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Companion animal practice

Investigation of lameness in dogs

1. Forelimb

Harry Scott and Philip Witte

Lameness associated with musculoskeletal disorders of the forelimb accounts

for approximately 25 per cent of the authors’ canine referral caseload.
Lameness due to an underlying neurological disorder is less common and
Harry Scott graduated from is often associated with weakness and, in some dogs, neurological deficits.
Liverpool in 1977. He worked Most cases of chronic forelimb lameness of musculoskeletal origin seen at
in small animal general practice the authors’ clinic involve the elbow or, less frequently, the shoulder. The
and completed certificates in practitioner should, however, be mindful of the fact that lameness can be
dermatology and orthopaedics associated with any aspect of forelimb function. When dealing with chronic
followed by a fellowship by forelimb lameness, a diagnosis can be elusive and, with limited investigative
examination in canine spinal techniques, frustrating. A structured approach to the investigation of lameness
surgery. Since 1999, he has is therefore vital if the practitioner is to treat or refer animals appropriately.
worked in referral practice both in This article describes a step-by-step approach to investigating lameness in
the UK and abroad, and is currently the forelimb in dogs. A second article, to be published in the February issue
head of orthopaedics at Southern of In Practice, will describe the approach for investigating hindlimb lameness.
Counties Veterinary Specialists. He
holds the RCVS diploma in small
animal surgery (orthopaedics) Signalment be perceived as such by some clients. Accurate history
and is an RCVS specialist in small taking necessitates specific initial questioning.
animal surgery (orthopaedics). He Signalment can help to formulate a list of differential Osteoarthritis is a common cause of forelimb lame-
has recently become a certified diagnoses. For example, forelimb lameness in English ness in the adult dog and typically presents with insid-
canine rehabilitation practitioner. springer spaniels may be associated with incomplete ious-onset transient stiffness on rising after rest and
ossification of the humeral condyle (IOHC), while the gradually progressive waxing and waning lameness,
primary differential diagnosis for forelimb lameness especially after exercise. Lameness in dogs with osteo­
in juvenile Labrador retrievers may be elbow dyspla- arthritis may have a more acute and severe presenta-
sia or, more specifically, fragmentation of the medial tion following a sprain associated with overactivity or
coronoid process. Therefore, while both diagnoses sepsis as a result of haematogenous spread. A 12-month
should be listed as differential diagnoses for both history of mild intermittent lameness or reluctance to
breeds, signalment can alter the ranking. walk before acute-onset severe lameness may only come
to light in response to appropriate questioning. In the
absence of a detailed history, a practitioner may fail to
Philip Witte graduated from
History recognise the full aetiology of a case of lameness.
Bristol in 2005. He spent two
years working in mixed general
As with any other discipline, it is important to obtain
practice in Herefordshire followed a thorough history when investigating orthopaedic Gait examination
by six months working with disease. Furthermore, a detailed knowledge of response
Cape buffaloes in South Africa. to previous treatments will prove useful in decision Gait can be defined as the sequence of limb and body
He subsequently completed an making. Client perception of current and desired fore- movements used for locomotion. Gait analysis is the
internship in surgery at Southern limb function can vary widely. The owner of a lapdog study of locomotion. For the purposes of this article,
Counties Veterinary Specialists, Shih-Tzu may be less aware of, and less concerned with, lameness is any variance from a normal gait (includ-
where he is now an orthopaedic mild forelimb lameness than the hill-walking owner ing ataxia or paresis) and a stride is the cycle of body
resident. He is currently working of a usually extremely active Border collie. Lameness and limb movements that begins with the contact of
towards the RCVS certificate in should be addressed with equal attention in both of one foot on the ground and ends when the same foot
advanced veterinary practice these dogs, but client perception of the problem may contacts the ground again. With every stride each indi-
(small animal surgery). vary. Some owners will not perceive stiffness when ris- vidual limb goes through a step cycle that comprises a
ing as abnormal, particularly in older dogs, despite this stance (weightbearing) phase and a swing (non-weight-
being commonly associated with chronic joint pain. bearing) phase. In the average dog, each forelimb is
Similarly, clients will grade lameness in different ways. responsible for 30 per cent of weightbearing when
While some clients will present a dog with very mild or standing. Before gait assessment, a thorough general
intermittent lameness, others may present the dog only examination should be performed to ensure that non-
when it is severely lame and non-weightbearing. Gait specific signs of overall ill health are not omitted from
doi:10.1136/inp.c7447 asymmetry constitutes lameness, although it may not the decision making.

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The initial part of an orthopaedic examination Table 1: Grading lameness at a walk and trot
should include observation of the dog’s gait and stance Grade Description
in the consulting room (orthopaedic examination of 0 (None) No lameness is observed at a walk or trot
the forelimb in dogs will be discussed in more detail
1 (Mild) Lameness is present, but may only be consistently apparent at a trot
in an article to be published in the March 2011 issue
of In Practice). For example, dogs with elbow dysplasia 2 (Mild to moderate) Mild lameness is obviously present at a walk and is worse at a trot
will often sit or stand with the elbow adducted and 3 (Moderate) Obvious lameness is present at both gaits
the distal extremity supinated. Gait analysis should 4 (Moderate to severe) Obvious lameness is present at both gaits and may be intermittently
be conducted at a walk and at a trot. The dog should non-weightbearing
be led for a distance of about 15 metres directly away 5 (Severe) Lameness is non-weightbearing most or all of the time
from and then towards the assessor to allow gait obser- Grading lameness can be useful for monitoring changes in the severity of lameness over time,
vation in both directions. To fully assess the gait, it and may also be indicative of the condition involved
is often also useful to walk alongside the dog or have
it walked past the examiner. Initial evaluation should
be performed at a slow walk (a symmetrical four- a feature of hindlimb lameness. In cases of hindlimb
beat gait) so that the movement of each limb can be lameness, the head will tend to nod down when the
observed individually. affected hindlimb contacts the ground.
Mild lameness that may not be detectable when the Disparity in the stride length is seen as a ‘limp’. This
dog is walking will become more apparent when the indicates avoidance of equal weightbearing and/or
animal is made to trot as more force is placed on the flexion and extension in the forelimbs. Theoretically,
limbs at greater velocity. However, at a trot (a symmetri- by reducing the cranial portion of a stride, a dog may
cal two-beat gait), diagonal fore- and hindlimbs strike minimise shoulder extension. Similarly, by reducing
the ground simultaneously, making differentiation the caudal portion of the stride, shoulder flexion,
between fore- and hindlimb lameness more difficult. elbow extension and weightbearing may be reduced.
It should be noted that some dogs will preferentially By swinging the affected forelimb in a semicircle
adopt a pacing gait rather than a trot. Pacing is similar during the swing phase (circumduction), a lame dog
to the trot except that there is less range of joint motion may avoid movement of painful joints. High-stepping
and, instead of diagonal, ipsilateral fore- and hindlimbs (hypermetric) gaits and dragging limbs are often associ-
strike the ground simultaneously. The pace may appear ated with neurological disorders of the cerebellum and
stiff and stilted compared with the trot and there is relevant upper or lower motor neurons, respectively,
more side to side rolling of the body. The pace is a nor- although this may also be associated with attempts to
mal gait for some dogs (usually large breeds), but may reduce weightbearing on painful limbs or alter the posi-
be used preferentially by some dogs with osteo­arthritis tion of painful joints. Neurological assessment should
to reduce joint excursion. A video record of the gait can be performed if deemed necessary (see McKee 2007 for
be useful to monitor changes over time and is especially further information).
useful for smaller dogs and those with faster gaits so
that they can be viewed in slow motion. A system of
subjective lameness grading is outlined in Table 1. Physical examination
By altering the carriage of the head, lame dogs
attempt to reduce the forces acting through a painful Following gait examination, the examiner should
forelimb. Head nodding is one of the most useful signs know which limb(s) is/are affected. The purpose of the
of forelimb lameness. The head is raised when the lame physical examination is to localise the affected area
limb is weightbearing and lowered (‘nodded’) when or joint on the limb. Physical examination of affected
the sound limb is weightbearing. A nod of the head limbs should always be performed in conjunction with
is sometimes accompanied by dropping of the shoul- an assessment of the contralateral limbs, bearing in
der on the contralateral side to the lameness. Lateral mind that conditions may be bilateral. Examination
deviation of the head transfers some of the weight of should be performed in a systematic and consistent
the head and neck to the sound limb. It should be noted manner (eg, from distal to proximal), so that nothing
that head nodding, although less marked, can also be is missed. Contralateral limbs should be palpated first
so that the dog becomes accustomed to being handled
before any painful areas are touched.
Box 1: Key visual signs of forelimb
lameness
Palpation of musculature
■■ Stride/step alterations Palpation of musculature can provide information
●● Short-stepping (‘limp’) about the use of a limb over a period of time. Disuse
●● Ratio of stance to swing portion
(or reduced use) atrophy will produce a palpable asym-
■■ Head posture metry in the musculature within a few weeks, which
●● Head nodding
is easiest to appreciate adjacent to a bony prominence
●● Lateral head deviation

●● Ventral head deviation

(eg, the scapular spine). In general, the muscles that
■■ Altered limb movement are most vulnerable to atrophy are anti-gravity mus-
●● Circumduction cles that cross a single joint (eg, the supraspinatus
●● High-stepping versus claw scuffing and infraspinatus). Muscles that are least vulnerable
■■ Altered limb placement are flexor muscles that cross more than one joint (eg,
●● External rotation
the biceps brachii). Muscle mass is generally slower
●● Internal rotation
to recover, and apparently normal animals will show

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Companion animal practice

atrophy for weeks or months following resolution of Manipulation of specific joints

lameness as muscle bulk returns.
Shoulder
Palpation of bones The shoulder joint has minimal intrinsic stability,
Bone conformation may be determined by palpation, relying on static (joint capsule and ligaments) and
although imaging, particularly computed tomography dynamic (rotator cuff muscles and tendons) stabilis-
(CT) (see later), is more useful for investigating angu- ers to maintain alignment of the glenoid and humeral
lar deformities or torsion. Swelling and discomfort head. Stability is maintained mainly by the medial and
at the proximal humerus or distal radius/ulna in an lateral glenohumeral ligaments and muscles that cross
adult dog warrants further assessment for bone neo- the scapulohumeral joint, primarily the subscapularis
plasia, including examination of the local lymph nodes medially, the infraspinatus laterally and the biceps
(osteo­sarcomas rarely spread to lymph nodes, but these brachii tendon craniomedially. The static stabilisers
should not be neglected) and thoracic radiography in do not appear to have a significant role in providing
three views. A marked pain response elicited on palpa- joint constraint during normal range of joint motion.
tion of bone is a feature of panosteitis, which is seen Rupture or degeneration of any of these stabilisers
predominantly in juvenile German shepherd dogs. An
attempt should be made to differentiate bone pain
from surrounding soft tissue or adjacent joint pain. Box 2: Shoulder abduction test
The shoulder abduction test has been advocated for
Palpation of joints assessing medial ligamentous joint instability. This
Joint effusion (fluid distension of the joint capsule) should be performed with the dog under sedation
may be palpated most readily in the standing animal or general anaesthesia. The dog is placed in lateral
at specific sites for particular joints (eg, just caudal to recumbency with the affected limb uppermost and the
the lateral epicondyle in the elbow joint). Harder joint elbow maintained in a neutral position to avoid internal
thickening is suggestive of fibrosis, periosteal reaction, rotation. To perform the test, the examiner should
hold the scapula in a fixed position with one hand and
new bone formation and a more chronic disease. Due
abduct the limb at the shoulder joint using the other
to overlying soft tissues, shoulder joint effusion and hand. An increased abduction angle is considered
thickening cannot usually be appreciated. During the indicative of medial instability. Normal abduction
course of an examination, firm digital pressure applied angles are usually around 30°. False positive results may
to areas of pain may elicit signs of resentment, allow- be seen if there is shoulder muscle atrophy from any
ing an examiner to localise the source of discomfort. cause, although angles greater than 40° are more likely
to be significant. The affected shoulder should always
Reproducible resentment responses to firm digital pres-
be compared with the contralateral joint.
sure applied in the region of the anconeal process or
medial aspect of the coronoid process indicate the need
for further investigation of ununited anconeal and frag- Box 3: Biceps tendon test
mented coronoid processes, respectively.
The biceps tendon test is performed in the conscious
dog by flexing the shoulder fully (ie, stretching the
Manipulation of joints biceps muscle tendon unit) and applying digital
All joints in the limb should be tested in flexion, pressure in the intertubercular groove on the
extension, and internal and external rotation to note craniomedial aspect of the proximal humerus to test
the range of motion, resentment, crepitus and end- for a pain response. A positive result may be indicative
feel. End-feel is the sensation felt by the examiner’s of abnormalities of the biceps tendon of origin.
hands when the end of passive range of joint motion However, the validity of the test has been questioned
because this manoeuvre also places tension on the
is reached (Table 2). Tissues limiting passive range
tendons of insertion of the biceps and brachialis
of motion may be normal or pathological and may
muscles on the ulna, which forces the medial coronoid
include muscles, ligaments, tendons, the joint capsule of the ulna against the radial head and produces pain
and periarticular fibrosis or bone (osteophytosis). If in dogs with medial coronoid disease. In the authors’
pain is felt before resistance, the end-feel is empty and experience, many medium and large breed dogs
the primary problem is pain and not physical restric- referred for apparent shoulder pain are lame due
tion of joint motion. to elbow joint pathology.

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 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 end of passive range of joint motion

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may result in lameness and instability. The shoulder’s

loose ball and socket arrangement lends itself to assess- Box 4: Views of the shoulder
ment of flexion and extension, mediolateral instability Mediolateral
(adduction and abduction) and internal and external ■■ Patient in lateral recumbency, with slight dorsal
rotation. The shoulder abduction test (Box 2) and the rotation
biceps tendon test (Box 3) may be performed as part of ■■ Limb of interest closest to the plate pulled cranially
the examination for shoulder-related lameness. ■■ Contralateral limb is pulled caudally and dorsally
■■ Neck extended so that the trachea is not
superimposed over the shoulder joint, as the
Elbow cartilaginous rings may obscure true lesions
The elbow should be assessed in flexion and extension
to note the range of motion and any resentment shown Caudocranial
by the animal, as well as the presence or absence of ■■ Patient in dorsal recumbency
crepitus. Pronation and supination of the elbow joint ■■ Limb extended and pulled cranially
performed in flexion and extension may provide infor-
mation about discomfort associated with stressing the
medial or lateral collateral ligaments, respectively.

Carpus
The carpus consists of three levels of joints and stabilis-
ing soft tissues. The number of conditions commonly
affecting these joints is small, mostly consisting of frac-
tures of the styloid processes, trauma to the collateral
ligaments, hyperextension injury and fracture/luxation
of individual carpal bones. Instability, discomfort and
soft tissue swelling in the area of the carpus are gen-
erally easily recognised features of these conditions. Positioning for mediolateral (Fig 1a, above) and
Radial carpal bone fractures may cause chronic discom- caudocranial (Fig 1b, below) radiographs of the
fort that is apparently localised to the dorsal proximal right shoulder
carpus and are particularly common in boxers. This
condition is thought to be associated with incomplete
ossification of one or more of the three ossification cen-
tres within the developing radial carpal bone, although
traumatic shearing injuries of the dorsal surface of the
radial carpal bone are possible in all breeds.

Metacarpus and manus

The metacarpophalangeal and interphalangeal joints
are uncommon sources of lameness. Chronic fluctu-
ating lameness as a sequela to malunion/non-union
of previous digital fractures is rare. The presence of
foreign bodies, particularly in interdigital webbing
and the pads, must not be omitted from the list of dif- The scapula should be assessed radiologically in a
ferential diagnoses in cases of chronic forelimb lame- similar manner to the long bones. Periosteal reaction,
ness. In greyhounds and other sight hounds, corns are new bone formation and areas of lucency observed
a common cause of chronic forelimb lameness, which radiologically within the scapula carry the same sig-
is exacerbated by exercise on hard ground. Corns typi-
cally affect the main weightbearing digital (third and
fourth) pads of the forelimb.

Radiography

Radiography is typically the primary imaging modality

for the investigation of lameness in dogs. Orthogonal
radiographic views should be obtained for all cases.

Scapula and glenohumeral joint

Radiography of the scapula and glenohumeral joint
is limited due to the close proximation of the thorax
and increased musculature around the proximal tho-
racic limb. The two standard orthogonal views are
caudocranial and mediolateral (Box 4). Oblique angle Fig 2: Flattening of the
views are not routinely performed, but may be ben- subchondral bone (arrow)
of the caudal humeral head
eficial for investigating small lesions of the glenoid or
in lateral radiographs is
humeral head and fractures of the scapula. indicative of osteochondrosis

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nificance as in the long bones. The most common indi-

cation for radiography of the scapula is fracture, and
multiple views and CT (where available) should be per-
formed for a complete assessment. Glenohumeral joint
luxation usually occurs in a medial direction and is
clearly appreciable radiographically. Osteochondrosis
of the proximal humerus can occur in young middle to
large breed dogs, and is apparent on the lateral radio-
graphic view of the shoulder as a well-circumscribed
lucency in the subchondral bone of the caudal humeral
head (Fig 2), with an overlying linear radiopacity if
there is a mineralised cartilage flap (osteochondritis
dissecans). Contrast arthrography (injection of 2 to 3
ml iohexol 300 mg/ml diluted at a ratio of 50:50 with Fig 4: Periosteal new bone overlying the proximal
aspect of the anconeal process is known as a ‘ridge
sterile water) can be used to highlight an unmineral- sign’ (white arrow). An area of bone sclerosis within
ised cartilage flap. Two to three times this volume of the subchondral bone of the ulna at the level of the
iohexol at the same concentration can be used for con- semilunar notch is indicative of medial coronoid
disease (black arrow)
trast studies of the biceps tendon in the intertubercular
groove.

Elbow and humerus

The elbow is more readily radiographed with less
soft tissue overlap than the shoulder. It is, however,
a close-fitting joint and radiographic assessment is lim-
ited by the inevitable radiographic superimposition of
various features of the humerus, radius and ulna within
the articulations. Mediolateral (neutral), medio­lateral
(flexed) and craniocaudal radiographic views of the
elbow should be performed as standard for a thorough
investigation (Box 5); two extra oblique views may
provide additional information in selected cases.
The neutral mediolateral view shows the bone
margins of the humeroradial and humeroulnar joints
and overall elbow congruity. The flexed mediolateral
view is performed to highlight the anconeal process by
removing the superimposition of the medial humeral Incomplete ossification of the humeral condyle (IOHC)
epicondyle. New bone formation on the proximal (Fig 5a, left) (arrow) and osteochondrosis of the medial
aspect of the anconeal process is known as a ‘ridge part of the humeral condyle (Fig 5b, right) (arrow) may
be apparent in craniocaudal radiographs of the elbow,
sign’ and is usually indicative of elbow dysplasia in
although these lesions (particularly IOHC) can be
immature dogs (Fig 4). Subchondral sclerosis in the easily missed. Computed tomography is therefore the
ulna at the level of the semilunar notch visible in a modality of choice for accurate imaging of the elbow

Box 5: Views of the elbow

Mediolateral (in both neutral and Craniocaudal Craniomedial-caudolateral oblique
fully flexed positions) ■■ Patient in sternal recumbency ■■ As for the craniocaudal view, but with
■■ Patient in ipsilateral lateral ■■ Limb of interest extended cranially some outward rotation (about 15°)*
recumbency ■■ Head and neck deviated to the contralateral side
■■ Limb of interest closest to *The oblique views
the plate Craniolateral-caudomedial oblique are not routinely
■■ Contralateral limb pulled ■■ As for the craniocaudal view, but with some performed at the
caudally inward rotation (about 15°)* authors’ clinic

Positioning for mediolateral (neutral) (Fig 3a), mediolateral (flexed) (Fig 3b) and craniocaudal (Fig 3c) radiographs of the right elbow

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mediolateral view of the elbow is one of the first radio-

logical signs apparent in dogs with elbow dysplasia. Box 6: Views of the carpus
The craniocaudal view of the elbow highlights the Dorsopalmar views (including stressed
margins of the humeral condyle. The epicondylar ridges valgus/varus)
are common sites for periarticular new bone (osteo­ ■■ Patient in sternal recumbency
phyte) production as a result of elbow osteoarthritis. ■■ Limb pulled cranially
This view also facilitates assessment of the continuity
Stressed dorsopalmar views (valgus and varus)
of the humeral condylar articular surface (eg, distal
■■ Can highlight carpal instability, which is often
humeral osteochondrosis, ‘kissing lesions’ associated present if there is collateral ligament injury
with coronoid disease and incomplete ossification of
the humeral condyle, Fig 5). Mediolateral
Oblique views of the elbows are often taken follow- ■■ Patient in lateral recumbency
ing the appearance of suspicious lesions on mediolateral ■■ Limb of interest should be placed closest
and/or craniocaudal views. The craniolateral-caudo- to the plate
medial oblique view allows further visualisation of the
Stressed mediolateral (flexion and extension)
medial coronoid process. The craniomedial-caudo­ ■■ May be used to highlight instability secondary
lateral oblique view offers superior highlighting of the to hyperextension injury
lateral epicondylar and radial articular margins.

Carpus and manus small bone chips or avulsion fracture fragments often
The carpus consists of seven bones in two rows stabi- lying adjacent to the normal structures. Fractures of
lised by a sheath of soft tissues, the short radial and the proximal aspect of the fifth metacarpal bone are
short ulnar collateral ligaments and numerous small almost invariably associated with palmar instability/
ligaments. Radiographic interpretation is limited due to hyperextension injury.
superimposition of the other bones. Standard orthogo-
nal views should be obtained as a minimum database.
Stressed dorsopalmar or mediolateral views may eluci- Arthroscopy
date medial/lateral or palmar instability, respectively
(Box 6). Arthroscopy is commonly performed in the larger
Fractures of the distal ulna or radius (styloid proc- joints of the forelimb – that is, the shoulder and
esses) are often associated with carpal joint instability, elbow – and, occasionally, the antebrachiocarpal
laterally or medially, respectively. Such fractures are joint. Shoulder arthroscopy can provide information
seen clearly on dorsopalmar views, although they may regarding injury to the soft tissue structures, notably
be obscured in mediolateral views. Stressed views of the articular cartilage, the synovial membrane, the lat-
these lesions are sometimes useful. eral and medial glenohumeral ligaments, the origin of
Fractures of the radial (seen mostly in box- the biceps tendon and the insertion of the subscapu-
ers), accessory (particularly in racing greyhounds) laris tendon, all of which are thought to be sources of
and ulnar (rare) carpal bones can be appreciated on significant forelimb lameness.
radiographs, although CT is the imaging modality of Indications for arthroscopy of the elbow include
choice for assessing these bones. Chip fractures of the radiographic signs of ulnar subchondral sclerosis in
numbered carpal bones are also not uncommon, with the region of the semilunar notch, periarticular new
bone formation and directly appreciable lesions of
the anconeal or coronoid processes, or osteochon-
drosis of the humeral condyle. Arthroscopy has been
shown to allow a more detailed and more extensive
view of the elbow than arthrotomy and is considerably
less invasive. As well as being a useful diagnostic
tool, arthroscopy facilitates minimally traumatic
removal of osteochondral fragments and debridement
of cartilage defects (Fig 6).

Synoviocentesis

Synovial fluid samples may provide evidence of trau-

ma (eg, macrophages showing erythrophagia suggest
previous haemorrhage) and inflammatory (septic or
immune-mediated) conditions. The joints that are
routinely tapped are the shoulder, the elbow and the
Fig 6: Arthroscopic image of the left elbow of a carpus. The shoulder is typically approached cranio­
dog showing a loose osteochondral fragment of laterally with the limb held in a neutral position. The
the medial coronoid process and severe erosion of elbow is approached from the medial or lateral direc-
articular cartilage with exposed subchondral bone
tion, distal to the medial or lateral epicondyle, with the
on the medial part of the humeral condyle (medial
compartment disease). White articular cartilage is needle aimed at a gentle proximal incline. The ante-
apparent on the lateral part of the humeral condyle brachiocarpal joint is most commonly aspirated with

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the carpus fully flexed via a dorsal approach with the mation of a strand of fluid between finger and thumb
needle introduced perpendicular to the skin into the stretching up to 3 cm.
radiocarpal joint space. The middle carpal and car- Reduced viscosity is a non-specific indicator of joint
pometacarpal joints communicate with one another, pathology. Any synovial fluid deemed to be apparently
and can be approached in the fully flexed carpus from abnormal should be submitted to a laboratory for cyto-
a dorsal direction. Occasionally, aspiration of one or logical examination.
more of the metacarpophalangeal joints may be indi-
cated. The normal joint is difficult to aspirate, although
an effused joint may be sampled from a dorsal approach Further imaging
(taking care to avoid the digital extensor tendon and
dorsal sesamoid). Further diagnostic imaging of the canine forelimb
Gross assessment of joint fluid involves evaluating using CT, ultrasonography, magnetic resonance imag-
the volume, colour, turbidity and viscosity of samples. ing (MRI), and nuclear scintigraphy can provide valu-
Aspiration of more than 1 ml of synovial fluid can usu- able diagnostic information and can help to localise
ally be assumed to be abnormal. The fluid should be lameness. Access to these modalities is largely limited
colourless to clear light yellow. Discoloration may be to referral centres. Nuclear scintigraphy is used pri-
indicative of joint pathology, prior haemorrhage or marily to localise increased rates of bone remodelling
contamination with fresh blood during aspiration. which, in subtle causes of lameness, can help to identify
A turbid joint fluid indicates a raised cell count. The the site of pathology. However, this is a scarcely avail-
normal viscosity of synovial fluid should allow the for- able imaging modality in the UK. Ultrasonography of

Box 7: Differential diagnosis

Lameness localised to the joints of the forelimb

Shoulder Elbow ■■ Carpal ulnar and radial
■■ Osteochondrosis/ ■■ Elbow dysplasia collateral ligament trauma +
osteochondritis dissecans ++ Fractured medial coronoid
●●  ■■ Carpal laxity +
■■ Congenital luxation + process +++ ■■ Accessory carpal bone
■■ Shoulder dysplasia + ●● 
Osteochondrosis/ displacement/avulsion
■■ Bicipital tendinopathy/ osteochondritis dissecans ++ fracture +
rupture + ●● Ununited anconeal process ++ ■■ Centrodistal lameness (plantar
■■ Subscapularis ●● Incongruity ++ ligament enthesopathy
tendinopathy + ■■ Ununited medial epicondyle + and centrodistal joint
■■ Traumatic luxation + ■■ Congenital luxation osteophytosis) +
■■ Glenohumeral instability/ (type I, type II) +
subluxation + ■■ Incomplete ossification of Any joint
■■ Infraspinatus bursal the humeral condyle + ■■ Osteoarthritis +++
ossification + ■■ Polyarthritis ++
■■ Infraspinatus/supraspinatus Carpus ■■ Septic arthritis ++
contracture + ■■ Valgus/varus hyperextension ■■ Articular fracture ++
■■ Supraspinatus tendon injury ++ ■■ Joint neoplasia +
calcification + ■■ Incomplete ossification of the
■■ Incomplete ossification radial carpal bone (boxer) ++ Any bone/soft tissue
of the caudal glenoid + ■■ Dorsal radiocarpal ligament ■■ Neoplasia ++
■■ Metaphyseal osteopathy + trauma + ■■ Sepsis +

Lameness localised to the bones/soft tissues of the forelimb

Scapula ■■ Osteochondrosis/ commonly affects the distal
■■ Shoulder dysplasia + osteochondritis dissecans ++ radial metaphysis) +
■■ Incomplete ossification ■■ Panosteitis ++ ■■ Abductor pollicis longus
of the caudal glenoid + ■■ Early growth plate closure tenosynovitis +
leading to caudal/cranial
Humerus bowing ++ Digits
■■ Panosteitis ++ ■■ Congenital deformities ++ ■■ Fracture – chronic/
■■ Incomplete ossification ■■ Neoplasia ++ acute +++
of the humeral condyle ++ ■■ Retained endochondral ■■ Luxation ++
■■ Flexor tendon cartilage core (ulna) + ■■ Sesamoid disease ++
enthesopathy + ■■ Bone monostotic/congenital ■■ Corn ++
■■ Neoplasia ++ cysts + ■■ Osteomyelitis +
■■ Bone cyst + ■■ Osteomyelitis + ■■ Septic arthritis +
■■ Osteomyelitis + ■■ Hypertrophic pulmonary
osteopathy (Marie’s Any bone/soft tissue
Radius/ulna disease) + ■■ Neoplasia ++
■■ Fracture +++ ■■ Metaphyseal osteopathy (most ■■ Sepsis +

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

26 In Practice  January 2011 | Volume 33 | 20–27

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Companion animal praCtiCe

the forelimb can be useful in the investigation of soft for histopathology. The results of a recent study indi-
tissue injuries of the shoulder (Cogar and others 2008) cate that ultrasound-guided fine-needle aspiration of
although it requires the use of specialised equipment aggressive bone lesions is also a viable technique for
and expertise. CT is clinically useful for evaluating identifying malignant mesenchymal cells and for diag-
joint and bone pathology, with higher sensitivity and nosing appendicular sarcomas (Britt and others 2007).
specificity than conventional radiography, and is more
readily available than MRI. CT is invaluable for inves-
tigating elbow-related lameness. MRI offers sensitivity Summary
comparable to that of CT for joint and bone pathology
along with higher specificity in the diagnosis of soft Effective treatment of forelimb lameness requires
tissue lesions in the forelimb. When investigating fore- accurate diagnosis. Investigation of forelimb lame-
limb lameness, MRI is commonly reserved for imaging ness should begin with gait analysis, which may not
shoulders where it may complement arthroscopy by accurately predict the joint in question, but does pro- Acknowledgements
allowing visualisation of the extra-articular soft tissue vide information regarding the severity of disease and The authors would like to thank
structures such as the rotator cuff muscles. the limb affected. Palpation and manipulation of the Steve Joslyn and Mark Bush
for their suggestions during
forelimbs of the conscious animal should follow gait
the preparation of the original
analysis. Radiography, biopsy sampling and advanced manuscript of this article and
Biopsy imaging may be necessary, as appropriate. A struc- the nurses at Southern Counties
tured approach to investigation is vital to ensure that Veterinary Specialists for their
Radiographic signs of osteolysis with proliferation appropriate therapy is instituted. help with the images.
and sclerosis, cortical destruction along with peri-
osteal new bone formation (sometimes resulting in a
Further reading
Codman’s triangle) suggest bone neoplasia. Primary
BRITT, T., CLIFFORD, C., BARGER, A., MOROFF, S., DROBATZ, K., THACHER, C. & DAVIS,
osteosarcoma is by far the most common type of bone G. (2007) Diagnosing appendicular osteosarcoma with ultrasound-guided fine-needle aspiration:
neoplasia and typically arises from the metaphyseal 36 cases. Journal of Small Animal Practice 48, 145-150
region of the proximal humerus and distal radius. COGAR, S. M., COOK, C. R., CURRY, S. L., GRANDIS, A. & COOK, J. L. (2008) Prospective
Aggressive osteomyelitis (which may be bacterial evaluation of techniques for differentiating shoulder pathology as a source of forelimb lameness
or fungal; the latter has been rarely reported in the in medium and large breed dogs. Veterinary Surgery 37, 132-141
UK) may appear similar radiographically. Some very COOK, J. L. & COOK, C. R. (2009) Bilateral shoulder and elbow arthroscopy in dogs with forelimb
lameness: diagnostic findings and treatment outcomes. Veterinary Surgery 38, 224-232
lytic bone tumours may resemble cystic bone lesions.
MCKEE, M. & MACIAS, C. (2004) Orthopaedic conditions of the shoulder in the dog.
Unlike osteosarcoma, joint neoplasia such as synovial In Practice 26, 118-129
sarcoma is an uncommon cause of chronic progres- MCKEE, M. (2007) Lameness and weakness in dogs: is it orthopaedic or neurological?
sive lameness. Radiographically, joint tumours usually In Practice 29, 434-444
have a poorly defined periosteal reaction and multiple ROCH, S. & GEMMILL, T. (2009) Orthopaedic conditions of the metacarpus, metatarsus
punctate osteolytic lesions involving the epiphyses and digits in dogs. In Practice 31, 484-494
SAUNDERS, D. G., WALKER, J. R. & LEVINE, D. (2005) Joint mobilization.
on either side of the joint. Although radiographic find-
Veterinary Clinics of North America: Small Animal Practice 35, 1287-1316
ings may be highly suggestive, definitive diagnosis of
bone and joint tumours requires biopsy. Proper staging
of suspected neoplastic conditions must be performed.
Bone biopsies are easily obtained using a Jamshidi
needle (Fig 7). The technique involves making a stab
incision overlying the lesion (this should be sited
so that scar removal is possible at later surgery) and
advancing the needle into the bone. The stylet should
then be removed and the needle advanced a further
2 cm with a gentle to-and-fro twisting motion. Several
samples should be harvested. Samples may be rolled
onto a slide to create an impression smear for more
rapid cytological assessment before fixing in formalin

Fig 7: Jamshidi needle used to acquire core biopsy

samples of bone

In Practice January 2011 | Volume 33 | 20–27 27

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Investigation of lameness in dogs: 1.

Forelimb
Harry Scott and Philip Witte

In Practice 2011 33: 20-27

doi: 10.1136/inp.c7447

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