoral
conformation on the right

Fig 6a, b (left and right):

Positioning for mediolateral
and caudocranial radiography
of the stifle, including full-length
views of the tibia, which enables
measurement of the tibial
plateau angle

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Box 9: Views of the stifle Box 10: Views of the tarsus

Mediolateral Dorsoplantar (views in neutral ± stressed/
■■ Patient in lateral recumbency unstressed valgus/varus)
■■ Limb of interest closest to the plate ■■ Patient in dorsal recumbency
■■ Contralateral limb pulled cranially or abducted ■■ Limb pulled caudally to place the paw horizontally
on the table
Caudocranial
■■ Patient in sternal recumbency Mediolateral (± stressed flexed/extension)
■■ Limb of interest extended caudally with the pelvis ■■ Patient in lateral recumbency
raised using a foam wedge ■■ Limb of interest closest to the plate

within the gastrocnemius muscle caudal to the joint Arthroscopy of the stifle joint is commonly per-
space. Periarticular osteophytosis typically occurs on formed before surgery to address stifle instability
the distal pole of the patella, the fabellae and on the occurring secondarily to cranial cruciate ligament dis-
caudal aspect of the tibial plateau. ease. A thorough assessment of the cruciate ligaments
and the menisci may be performed arthroscopically
Tarsus and pes (Fig 7) with removal or debridement, as necessary.
The tarsus consists of three rows of seven bones sta- The articular fat pad obscures the view (particularly
bilised by a sheath of soft tissues, collateral ligaments when there is inflammation present in the joint) and
and numerous small ligaments. Radiographic interpre- may be debrided using a motorised shaver to improve
tation, as in the carpus, is limited by superimposition visibility. Meniscal injury in the absence of cranial
of the other bones. CT, where available, is the modal- cruciate ligament rupture accounts for a significant
ity of choice for imaging tarsal bone injuries. proportion of knee joint arthroscopy in humans, but
Stressed dorsoplantar views are used to reveal is rare in dogs. Arthroscopy allows minimally invasive
tarsal valgus or varus instability associated with col- investigation of the intra-articular stifle features in
lateral ligament injury or malleolar avulsion fracture cases where a partial tear of the cranial cruciate liga-
(Box 10). ment is suspected. Partial tears typically progress to
complete rupture if treated non-surgically, although
the timeframe varies from weeks to years. Onset and
Arthroscopy progression of OA in the canine stifle in the absence
of the stabilising effect of the cranial cruciate liga-
Arthroscopy is of limited application in the hip and ment is rapid (with radiographic signs of periarticular
tarsal joints. Hip arthroscopy has been used to assess osteophytosis developing within four weeks of the ini-
the joint before triple pelvic osteotomy to address tiating cause). Arthroscopy of the stifle carries mini-
hip dysplasia and for arthroscopically guided biopsy mal morbidity and, therefore, should be performed
of femoral head lesions (Scherrer and others 2005). sooner rather than later in the course of stifle-related
Arthroscopic removal of avulsed bone fragments in lameness.
cases of coxofemoral luxation has also been reported.
Tarsal arthroscopy is challenging because of the small
size of the joint, but can be used to evaluate the articu- Synoviocentesis
lar surfaces of the tibiotarsal joint and to identify and
remove osteochondral flaps associated with osteo- Synoviocentesis was discussed in Part 1, and carries
chondritis dissecans. similar indications for the investigation of hindlimb
lameness. Joint fluid samples should be grossly assessed
for colour, turbidity, viscosity and volume, and should
be submitted to a laboratory for cytology, and for
Caudal cruciate ligament culture and sensitivity testing, if deemed abnormal.
Haematogenous spread of sepsis to severely osteoar-
thritic hip joints occurs with some frequency. Acute
Lateral femoral condyle non-weightbearing lameness in cases of chronic OA
should be considered an indication for synovial fluid
cytology, culture and sensitivity testing. Samples should
be submitted in blood culture medium to improve diag-
Cranial cruciate ligament
nostic yield (Montgomery and others 1989).
(intact caudolateral band) The hip joint may be sampled via a craniolateral
approach to avoid the sciatic nerve situated caudally.
‘Bobbling’ of the craniomedial
band of the cranial cruciate By slightly abducting and externally rotating the femur,
ligament, which is indicative the dorsal joint space may be opened, thus allow-
of a partial tear
ing needle insertion dorsal to the greater trochanter.
The needle will contact the dorsal acetabular rim and
may be walked ventrally into the joint space from that
point. Needle size depends on the size of the dog, but
Fig 7: Arthroscopic view of the cranial and caudal cruciate ligaments, showing partial the authors commonly use 21 gauge, 40 mm needles for
rupture of the cranial cruciate ligament medium to large breed dogs.

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Companion animal practice

patellar ligament midway between the tibial tuber-

osity and the patella at a 45° angle to the skin with
the tip directed towards the lateral parapatellar joint
pouch (Fig 8). In view of the frequency with which
hindlimb lameness associated with the stifle joint is
encountered in veterinary practice, synoviocentesis of
this joint should be within the general practitioner’s
repertoire.
The tarsus is sampled with the tibiotarsal joint held
in 90° flexion. The needle (23 gauge, 16 mm) should
be inserted plantaromedially, parallel to the calcaneus
into the gap between the medial aspect of the lateral
Fig 8: Stifle arthrocentesis should be performed in a malleolus and the distal tibia.
sterile manner with the needle inserted into the joint
space lateral to the distal pole of the patella
Further imaging
Stifle synoviocentesis may be performed with the
joint in a neutral position. The needle (23 gauge, 25 Further diagnostic imaging of the canine hindlimb
mm) should be inserted just lateral to the straight (eg, CT, ultrasonography, magnetic resonance imag-

Box 11: Differential diagnosis

Lameness localised to the joints of the hindlimb

Coxofemoral joint ■■ Spontaneous fracture of ■■ Central tarsal bone fracture/
■■ Hip dysplasia +++ the lateral fabella + luxation ++
■■ Legg-Calvé-Perthes disease ++ ■■ Patellar fracture + ■■ Calcaneus fractures +
■■ Coxofemoral luxation ++ ■■ Patellar tendon rupture/ ■■ Talus fractures +
avulsion + ■■ Fractures of the numbered
Stifle ■■ Medial/lateral collateral tarsal bones +
■■ Cranial cruciate ligament ligament rupture + ■■ Avulsion of the gastrocnemius
disease +++ ■■ Stifle luxation + tendon +
■■ Meniscal injury (medial injuries ■■ Avulsion/displacement of the ■■ Achilles tendinopathy +
are more common than lateral long digital extensor tendon + ■■ Superficial digital flexor tendon
ones) +++ avulsion/luxation +
■■ Patellar luxation (medial Tarsus ■■ Tarsometatarsal luxation +
luxation is more common ■■ Talar osteochondrosis/
than lateral luxation) +++ osteochondritis dissecans ++ Any joint
■■ Femoral condylar ■■ Tarsocrural luxation/subluxation ■■ Osteoarthritis +++
osteochondrosis/osteochondritis (and associated malleolar ■■ Septic arthritis ++
dissecans (lateral condyle fracture) ++ ■■ Articular fracture ++
more common than medial ■■ Shear injuries ++ ■■ Joint neoplasia +
condyle) + ■■ Intertarsal subluxation ++ ■■ Polyarthritis +

Lameness localised to the bones/soft tissues of the hindlimb

Pelvis ■■ Femoral capital physeal ■■ Hypertrophic pulmonary
■■ Sacroiliac luxation +++ fracture/separation ++ osteopathy +
■■ Fracture ■■ Neoplasia ++
●● Ilial +++ ■■ Gracilis/semitendinosus Metatarsals
●● Acetabular +++ myopathy + ■■ Fracture +++
●● 
Pubic/symphyseal ■■ Iliopsoas strain + ■■ Luxation ++
+++ ■■ Metaphyseal osteopathy +
●● Ischial +++ Tibia/fibula ■■ Neoplasia +
■■ Fracture of the ischial ■■ Tibial tuberosity with or without
tuberosity + proximal tibial physeal fracture Digits
■■ Von Willebrand’s heterotopic +++ ■■ Chronic/acute fracture +++
osteochondrofibrosis + ■■ Diaphyseal fracture +++ ■■ Luxation ++
■■ Neoplasia + ■■ Panosteitis ++ ■■ Sesamoid disease ++
■■ Medial/lateral malleolar ■■ Osteomyelitis – haematogenous
Femur fracture ++ spread of infection +
■■ Distal femoral physeal ■■ Neoplasia ++ ■■ Septic arthritis +
fracture +++ ■■ Metaphyseal osteopathy + ■■ Neoplasia +
■■ Aseptic necrosis of the ■■ Distal tibial varus/valgus
femoral head +++ secondary to premature All bones
■■ Femoral diaphyseal closure of the distal tibial/ ■■ Osteomyelitis +
fracture +++ fibular physis + ■■ Bone cyst +

Immature dog, Mature dog, + Rare, ++ Seen with some regularity, +++ Common
Note some conditions may be seen in both immature and mature dogs

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Companion animal practice

ing [MRI] and nuclear scintigraphy) may provide Bone biopsy

useful information in some cases. CT has been used
for assessing acute and chronic malleolar avulsion Bone biopsy was discussed briefly in Part 1. Despite
fractures and can give a more accurate prognosis for the mantra that primary bone tumours occur com-
the likely success of surgical reduction of such frag- monly in the distal femur and proximal tibia (‘away
ments. CT is also invaluable for accurately assessing from the elbow, close to the knee’), areas of lytic
the individual bones of the hock (eg, in cases of cen- bone at any site should be sampled if neoplasia is
tral tarsal bone fracture/luxation, Fig 9) where super- suspected.
imposition in plain radi­ography is limiting. Recent
literature regarding contrast CT or MRI for assessing
stifle anatomy (particularly meniscal injury) has been Summary
encouraging, although these modalities are unlikely
to replace arthroscopy for the evaluation of the menisci Effective treatment of hindlimb lameness requires
because complete assessment requires manual prob- accurate diagnosis. Lameness associated with the
ing. Where evidence of neurological dysfunction is hindlimbs is most commonly associated with two com-
associated with hindlimb lameness, imaging involving mon conditions: cranial cruciate ligament disease and
myelography or, preferably, MRI of the lumbar and hip dysplasia. It is, however, inappropriate to make
lumbosacral spine should be performed. assumptions about the aetiology of hindlimb lame-
Ultrasonography may be of use in investigating ness without a thorough investigation, which should
hindlimb lameness that is thought to be associated begin with gait analysis and palpation/manipulation of
with trauma to tendons or ligaments, particularly the hindlimbs in the conscious animal. Radiography,
the straight patellar ligament/quadriceps tendon and advanced imaging and biopsy sampling may follow,
the common calcanean tendon. The straight patellar as appropriate. A structured approach to the inves-
ligament may occasionally be partially or completely tigation of hindlimb lameness will aid consistent
ruptured or avulsed following trauma. Radiographic diagnosis.
features of straight patellar ligament rupture include
patella alta and stifle joint effusion. Depending on the Acknowledgements
chronicity of the condition, thickening and a deficit The authors would like to thank
in the straight patellar ligament may be apparent on Steve Joslyn and Mark Bush for their
ultrasonography (Fig 10). suggestions during the preparation of
Ultrasonographic assessment of the common the original manuscript of this article
and the nurses at Southern Counties
calcanean tendon may similarly help to deter-
Veterinary Specialists for their help
mine the extent of trauma to the three individual with the images.
components.

References and further reading

BREUR, G. J. & BLEVINS, W. E. (1997)
Traumatic injury of the iliopsoas muscle
Femur
SPL in three dogs. Journal of the American
Veterinary Medical Association 210,
1631-1634
KAPATKIN, A. S., GREGOR, T. P.,
HEARON, K., RICHARDSON, R. W.,
MCKELVIE, P. J., FORDYCE, H. H. &
SMITH, G. (2004) Comparison of two
radiographic techniques for evaluation
of hip joint laxity in 10 breeds of dogs.
Journal of the American Veterinary
Medical Association 224, 542-546
MONTGOMERY, R., LONG, I.,
MILTON, J., DI PINTO, M. N. & HUNT,
J. (1989) Comparison of aerobic culture,
synovial membrane biopsy and blood
culture medium in detection of canine
bacterial arthritis. Veterinary Surgery
18, 300-303
SCHERRER, W., HOLSWORTH, I.,
GOOSSENS, M. & SCHILZ, K. (2005)
Coxofemoral arthroscopy and total
hip arthroplasty for management of
intermediate grade fibrosarcoma in
Discontinuity in SPL a dog. Veterinary Surgery 34, 43-46
TIVERS, M. S., MAHONEY, P. N.,
BAINES, E. A. & CORR, S. A. (2009)
Fig 9: 3-D computed
Tibia Diagnostic accuracy of positive contrast
tomography reconstruction
computed tomography arthrography for the
of the right hock, showing
central tarsal bone fracture/ Fig 10: Ultrasonographic image of avulsion of detection of injuries to the medial meniscus
luxation (arrow) in a four- the straight patellar ligament (SPL) from the tibial in dogs with naturally occurring cranial
year-old male collie-cross tuberosity. This is a rare traumatic condition causing cruciate ligament insufficiency. Journal
following trauma severe stifle instability and hindlimb lameness of Small Animal Practice 50, 324-332

66 In Practice  February 2011 | Volume 33 | 58–66

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Investigation of lameness in dogs: 2.

Hindlimb
Philip Witte and Harry Scott

In Practice 2011 33: 58-66

doi: 10.1136/inp.d453

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