Canine Lameness

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Canine Lameness
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Canine Lameness
Edited by
Felix Michael Duerr, Dr. med. vet., MS, DACVS‐SA, DECVS, DACVSMR
Associate Professor, Small Animal Orthopedics
Department of Clinical Sciences
College of Veterinary Medicine and Biomedical Sciences
Colorado State University
Fort Collins, CO, USA
This edition first published 2020
© 2020 John Wiley & Sons, Inc.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in
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The right of Felix Michael Duerr to be identified as the author of the editorial material in this work has been asserted
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Library of Congress Cataloging‐in‐Publication Data

Names: Michael Duerr, Felix, editor.
Title: Canine lameness / edited by Felix Michael Duerr, Dr. med. vet., MS,
DACVS-SA, DECVS, DACVSMR, Associate Professor, Small Animal Orthopedics,
Department of Clinical Sciences, College of Veterinary Medicine and
Biomedical Sciences, Colorado State University, USA.
Description: Hoboken : Wiley-Blackwell, 2020. | Includes bibliographical
references and index.
Identifiers: LCCN 2019045104 (print) | LCCN 2019045105 (ebook) | ISBN
9781119474029 (paperback) | ISBN 9781119474036 (adobe pdf ) | ISBN
9781119474050 (epub)
Subjects: LCSH: Lameness in dogs.
Classification: LCC SF992.L36 C36 2020 (print) | LCC SF992.L36 (ebook) |
DDC 636.7/089758–dc23
LC record available at https://lccn.loc.gov/2019045104
LC ebook record available at https://lccn.loc.gov/2019045105
Cover Design: Wiley

Cover Images: Courtesy of Felix Duerr
Set in 9.5/12.5pt STIX Two Text by SPi Global, Pondicherry, India
10 9 8 7 6 5 4 3 2 1
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This book is dedicated to Alice, Banjo, Karla, Connor, Enno, Fine, Frankie, Harley,
Keester, Kelsey, Kono, Kutya, Lefty, Tide, Tootle, and Zach, and their phenomenal
people at the other end of the leash.
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Contents
List of Contributors xix

Preface xxi
Acknowledgments xxiii
Editor Biography xxiv
About the Companion Website xxv
Section 1 Lameness Diagnosis 1

Part I Lameness Evaluation 3
1 Subjective Gait Evaluation 5

Felix Michael Duerr
1.1 Introduction 5
1.2 Observation at Rest 5
1.3 Observation in Motion 6
1.3.1 Presentation 6
1.3.2 Gait Patterns 7
1.3.3 Head Nod and Pelvic Tilt 8
1.3.4 Lameness Characteristics 11
1.3.5 Lameness Grading 12
References 13
2 Objective Gait Analysis 15

Bryan T. Torres
2.1 Introduction 15
2.2 Kinetic Analysis 15
2.2.1 Force Plate Systems: The Basics 16
2.2.2 Force Plate Systems: Kinetic Measurements 17
2.2.3 Force Plate Systems: Clinically Reported Values 18
2.2.4 Pressure-sensitive Walkway Systems: The Basics 19
2.2.5 Pressure-sensitive Walkway Systems: Clinically Reported Values 20
2.2.6 Static or Standing Kinetic Analysis 20
2.3 Kinematic Analysis 21
2.3.1 Description and Measurement of Joint Motion 22
2.3.2 Kinematic Systems 23
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2.3.3 Kinematic Models 25

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2.3.4 Other Methods of Kinematic Analysis 27

2.3.5 Kinematic Variables 27
2.4 Making the Best of Your Gait Data Collection 27
2.4.1 Habituation 27
2.4.2 Animal Handlers 28
2.4.3 Velocity and Acceleration 28
2.4.4 Marker Application 28
2.4.5 Comparing Averages 28
2.5 Evaluating Gait Data 28
2.5.1 Normalization to Body Weight 29
2.5.2 Percent Change 29
2.5.3 Gait Symmetry 29
References 29
3 The Orthopedic Examination 31

Dirsko J.F. von Pfeil and Felix Michael Duerr
3.1 Introduction 31
3.2 The Orthopedic Examination 31
3.2.1 History and Signalment 32
3.2.2 Visual Exam 33
3.2.3 Palpation 33
3.2.3.1 Pelvic Limb Palpation 37
3.2.3.2 Thoracic Limb Palpation 38
3.2.3.3 Other Techniques for Lameness Detection 38
References 39
4 The Neurologic Examination 41

Lisa Bartner
4.1 Introduction 41
4.2 Neuroanatomy Related to Limb Function 42
4.2.1 Anatomical Components of the Nervous System 42
4.2.2 Functional Components of the Nervous System 44
4.2.2.1 Motor Systems 44
4.2.2.2 Sensory System 47
4.3 The Neurologic Examination 48
4.3.1 Mentation Status (Awareness) and Behavior 50
4.3.2 Posture 51
4.3.3 Gait 51
4.3.4 Cranial Nerves 53
4.3.5 Postural Reactions 53
4.3.5.1 Proprioceptive Positioning and Placing Reaction 55
4.3.5.2 Hopping Reaction 56
4.3.6 Muscle Mass and Tone 56
4.3.7 Spinal Reflexes 56
Contents ix
4.3.7.1 Myotatic (Stretch) Reflexes 58

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4.3.7.2 Flexor (Pedal and Withdrawal) Reflexes 59

4.3.7.3 Perineal Reflex 60
4.3.7.4 Cutaneous Trunci (“Panniculus”) Reflex 60
4.3.8 Sensory Testing and Palpation 61
4.3.8.1 Nociception 61
4.3.8.2 Spinal and Limb Palpation 62
4.3.8.3 Cutaneous Sensory Testing 62
4.4 Diagnostic Tests 63
4.4.1 Survey Radiographs 64
4.4.2 Myelography 64
4.4.3 Computed Tomography 64
4.4.4 Magnetic Resonance Imaging 64
4.4.5 Electrodiagnostic Examination 65
4.4.6 Cerebrospinal Fluid Analysis 65
References 65
5 The Rehabilitation Examination 67

Sasha Foster
5.1 Introduction 67
5.2 Passive Range of Motion 68
5.2.1 How to Perform Passive Range of Motion Testing 73
5.2.2 How to Interpret Passive Range of Motion Testing 76
5.3 Joint Play 77
5.3.1 How to Perform Joint Play Testing 77
5.3.2 How to Interpret Joint Play Testing 79
5.4 Flexibility Testing 79
5.4.1 How to Perform Flexibility Testing 80
5.4.2 How to Interpret Flexibility Testing 80
5.5 Strength Testing 81
5.5.1 How to Perform Strength Testing 81
5.5.2 How to Interpret Strength Testing 82
References 83
6 The Myofascial Examination 85

Rick Wall
6.1 Introduction 85
6.2 Characteristics of Myofascial Trigger Points 85
6.3 Etiology and Pathophysiology of Myofascial
Trigger Points 86
6.4 The Myofascial Examination 87
6.5 Myofascial Pain Syndrome Patterns Associated with Lameness 88
6.6 Clinical Significance 89
References 90
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Part II Diagnostic Techniques 93

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7 Arthrocentesis Technique 95
Bryan T. Torres and Felix Michael Duerr
7.1 Introduction 95
7.2 Risks and Contraindications 96
7.3 Restraint 96
7.4 Site Preparation 96
7.5 Equipment 96
7.6 Approaches 98
7.6.1 Carpus 99
7.6.2 Elbow 99
7.6.3 Shoulder 100
7.6.4 Tarsus 101
7.6.5 Stifle 102
7.6.6 Hip 102
References 104
8 Diagnostic Joint Anesthesia 105

Bryan T. Torres and Felix Michael Duerr
8.1 Introduction 105
8.2 Patient Selection 105
8.3 Sedation Protocols 106
8.3.1 Sedation Protocol A: Sedation with an α₂-Adrenergic Receptor Agonist 106
8.3.2 Sedation Protocol B: Sedation with a Neuroleptanalgesic and Opiate 107
8.4 Intra-articular Anesthetic Instillation 108
8.5 Lameness Evaluation and Interpreting the Effect of Diagnostic Joint Anesthesia 108
References 110
9 Joint Fluid Analysis and Collection Considerations 111

Adam Harris and Kelly Santangelo
9.2 Sample Submission and Prioritization of Diagnostic Tests 111
9.3 Gross, Biochemical, and Cytologic Examination 113
9.3.1 Gross Appearance 113
9.3.2 Protein Concentration 113
9.3.3 Total Nucleated Cell Counts 113
9.3.4 Cytological Analysis 116
9.3.5 Mucin Clot Test 116
9.4 Canine Arthropathies 120
9.4.1 Suppurative Arthropathies 120
9.4.1.1 Immune-mediated 120
9.4.1.2 Infectious 120
9.4.2 Nonsuppurative Arthropathies 121
9.4.2.1 Mononuclear Inflammation 121
9.4.2.2 Hemarthrosis 122
9.4.3 Neoplasia 122
References 122
Contents xi
10 Diagnostic Imaging Techniques in Lameness Evaluation 125

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Angela J. Marolf
10.2 Radiography 125
10.3 Ultrasonography 126
10.4 Computed Tomography 127
10.5 Magnetic Resonance Imaging 130
10.6 Nuclear Medicine 131
References 133
11 Diagnostic Approach to Neoplastic Conditions Causing Lameness 135

Bernard Séguin
11.2 Diagnostic Methods 135
11.2.1 Physical Examination 135
11.2.2 Fine-needle Aspirate and Biopsy 135
11.2.3 Diagnostic Imaging 137
11.2.4 Staging 137
11.3 Specific Tumors 138
11.3.1 Skin and Subcutaneous Neoplasia 138
11.3.2 Muscle Neoplasia 138
11.3.3 Bone Neoplasia 138
11.3.4 Joint Capsule Neoplasia 138
References 139
Section 2 Regional Diagnosis 141

Part III Distal Limb Lameness 143
12 Distal Limb Region 145

Nicolaas E. Lambrechts
12.2 Normal Anatomy 145
12.2.1 Thoracic Limb 145
12.2.2 Pelvic Limb 151
12.2.3 Function, Posture, and Carriage 152
12.3 Arthritis 152
12.4 Fractures of the Distal Limb Region 154
12.4.1 Metacarpal and Metatarsal Fractures 154
12.4.2 Digit Fractures and Luxations 154
12.4.3 Sesamoid Disease 155
12.5 Conditions of Muscles, Tendon, and Ligaments 157
12.5.1 Dorsal Digital Ligament Sprain 157
12.5.2 Digital Flexor Muscle and Tendon Injuries 157
12.5.2.1 Superficial Digital Flexor Muscle 157
12.5.2.2 Deep Digital Flexor Muscle 159
12.5.2.3 Flexor Tendon Strain: Bowed Tendon 159
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12.6 C onditions of the Digital and Paw Pads 159

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12.6.1 Trauma 159

12.6.2 Corns 159
12.6.3 Abnormal Wear and Migration 161
12.6.4 Dermatologic Conditions Causing Lameness 161
12.6.4.1 Pemphigus Foliaceus 162
12.6.4.2 Superficial Necrolytic Dermatitis 162
12.6.4.3 Paw Pad Hyperkeratosis 162
12.6.4.4 Zinc‐responsive Dermatoses 162
12.7 Conditions of the Digit/Paw Skin 162
12.7.1 Interdigital Web Injuries 162
12.7.2 Pododermatitis 163
12.7.3 Acral Lick Dermatitis 163
12.8 Conditions of the Claws 163
12.8.1 Trauma 164
12.8.2 Paronychia 164
12.8.3 Deformed Claws 164
12.8.4 Symmetrical Lupoid Onychodystrophy 164
12.9 Other Conditions Affecting the Distal Limb Region 164
12.9.1 Neurological Conditions 164
12.9.2 Dysostoses 165
12.9.3 Hypertrophic Osteopathy 165
12.9.4 Metabolic Bone Diseases 166
12.9.5 Distal Limb Region Neoplasia 166
References 166
Part IV Thoracic Limb Lameness 169
13 Carpal Region 171

Denis J. Marcellin-Little and Dirsko J.F. von Pfeil
13.1 Introduction and Common Differential Diagnoses 171
13.2 Normal Anatomy and Osteoarthritis 171
13.2.1 Immune-Mediated Polyarthritis 175
13.3 Fractures of the Carpal Region 175
13.3.1 Signalment and History 177
13.3.3 Diagnostics 179
13.4 Carpal Hyperextension and Other Carpal Ligamentous Injuries 179
13.4.4 Other Carpal Ligamentous Injuries 184
13.5 Deformities of the Carpal Region 185
Contents xiii
13.6 T
endinous and Muscular Lesions of the Carpal Region 186
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13.7 Other Diseases Affecting the Carpal Region 187

13.7.1 Lack or Loss of Carpal Extension 187
13.7.2 Lack or Loss of Carpal Flexion 188
13.7.3 Hypertrophic Osteodystrophy 189
13.7.4 Shearing Injuries 190
13.7.5 Carpal Region Neoplasia 191
13.7.6 Miscellaneous Other Conditions 191
References 191
14 Elbow Region 195

Felix Michael Duerr
14.2 Normal Anatomy and Arthritis 195
14.3 Fractures of the Elbow Region 200
14.3.2 Physical Exam 201
14.4 Incomplete Ossification of the Humeral Condyle 201
14.5 Elbow Dysplasia/Incongruity 203
14.6 Medial Compartment Disease 205
14.7 Traumatic Fracture of the Medial Coronoid Process 208
14.8 Osteochondrosis Dissecans 209
14.9 Ununited Anconeal Process 209
14.10 Elbow Luxation 210
14.11 Panosteitis 212
14.12 Septic Arthritis 214
14.13 Flexor Enthesopathy 215
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14.14 Other Diseases Affecting the Elbow Region 217
14.14.1 Calcinosis Circumscripta 217
14.14.2 Radioulnar Ischemic Necrosis 218
14.14.3 Triceps Tendon Disruption 218
14.14.4 Elbow Region Neoplasia 218
References 219
15 Shoulder Region 223

Kristina M. Kiefer and Dirsko J.F. von Pfeil
15.2 Normal Anatomy and Osteoarthritis 223
15.3 Fractures of the Shoulder Region 229
15.4 Medial Shoulder Instability 231
15.5 Traumatic Shoulder Luxation 235
15.6 Biceps Brachii Tendinopathy 237
15.7 Supraspinatus Tendinopathy 242
15.8 Infraspinatus Disease 243
15.10 Other Diseases Affecting the Shoulder Region 248
15.10.1 Caudal Glenoid Fragments 248
15.10.2 Glenoid Dysplasia 248
15.10.3 Adhesive Capsulitis 248
15.10.4 Shoulder Region Neoplasia 249
References 250
Contents xv
16 Neurological Disease of the Thoracic Limb 255

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Lisa Bartner
16.2 Relevant Anatomy 255
16.3 Neurological Diseases Affecting the Thoracic Limb 257
16.3.1 Myelopathies and Radiculopathies 257
16.3.1.1 Degenerative Intervertebral Disc Disease and Herniation 260
16.3.1.2 Acute Non-Compressive Nucleus Pulposus Extrusion 261
16.3.1.3 Fibrocartilaginous Embolism 262
16.3.1.4 Cervical Spondylomyelopathy 262
16.3.1.5 Other Causes of Cervical Myelopathies and Radiculopathies 263
16.3.2 Neuropathies (Nerves and Brachial Plexus) 263
16.3.2.1 Neoplasia 264
16.3.2.2 Traumatic Neuropathies 264
16.3.2.3 Neuritis 265
16.3.3 Myopathies and Junctionopathies 266
16.3.4 Other Spinal Diseases Affecting the Thoracic Limb 266
References 268
17 Neoplastic Conditions of the Thoracic Limb 271

Bernard Séguin
17.2 Neoplasia of Specific Regions 271
17.2.1 Distal Limb Region 271
17.2.2 Carpal Region 273
17.2.3 Elbow Region 273
17.2.4 Shoulder Region 273
17.2.5 Nervous System 274
17.2.5.1 Spinal Cord Tumors 274
17.2.5.2 Peripheral Nerve Tumors 276
References 277
Part V Pelvic Limb Lameness 279
18 Tarsal Region 281

Kathleen Linn and Felix Michael Duerr
18.3 Fractures of the Tarsal Region 288
18.4 Tarsal Joint Luxations 291
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18.5 Pathology of the Common Calcanean Tendon 294

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18.5.1 Traumatic Rupture 295

18.5.2 Chronic Gastrocnemius Tendinopathy 296
18.5.3 Luxation of the Superficial Digital Flexor Tendon 297
18.7 Other Diseases Affecting the Tarsal Region 300
18.7.1 Tarsal Deformities 301
18.7.2 Idiopathic Tarsal Hyperflexion 302
18.7.3 Idiopathic Tarsal Hyperextension 302
18.7.4 Osteochondrosis Fragment Migration into the DDF Tendon Sheath 303
18.7.5 Tarsal Region Neoplasia 304
References 304
19 Stifle Region 307

Jennifer Warnock and Felix Michael Duerr
19.2.1 The Stifle Joint 307
19.2.2 Muscles of the Stifle Joint 313
19.3 Fractures of the Stifle Region 314
19.3.1 Patellar Fractures 315
19.3.2 Salter-Harris Fractures 316
19.4 Cranial Cruciate Ligament Disease 316
19.4.2.1 Postural and Gait Changes 318
19.4.2.2 Palpation 319
19.5 Patellar Luxation 329
19.6 Stifle Luxation 334
19.7 Isolated Caudal Cruciate Ligament Rupture 336
19.9 Patellar Ligament Pathology 339
19.9.1 Nontraumatic Patellar (Ligament) Desmopathy 340
19.9.2 Patellar Ligament Laceration/Rupture 340
19.10 Other Diseases Affecting the Stifle Region 340
19.10.1 Angular Limb Deformity 340
19.10.2 Gastrocnemius Injury 341
Contents xvii
19.10.3 Long Digital Extensor Tendon Injury 341

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19.10.4 Stifle Region Neoplasia 342

References 343
20 Hip Region 347

Nina R. Kieves
20.3 Fractures of the Hip Region 353
20.3.1 Sacroiliac Joint Luxation and Sacral fractures 353
20.3.2 Fractures of the Ilium 353
20.3.3 Fractures of the Coxofemoral Joint 354
20.3.3.1 Fractures of the Acetabulum 354
20.3.3.2 Slipped Capital Femoral Physis and Femoral Neck Fractures 355
20.4 Coxofemoral Luxation 356
20.5 Hip Dysplasia 358
20.6 Avascular Necrosis of the Femoral Head 366
20.7 Muscle Contractures 367
20.7.1 Gracilis Contracture 367
20.7.1.1 Signalment and History 368
20.7.1.2 Physical Exam 369
20.7.1.3 Diagnostics 370
20.7.2 Quadriceps Contracture 370
20.7.2.1 Signalment and History 370
20.7.2.2 Physical Exam 370
20.7.2.3 Diagnostics 371
20.8 Iliopsoas Tendinopathy 371
20.9 Other Diseases Affecting the Hip Region 373
20.9.1 Sacroiliac Joint 373
20.9.2 Septic Arthritis 374
20.9.3 Muscle Strains and Tears 374
20.9.4 Hip Region Neoplasia 374
References 376
xviii Contents
21 Neurological Disease of the Pelvic Limb 379

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Lisa Bartner
21.2 Relevant Anatomy 379
21.3 Neurological Diseases Affecting the Pelvic Limb 381
21.3.1 Myelopathies and Radiculopathies 381
21.3.1.1 Neoplasia 383
21.3.1.2 Spinal Cord Injury 383
21.3.1.3 Degenerative Lumbosacral Stenosis and Foraminal Stenosis 383
21.3.1.4 Discospondylitis 384
21.3.2 Neuropathies (Nerves and Lumbosacral Plexus) 386
21.3.2.1 Sciatic Nerve Injury 386
21.3.2.2 Fibular (Peroneal) Nerve Injury 387
21.3.2.3 Tibial Nerve Injury 387
21.3.2.4 Femoral Nerve Injury 388
21.3.3 Myopathies and Junctionopathies 388
21.3.4 Other Neurologic and Spinal Diseases Affecting the Pelvic Limb 389
References 389
22 Neoplastic Conditions of the Pelvic Limb 391

Bernard Séguin
22.2 Neoplasia of Specific Regions 391
22.2.1 Distal Limb Region 391
22.2.2 Tarsal Region 391
22.2.3 Stifle Region 392
22.2.4 Hip Region 393
22.2.5 Nervous System 393
References 394
Glossary 397
List of Abbreviations 401
Index 403
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List of Contributors
Lisa Bartner, DVM, MS, DACVIM (Neurology) Kristina M. Kiefer, DVM, PhD, CCRP, DACVSMR
Assistant Professor VetSSMART, LLC
Neurology/Neurosurgery Veterinary Surgery and
Department of Clinical Sciences Sports Medicine Assistance,
College of Veterinary Medicine and Research and Tutelage
Biomedical Sciences St. Paul, MN
Colorado State University USA
Fort Collins, CO
USA Nina R. Kieves, DVM, DACVS‐SA, DACVSMR
Assistant Professor
Felix Michael Duerr, Dr. med. vet., MS, Small Animal Orthopedic Surgery
DACVS‐SA, DECVS, DACVSMR Department of Veterinary
Associate Professor Clinical Sciences
Small Animal Orthopedics The Ohio State University
Department of Clinical Sciences Columbus, OH
College of Veterinary Medicine and USA
Biomedical Sciences
Colorado State University Nicolaas E. Lambrechts, BVSc, MMedVet
Fort Collins, CO (Surgery), DECVS, DACVSMR
USA Associate Professor
Small Animal Orthopedics
Sasha Foster, MSPT, CCRT Department of Clinical Sciences
James L. Voss Veterinary Teaching Hospital College of Veterinary Medicine and
Colorado State University Biomedical Sciences
Fort Collins, CO Colorado State University
USA Fort Collins, CO
USA
Adam Harris, DVM
Resident Kathleen Linn, DVM, MS, DACVS
Clinical Pathology Associate Professor
Department of Microbiology, Immunology, Small Animal Surgery
and Pathology Department of Small Animal Clinical
College of Veterinary Medicine and Sciences
Biomedical Sciences Western College of Veterinary Medicine
Colorado State University University of Saskatchewan
Fort Collins, CO Saskatoon, Saskatchewan
USA Canada
xx List of Contributors
Denis J. Marcellin‐Little, DEDV, DACVS, DACVSMR Flint Animal Cancer Center

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(Charter) Colorado State University

Professor Fort Collins, CO
Orthopedic Surgery USA
Department of Veterinary Surgical and
Radiological Sciences Bryan T. Torres, DVM, PhD, DACVS‐SA, DACVSMR
School of Veterinary Medicine Assistant Professor
University of California Small Animal Orthopedic Surgery
Davis, CA Director of the Motion Analysis Laboratory
USA Department of Veterinary Medicine and
Surgery
Angela J. Marolf, DVM, DACVR College of Veterinary Medicine
Associate Professor University of Missouri
Radiology Columbia, MO
Department of Environmental and USA
Radiological Health Sciences
College of Veterinary Medicine and Dirsko J.F. von Pfeil, Dr. med. vet., DVM, DACVS,
Biomedical Sciences DECVS, DACVSMR
Colorado State University Owner, Surgeon:
Fort Collins, CO Small Animal Surgery Locum, PLLC
USA Dallas, TX
USA
Kelly Santangelo, DVM, PhD, DACVP Staff Surgeon:
Associate Professor Sirius Veterinary Orthopedic Center
Clinical Pathology Omaha, NE
Department of Microbiology, Immunology, USA
and Pathology
College of Veterinary Medicine and Rick Wall, DVM, DACVSMR
Biomedical Sciences Animal Clinics of The Woodlands
Colorado State University The Woodlands, TX
Fort Collins, CO USA
USA Center for Veterinary Pain Management and
Rehabilitation
Bernard Séguin, DVM, MS, DACVS The Woodlands, TX
ACVS Founding Fellow USA
Surgical Oncology
Associate Professor Jennifer Warnock, DVM, PhD, DACVS‐SA
Surgical Oncology Carlson College of Veterinary Medicine
Department of Clinical Sciences Oregon State University
College of Veterinary Medicine and Corvallis, OR
Biomedical Sciences USA
xxi
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Preface
Canine lameness is a common problem in clinical practice. While there is a plethora of equine
literature illuminating causes of equine lameness, few such resources are available in the canine
field. This is likely because of the greater emphasis on lameness in daily equine practice. However,
with the recent surge of canine sports and pet owners placing increasingly more emphasis on
maximizing their dogs’ happiness and activity, the field of canine orthopedics is changing – thus,
determining an accurate diagnosis and the prevention of orthopedic disease are playing a larger
role in canine practice. The goal of this textbook, therefore, is to address this gap in the literature
by providing a single resource of clinically relevant information for the veterinary health profes-
sional faced with canine lameness problems.
Within the orthopedic community, lameness is generally defined as an alteration of normal loco-
motion that may be due to pain (e.g. arthritis or fractures), mechanical dysfunction (e.g. muscle
contractures), or neurologic conditions (e.g. spinal cord compression from disc disease; Renberg
2001; Baxter and Stashak 2011). However, within the neurologic community, lameness is more
specifically defined as pain from compression of the nerve roots and meninges (Chapter 4; Dewey
et al. 2016). This “neurogenic lameness” and monoparesis (i.e. lower motor neuron disease of a
single limb) are the most common reason for confusion between orthopedic and neurologic dis-
ease. For the purpose of this book, the term lameness is applied in its broader meaning, unless
specified otherwise (i.e. Chapters 4, 16, 21).
This book is divided into two sections. Section 1 focuses on lameness evaluation, describing the
different types of exams (e.g. orthopedic and neurologic examination, etc.) that aid in localization of
a problem causing gait abnormalities (Part I) and the recommendations regarding specific diagnostic
procedures that aid in establishing a definitive diagnosis (Part II). Section 2 describes the most com-
mon reasons for lameness, organized by the anatomical regions of the distal limb (Part III), thoracic
(Part IV), and pelvic (Part V) areas including the major joints and surrounding areas. For ease of
identification these chapters are marked with colored tabs. This organization was chosen to provide
a resource that mimics the hypothetical clinical scenario where the examiner first identifies an
abnormality (e.g. pain or swelling) in a specific area and then develops a differential diagnosis list and
diagnostic plan based on that finding. Thus, each region chapter focuses on musculoskeletal diseases
of the specific area. The other two causes of lameness, namely oncologic and neurologic, are described
in the individual Chapters 16, 17 and 21, 22 for the thoracic and pelvic limb, respectively.
The emphasis of this text is to provide the necessary resources to establish a diagnosis for dogs
presenting with lameness, with a particular focus on physical exam and radiographic findings.
While neurologic conditions are included, the scope of the book is limited to conditions that can
be confused with lameness. For this reason, conditions that cause obvious neurologic abnormali-
ties in multiple limbs are only discussed to the degree that they apply as a differential diagnosis for
lameness. The reader is encouraged to consult other resources for further details on neurologic
xxii Preface
conditions. Similarly, the purpose of this book is not to provide a detailed anatomic description of
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each region but rather to limit the scope to the most clinically relevant information. Veterinary
anatomic textbooks will provide a useful resource to the reader seeking more detailed anatomic
descriptions. Additionally, since this book is focused on the diagnosis of lameness, treatment
options are only briefly mentioned. The reader should consult other texts for detailed information
on the best management of each individual condition. Recommended anatomy, surgery, and neu-
rology resources include the following texts: Evans and De Lahunta (2013), Tobias and Johnston
(2013), Dewey and Da Costa (2016), and Fossum (2018).
The more that you read, the more things you will know. The more that you learn, the more
places you’ll go.
Dr. Seuss
R
eferences
Baxter, G.M. and Stashak, T.S. (2011). Examination for lameness. In: Adams and Stashak’s Lameness in
Horses (ed. G.M. Baxter), 109–206. Hoboken: Wiley‐Blackwell.
Dewey, C.W. and Da Costa, R.C. (2016). Practical Guide to Canine and Feline Neurology. Hoboken:
Wiley‐Blackwell.
Dewey, C.W., Da Costa, R.C., and Thomas, W.B. (2016). Performing the neurologic examination. In:
Practical Guide to Canine and Feline Neurology, 3e (eds. C.W. Dewey and R.C. Da Costa), 92–137.
Hoboken: Wiley‐Blackwell.
Evans, H.E. and De Lahunta, A. (2013). Miller’s Anatomy of the Dog. Philadelphia: Saunders.
Fossum, T.W. (2018). Small Animal Surgery. St. Louis: Elsevier Health Sciences.
Renberg, W.C. (2001). Evaluation of the lame patient. Vet Clin North Am Small Anim Pract 31 (1): 1–16.
Tobias, K.M. and Johnston, S.A. (2013). Veterinary Surgery: Small Animal. St. Louis: Elsevier Health
Sciences.
xxiii
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Acknowledgments
Countless people have contributed to this book in such diverse ways that I am hesitant to start list-
ing names for fear of missing someone – all were critical to creating the text in hand and I am
grateful so many colleagues offered their expertise and made this book all the better through their
contribution. Karyl Whitman, our tireless editor and Jeremy Delcambre, the outstanding anato-
mist, helped get all the fine details right. The beautiful drawings were provided by Molly Borman.
Colorado State University’s Orthopedic Team contributed abundant case material, insightful dis-
cussions, and exceptional photographs. My friends and family, both the two‐ and four‐legged ones,
deserve a heartfelt “Thank You” for putting up with me throughout the protracted writing process,
particularly Colleen, who had avoided the topic of canine lameness throughout much of her pro-
fessional career only to be subjected to an unsolicited crash course in the comfort of our own
home. Many walks, rides, meals, drinks, and adventures are owed to them all. And finally, to my
fantastic parents, Christa and Ulrich M. Duerr, for decades of support and encouragement to
follow my passion and without whom none of this would have been possible.
Felix Duerr
xxiv
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E
ditor Biography
Felix Duerr completed his veterinary degree in Hannover, Germany, followed by internships in
Saskatoon, SK, Canada, and a residency in Small Animal Surgery at Colorado State University, Fort
Collins, CO, USA. He spent a number of years working as a surgeon in private practice before
returning to Colorado State University in 2011. He is a Diplomate of the American College of
Veterinary Surgeons (ACVS), European College of Veterinary Surgeons (ECVS), and the American
College of Veterinary Sports Medicine and Rehabilitation (ACVSMR). Dr. Duerr currently oversees
the Orthopedic Medicine and Mobility Program at Colorado State University and is passionate
about finding new treatment options for animals with mobility concerns. He has a particular inter-
est in injury prevention, which is what triggered the idea for this book – that establishing an accu-
rate diagnosis early in the disease process is the key to optimizing treatment solutions.
xxv
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About the Companion Website
Don’t forget to visit the companion website for this book:
www.wiley.com/go/duerr/lameness
There you will find valuable video clips to enhance your learning.
Scan this QR code to visit the companion website.

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1
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Section 1
Lameness Diagnosis
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3
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Part I
Lameness Evaluation
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5
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Subjective Gait Evaluation

Felix Michael Duerr
Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins,
CO, USA
1.1 Introduction
Lameness can be due to orthopedic, oncologic, or neurologic conditions that disrupt the tissues
responsible for normal locomotion. Subjective gait analysis is one component of the orthopedic
and neurologic examination and provides valuable information to assist in determining what
limb(s) and structures are affected. Succeeding chapters further discuss the other components
that play an important role in any canine lameness evaluation (e.g. history, orthopedic examina-
tion, etc.).
1.2 Observation at Rest
Subjective gait evaluation starts by observing the animal at rest, when it stands, or raises from a
sitting or lying position. Frequently, this can be accomplished by letting the animal roam freely in
the exam room during the history taking. During this time, the observer may also evaluate mental
status, behavior, and posture of the patient (which is part of the neurologic exam, see Chapter 4).
Many dogs will show obvious off‐loading of the affected limb during standing (Video 1.1), particu-
larly with cranial cruciate ligament disease and neurogenic (i.e. nerve root signature) lameness.
Caution should be used when interpreting off‐loading if the animal is not standing square. Anxious
animals may be encouraged to stand still by leading them toward an exit door, pausing prior to
opening the door. Most dogs will focus on the door being opened and while being distracted, the
observer can judge weight‐bearing in a square position.
Video 1.1:
Pelvic limb lameness – unilateral CCLD.
Canine Lameness, First Edition. Edited by Felix Michael Duerr.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/duerr/lameness
6 1 Subjective Gait Evaluation
Difficulty in either rising, or sitting, or both suggests a problem in the hind end. For example,
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animals with cranial cruciate ligament disease will display a classic sitting pattern avoiding flexion
of the affected stifle(s). Animals that sit “square” (Chapters 19 and 20; Video 20.2) are unlikely to
suffer from cruciate disease. Animals with lumbosacral disease may have difficulty rising, while
animals with bilateral cruciate disease will hesitate to sit down. Spontaneous knuckling (i.e. stand-
ing on the dorsum of their paw during stance) indicates neurologic disease.
1.3 Observation in Motion
During the subjective gait evaluation, the observer is attempting to localize and specify the type of
lameness (e.g. which leg is most severely affected, neurologic versus orthopedic origin, etc.).
Certain gait features, such as ataxia or dragging/scuffing of the toes, clearly indicate neurologic
disease. Decreased range of motion in a joint and the associated gait changes may point toward an
articular source of the lameness. Changes in stride length may indicate a musculoskeletal or neu-
rologic problem. Increased range of motion may indicate a ligament problem (such as carpal
hyperextension injury with increased carpal extension or Achilles tendon rupture with increased
tarsal flexion).
The use of slow‐motion video analysis for improving the observer’s ability to identify a lameness
has been reported in dogs and horses; however, no clinical benefit was observed in a recent canine
study using dogs (He Lane et al. 2015). Although in that study the degree of lameness was not
quantified. Nonetheless, in the author’s experience, this technique can be extremely helpful in
dogs with a subtle lameness (Video 1.2). Slow‐motion videography is integrated into newer smart
phone devices and numerous apps also offer this feature, thus making it easily utilized in daily
practice.
Video 1.2:
Thoracic limb lameness – case examples.
1.3.1 Presentation
Ideally, the animal is presented by a dedicated handler/technician. Since most owners are not used
to walking their dog without interfering with gait, this approach will allow reducing the time
required to complete the lameness evaluation: the handler should allow the animal to move freely
(e.g. not pulling on the leash) yet at a constant speed. Pulling on the leash makes observation of a
head nod more difficult. Ideally, the animal should look straight ahead during evaluation. This can
be accomplished by letting the animal walk toward the owner.
The animal should be observed at the walk and ideally at the trot if the severity of the lameness
allows. In general, if animals are unable to trot, their disease should be severe enough that lame-
ness identification can be done at a stance or walk. A flat, even surface with good traction, such as
a parking lot or driveway, is ideal to avoid distractions (such as areas to sniff/mark). The gait should
be viewed both from the side (to judge stride length, symmetry, and possible changes in sagittal
joint range of motion) and the animal moving toward and away from the examiner (to judge head
nod, pelvic tilt, and frontal plane abnormalities).
1.3 Observation in Motio 7
To make a lameness more detectable, the animal can be asked to trot in circles, walk stairs, go up
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and down hills, or perform the tasks that trigger an impaired gait or movement (e.g. such as jump-
ing for agility dogs). For example, animals with thoracic limb disease will display a more pro-
nounced head nod when going downstairs and will use the non‐affected limb to step down first.
Animals with hip dysplasia will show simultaneous advancement of the pelvic limbs (i.e. “bunny
hopping”) when going upstairs. Subjective gait evaluation generally is performed prior to manipu-
lation; however, sometimes manipulation may worsen the lameness.
1.3.2 Gait Patterns

To allow the clinician appropriate evaluation of gait, an understanding of normal gait patterns is
essential. Gait patterns are generally described by their beat, whether they have a suspension phase
and whether they are lateral or diagonal gait patterns. The beat describes the number of ground
impacts within each stride cycle (i.e. the walk is a four‐beat gait because each limb touches the
ground at different time points within the stride cycle). The suspension phase describes a phase
where none of the feet are touching the ground, which is observed only in gaits with a high velocity
like the trot and canter. The description of diagonal versus lateral gait describes which limb pair is
supporting the animal’s weight (i.e. a diagonal gait indicates that the diagonal limb pairs move
simultaneously such as when trotting; whereas, in a lateral gait, the ipsilateral limb pairs move
simultaneously such as when pacing). For detailed online descriptions of the footfall patterns and
slow‐motion animations, consult Datt and Fletcher (2012).
The dog’s ambulatory motion has been described to consist of up to seven different gait patterns:
walk, trot, pace, amble, canter, transverse and rotary gallop (Leach et al. 1977; Datt and Fletcher
2012). The walk is a four‐beat gait without a suspension phase. The amble is an accelerated walk,
maintaining the four‐beat gait pattern. The trot is a two‐beat, diagonal gait with suspension phase.
The pace is a two‐beat, lateral gait in which ipsilateral limb pairs move in synchrony (Figure 1.1 and
Video 1.3). The canter is an asymmetric gait (i.e. a three‐beat gait with different patterns on the right
and left side). The gallop is the fastest gait. While there has been controversy whether the pace is a
normal or abnormal gait, it has been described to be used by dogs without obvious orthopedic disease.
Proposed reasons for dogs to pace include orthopedic pathology, tiring, confirmation such as propor-
tionally long legs, or an acquired gait due to being forced to walk at speeds between the walk and trot
(Wendland et al. 2016). Particularly if a dog switches from a regular walk to pacing, evaluation for any
change in orthopedic status is indicated. However, while pacing as the only symptom (i.e. without
obvious lameness) may be an early indicator of musculoskeletal disease, it should not be considered
pathologic by itself. Regardless, it is important for the clinician to assess whether a dog uses the pace.
Video 1.3:
Trotting versus pacing.
Another important reason to understand gait patterns is to allow for interpretation of compensa-
tion patterns for lameness such as head nod or pelvic tilt. The trot is the most steady and rhythmic
gait and therefore generally the easiest gait to identify a mild–moderate lameness. Interpretation
of lameness becomes more complicated in animals that are pacing. As such, if the animal can be
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Figure 1.1 Simplification of the footfall patterns of the pace. The pace is a symmetrical lateral gait,
meaning that ipsilateral limb pairs move simultaneously. Black paw prints represent thoracic limb feet and
grey paw prints represent pelvic limb feet.
discouraged from pacing by choosing a different velocity (e.g. by having the handler increasing
speed, see Video 1.3), this may simplify the subjective gait analysis.
1.3.3 Head Nod and Pelvic Tilt

To unload a painful limb, animals use specific adaptive strategies to reduce pain associated with
weight‐bearing. This is accomplished by shifting weight toward the unaffected limb(s), changes in
joint angles, and alterations in foot flight. In horses, the most consistent compensatory movements
are the vertical displacement and acceleration of the head in thoracic limb lameness and the verti-
cal movement of the pelvis/tuber coxae in pelvic limb lameness (Baxter and Stashak 2011; Ross
2011). However, an overlap of these movements has been described (i.e. head movement with
pelvic limb gait abnormalities particularly if lameness is severe).
Vertical head movement (i.e. the head and neck moving up and down during ambulation), also
described as a head nod or head bob, is generally associated with thoracic limb lameness. It is
observed because the animal attempts to off‐weight the affected leg. The head is lowered when the
non‐affected thoracic limb touches the ground and raised when the affected thoracic limb touches
the ground (Figure 1.2 and Video 1.2). To reduce the amount of weight placed on the affected limb,
raising of the head happens just before the foot touches the ground. This can be observed in slow
motion and in horses it has been suggested that raising of the head and neck may be easier to
observe than the lowering (Ross 2011). A head nod may also be observed with severe pelvic limb
lameness, because the animal is attempting to shift its body weight forward. Since the trot is a diagonal
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Left thoracic limb lameness Left pelvic limb lameness
Head lowers during stance Head lowers during stance

phase of right thoracic limb phase of left pelvic limb
Animal places more Animal places more

weight on right weight on right
thoracic limb to unload thoracic limb to unload
left thoracic limb left pelvic limb
LEFT
thoracic limb
UPWARD movement of the head

in the TROT
during stance phase of the
………...
RIGHT
thoracic limb
Animal places more Animal places more
weight on left thoracic weight on left thoracic
limb to unload right limb to unload right
thoracic limb pelvic limb

phase of left thoracic limb phase of right pelvic limb
Right thoracic limb lameness Right pelvic limb lameness
Figure 1.2 Interpretation of head movement for canine lameness during trotting (a diagonal gait),
illustrating the interpretation of upward movement of the head and neck during stance phase.
gait, the head nod of a pelvic limb lameness will mimic a thoracic limb lameness of the ipsilateral
side. For example, if the head is lowered during the left front stance phase, this indicates a right
thoracic limb lameness or a right pelvic limb lameness (or both which would result in an exagger-
ated head nod). It is important to understand that these concepts only apply to a diagonal gait (i.e.
the trot). When the animal paces, the opposite is true (i.e. a right thoracic limb lameness mimics a
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Right pelvic limb lameness
Mimics diagonal thoracic limb Mimics ipsilateral thoracic limb

lameness lameness
Yes Pacing? No
Two-beat, Two-beat,
lateral gait diagonal gait
Animal places more weight on right Animal places more weight on left
thoracic limb to unload right pelvic thoracic limb to unload right pelvic
limb limb

phase of right thoracic limb phase of left thoracic limb
May be confused with left May be confused with right

thoracic limb lameness thoracic limb lameness
Figure 1.3 Interpretation of head movement for canine pelvic limb lameness comparing trotting (a
diagonal gait) and pacing (a lateral gait), illustrating the interpretation of downward movement of the head
and neck during stance phase. While this diagram is based on pelvic limb lameness, similarly the observer
may confuse a left thoracic limb lameness with a right pelvic limb lameness if the dog paces (and vice versa).
left pelvic limb lameness and vice versa, see Figure 1.3). It is therefore of critical importance that the
observer determines if the animal is displaying a diagonal (i.e. trot) or lateral (i.e. pacing) gait.
Pelvic movement, also termed the pelvic or hip hike, is displayed by animals with pelvic limb
lameness. The animal will attempt to reduce the amount of weight placed on the affected leg by
elevating the pelvis of the affected side, thereby shifting its body weight to the unaffected limb(s).
This may be more difficult to observe in long‐haired dogs. In dogs with a high‐grade lameness, a
significant drop of the pelvis is observed when the unaffected limb contacts the ground (Videos 1.1
and 1.4). In horses, it is described that the limb with the greater movement of the pelvis rather than
the absolute height determines the lame leg (Baxter and Stashak 2011). Another feature allowing
canines to shift their weight to the affected limb is excessive tail movement, generally observed
swinging up when the affected limb contacts the ground.
Video 1.4:
Pelvic limb lameness – bilateral CCLD.
To differentiate whether a head nod is arising from a thoracic limb or pelvic limb lameness during
subjective gait analysis, the following criteria can be applied: thoracic limb lameness – a pelvic hike is
only rarely present; pelvic limb lameness – generally impairment is so severe that off‐weighing at the
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stance can also be observed, the dog’s body weight is shifted forward resulting in a lower head and
neck carry age than usual, and obvious clinical exam findings (e.g. stifle instability) are present.
Multiple limb lameness provides a greater diagnostic challenge. In some cases, identification of
specific patterns clearly indicates that multiple limbs are involved. For example, a dog presenting
with a severe right pelvic limb lameness would be expected to display a downward movement of
the head on the left thoracic limb in the trot. If a downward movement is observed during weight‐
bearing of the right thoracic limb, this indicates that the animal is also suffering from a left thoracic
limb problem. If the animal is simultaneously suffering from an ipsilateral thoracic limb and pelvic
limb lameness, an exaggerated head nod will be observed. In horses, the concept of compensatory
(also termed secondary or complementary) lameness is well established. This lameness is defined
as pain secondary due to overloading of the unaffected limb. It is difficult to differentiate compen-
satory lameness from a primary cause. In general, the most severe lameness should be addressed
primarily; however, evaluation of all affected limbs is indicated.
While the above concepts are described for a diagonal gait, similar concepts can be applied if the
animal is unable to trot (i.e. during walking). The observer should look for off‐loading of specific
limbs, decreased stance phase, head nod, and pelvic hike. Following the simple concept, that animals
will try to shift their body weight away from the lame limb, helps identify the most affected limb.
1.3.4 Lameness Characteristics

In horses, the stride is divided into the cranial and caudal phase, which is the length of the stride of
the affected limb cranial or caudal to the stance position of the contralateral limb (Ross 2011). In
other words, the cranial phase of the stride is the phase in front of the hoofprint of the opposite limb
(Baxter and Stashak 2011). Lame horses frequently have a decreased cranial stride phase and a
lengthened caudal phase; however, the overall stride length is not changed with lameness. This
makes clinical sense since a unilaterally decreased stride length would not allow for movement in
a straight line (Ross 2011), unless the changes are symmetric. Little is known regarding stride
phases and lameness distribution in dogs and some misconceptions about it (e.g. that orthopedic
disease in canines always results in a decreased stride length) have been presented in the literature.
Clearly, further work in this area is needed but it is intuitive that an animal with bilateral coxofemo-
ral arthritis will show a decreased swing phase (to avoid pain during full range of motion) resulting
in the classic short‐strided gait (Video 20.2). Additionally, it is important to note that decreased
stride length is not pathognomonic for orthopedic disease but is also seen with neurologic condi-
tions (e.g. lower motor neuron disease; Chapter 4). This overlap between orthopedic and neurologic
causes can make differentiating the cause of lameness difficult. Therefore, careful neurologic and
orthopedic examinations are critical to confirm or exclude neurologic dysfunction.
In horses, supporting limb and swinging limb lameness are further differentiated. A supporting
limb lameness is observed when the foot first contacts the ground and indicates conditions of the
lower limb (a parallel example in canines would be a dog with a digit fracture). In contrast, the
definition of swinging limb lameness is not as clearly defined and varies between equine texts.
Ross (2011), for example, describes swinging limb lameness as a non‐painful lameness, rather than
a lameness during swing phase. Using this definition, canine infraspinatus contracture makes for
a good example of a correlate in dogs. However, some equine clinicians attribute a swinging limb
lameness to conditions of the upper limb (Baxter and Stashak 2011); when using this definition,
canine supraspinatus or biceps tendinopathy makes a good canine correlate.
1.3.5 Lameness Grading

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While there are many grading systems to score lameness subjectively, none of them have been vali-
dated or used consistently in canine orthopedics. The most commonly used grading scale in horses
is the American Association of Equine Practitioners (AAEP) system (Ross 2011): 0 = no lameness;
1 = inconsistent lameness under specific circumstances only; 2 = consistent lameness under spe-
cific circumstances only; 3 = consistent lameness at a trot; 4 = consistent lameness at a walk; and
5 = most severe lameness. While this scoring system simplifies the grading, it makes things poten-
tially confusing because it grades lameness at both the walk and trot.
Various grading systems have been proposed to score severity of lameness in dogs, including the
use of numerical rating scales (NRS) and visual analog scores (VAS). NRS describe the lameness in
descriptive terms such as sound and non‐weight‐bearing using scales of up to 11 points (Van Vynckt
et al. 2011). Although larger scales allow for differentiation of more subtle lameness, this results in
less consistency between multiple observers (such as multiple veterinarians within one practice).
Therefore, simple scales (Table 1.1) that allow subjective comparison within or between observers
and temporal periods (i.e. if different examiners evaluate a patient at different time points) are pref-
erable to use. VAS provide an assessment of continuous limb function. This is accomplished by ask-
ing the observer to mark the severity of lameness along a line (generally divided into 100 increments).
The results are recorded as continuous variables (Quinn et al. 2007). It is well known that subjective
gait analysis varies between observers and correlates poorly to objective gait analysis (Quinn et al.
2007; Waxman et al. 2008). Ideally, objective gait analysis would be used to provide a quantitative
analysis; however, given the lack of its availability, an effort should be made to at least use a consist-
ent scoring system by all healthcare professionals within one institution.
Table 1.1 Unvalidated numerical rating score used by the author to subjectively quantify canine lameness.
Score Lameness degree Lameness description
0 None No identifiable lameness

Weight‐bearing at all times
1 Slight Inconsistent lameness that is difficult to observe and/or it is difficult to
determine the affected limb (i.e. no consistent head movement/pelvic tilt is
observed)
2 Mild Clearly detectable lameness associated with minor head movement/pelvic tilt
3 Moderate Clearly detectable lameness associated with obvious head movement/pelvic tilt
4 Severe Clearly detectable lameness associated with obvious head movement/pelvic tilt
Occasionally non‐weight‐bearing/toe touching
5 Non‐weight‐ Always non‐weight‐bearing/toe touching
bearing
This scoring system can be applied at the walk and/or the trot depending on the patient’s clinical status. The patient
should only be scored during motion (i.e. off‐loading at a stance is not included in this assessment). To increase the
sensitivity, the scoring system can be applied for both gaits. If a comparison between different time points is
performed, only the scoring within one gait can be compared.
Reference 13
R
eferences
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Datt, V.L. and Fletcher, T.F. (2012). Gait foot‐fall patterns. http://vanat.cvm.umn.edu/gaits/index.html
(accessed 12 February 2019).
He Lane, D.M., Hill, S.A., Huntingford, J.L. et al. (2015). Effectiveness of slow motion video compared
to real time video in improving the accuracy and consistency of subjective gait analysis in dogs.
Open Vet. J. 5 (2): 158–165.
Leach, D., Sumner‐Smith, G., and Dagg, A.I. (1977). Diagnosis of lameness in dogs: a preliminary
study. Can. Vet. J. 18 (3): 58–63.
Quinn, M.M., Keuler, N.S., Lu, Y. et al. (2007). Evaluation of agreement between numerical rating
scales, visual analogue scoring scales, and force plate gait analysis in dogs. Vet. Surg. 36 (4): 360–367.
Ross, M.W. (2011). Movement. In: Diagnosis and Management of Lameness in the Horse, 2e (eds. M.W.
Ross and S.J. Dyson), 64–80. Saint Louis: W.B. Saunders.
Van Vynckt, D., Samoy, Y., Polis, I. et al. (2011). Evaluation of two sedation protocols for use before
diagnostic intra‐articular anaesthesia in lame dogs. J. Small Anim. Pract. 52 (12): 638–644.
Waxman, A.S., Robinson, D.A., Evans, R.B. et al. (2008). Relationship between objective and subjective
assessment of limb function in normal dogs with an experimentally induced lameness. Vet. Surg. 37
(3): 241–246.
Wendland, T.M., Martin, K.W., Duncan, C.G. et al. (2016). Evaluation of pacing as an indicator of
musculoskeletal pathology in dogs. J. Vet. Med. Anim. Health 8 (12): 207–213.
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Objective Gait Analysis

Bryan T. Torres
Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, MO, USA
2.1 Introduction
The use of objective gait analysis techniques to evaluate veterinary patients has increased recently.
In the past few years, gait analysis equipment has become more affordable and has begun to move
from a research and specialty setting into everyday practice. Despite this, there remains little to no
attention given to objective gait analysis techniques and equipment during veterinary school edu-
cation. Because of this, many veterinarians begin performing gait analysis with little understand-
ing of the fundamentals behind these techniques. Unfortunately, this can result in poor data
collection and/or erroneous interpretation of results – negatively impacting patient care. Therefore,
it is critical that veterinarians interested in these techniques are familiar with the basics of gait
analysis.
In general, objective gait analysis can be divided into two main categories: (i) kinetics and
(ii) kinematics. Kinetic gait analysis focuses on the forces generated during movement while
kinematic gait analysis focuses on motion that occurs during ambulation without concern for
forces.
2.2 Kinetic Analysis
Kinetic gait analysis evaluates the forces produced when an animal’s foot is in contact with the
ground. Therefore, the stance phase is the only portion of the full gait cycle where kinetic informa-
tion is recorded. In many musculoskeletal or neurologic conditions, patients may have a lameness
which results in reduced forces in the affected limb (e.g. reduced weight‐bearing) making this a
key method of detecting pathology as well as monitoring a response to therapy.
There are two major systems used in veterinary medicine to record kinetic information: (i) force
plates (FPs) (or platforms) and (ii) pressure‐sensitive walkways (PSWs). There are important differ-
ences between these two systems. It is important that clinicians understand the benefits as well as
the limitations of each system to maximize their clinical use.

16 2 Objective Gait Analysis
2.2.1 Force Plate Systems: The Basics

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FPs measure force or more specifically ground reaction forces (GRF). Put simply, GRF are the equal
yet opposing force produced when an animal’s foot interacts with the ground. For example, when
we stand still on solid ground here on Earth, we are exerting a downward force on the ground that
is equal to the product of our mass and Earth’s gravity (F = m × g). The reason that we do not sink
into the ground is because the ground is exerting an equal and opposite upward force. This concept
was first described by Sir Isaac Newton and is known as Newton’s third law. When we move, as
compared to standing still, these forces are exerted in multiple directions, not just up and down.
These equal and opposite GRF produced when moving are the main focus of kinetic analysis with
FP systems.
FP systems are a staple in most modern veterinary gait laboratories (Figure 2.1A) and have long
been considered the gold standard in kinetic measurement of lame animals. However, there are
aspects of these systems that must be considered by clinicians:
Ideal Animal Size – FPs often have a shorter working length compared to PSW systems
(Figure 2.1B). Because of this, evaluating individual footfalls can be challenging in smaller ani-
mals or animals with shorter stride lengths. This makes typical FPs ideal for medium‐ to large‐
breed dogs. A method of adapting an FP for smaller animals has been described but is difficult
in a clinical setting (Kapatkin et al. 2014).
(A) (B)
(C) (D)
Figure 2.1 Kinetic and kinematic equipment: (A) modern veterinary gait laboratory; (B) dual (in‐line) force
plate system; (C) pressure‐sensitive walkway (PSW) system (Tekscan Walkway™); and (D) weight distribution
platform.
2.2 Kinetic Analysi 17
Portability and Storage – Most veterinary FP systems are permanently affixed to the ground in a
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dedicated space. The limited mobility of these systems should be considered by clinicians with-
out dedicated space or where portability is of importance.
2.2.2 Force Plate Systems: Kinetic Measurements

FP systems measure force in three directions: (i) vertical force, (ii) craniocaudal force, and (iii)
mediolateral force (Figure 2.2):
Vertical Force (Fz) – This is the largest and most commonly evaluated force. Graphically, it
appears “bell‐shaped” during a trot and “M‐shaped” during a walk (Figure 2.3) due to the speed
difference between trotting and walking (Decamp 1997). Changes in Fz are frequently used as
measures of function and pain. Animals with lameness secondary to orthopedic disease often
have a reduction in Fz values in affected limbs.
Craniocaudal Force (Fy) – This is the second largest force and is biphasic with two components
that define distinct periods of forward movement – braking (deceleration) and propulsion
(acceleration). Braking occurs at the beginning of stance and propulsion at the end (Figure 2.3).
While these forces are less commonly reported, animals with lameness secondary to orthopedic
disease can have a reduction in these components.
Mediolateral Force (Fx) – This is the smallest force in dogs moving in a straight line (Figure 2.3)
and is rarely used for comparison (Torres 2018). However, with the increased interest in canine
Figure 2.2 Measurements that can be obtained with different kinetic systems.
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Figure 2.3 Ground reaction forces, impulse values, and pelvic limb kinematics from dogs walking and
trotting.
athletics, where dogs undergo rapid directional changes, it is possible that evaluation may prove
valuable in the future.
While forces are the primary measurement of clinical interest in veterinary patients, FPs also
allow researchers to measure moments (Mz, My, and Mx) and to calculate the center of pressure
(COP; Figure 2.2). Moments are the turning effect of a force (e.g. “torque”). The COP is where the
vertical GRF is centered under the foot and has been used to evaluate balance in humans. Currently,
moments and COP are infrequently evaluated in veterinary patients.
2.2.3 Force Plate Systems: Clinically Reported Values

Peak Force – This is the maximum force (Fz, Fy, and Fx) and is graphically represented as the
peak or “top” of the force curve (Figure 2.3). The vertical force (Fz) has one peak referred to as
the peak vertical force (PVF). The craniocaudal force (Fy) is biphasic and has a peak braking
(PFybraking) and peak propulsive force (PFypropulsion). Reduced peak forces are associated with
lameness. These are the most commonly reported and compared values.
Impulse – The impulse of any GRF is the product of that force and stance time and is simply the
area under the force‐time curve (Figure 2.3). The vertical impulse (VI) (Iz) is a single value and
the craniocaudal impulse (Iy) is separated into braking (Iybraking) and propulsive (Iypropulsion)
components. Reduced impulses are associated with lameness.
2.2 Kinetic Analysi 19
Body Weight Distribution (%BWD) – This is calculated from PVF and is expressed as a percent-
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age (Table 2.1). It represents the percentage of total body weight placed on each limb. For most
dogs, normal %BWD is 60% in the front limbs (30% right; 30% left) and 40% in the pelvic limbs
(20% right; 20% left). Lame dogs will shift their weight to the non‐lame legs and have a reduced
%BWD in the affected limb. It is less common that FP software programs will automatically
calculate these values. Therefore, clinicians may need to manually calculate these values.
2.2.4 Pressure-sensitive Walkway Systems: The Basics

Kinetic analysis with PSW systems is based on pressure, specifically paw pressure, instead of force
(Figure 2.2). Pressure is measured by thousands of sensors embedded in the walkway. The main
clinical benefit of PSWs is in reporting stride characteristics with temporospatial variables (TSVs,
described below), the ability to record several consecutive foot strikes, semiautomated analysis, and
improved portability. Manufacturers producing pressure‐sensitive systems commonly used with
companion animals include Tekscan, Inc. (Walkway™; Tekscan, South Boston, Massachusetts, USA)
and CIR Systems, Inc. (GAIT4Dog®; CIR Systems, Franklin, New Jersey, USA). Systems can vary in
overall physical dimension, measurement capabilities, as well as the degree of computerized auto-
mation. It is important that clinicians consider their needs before purchasing any kinetic system:
Dimensions – PSW systems often have longer working lengths than individual FPs allowing for
recording of multiple footfalls in one pass over the walkway (Figure 2.1C). PSWs can be pur-
chased in varying length, depending on clinical need (i.e. size of patient population).
Ideal Animal Size – A wide range of animal sizes can be easily evaluated due to the longer record-
ing platform (compared to serially placed FPs). Some PSWs have sensors of varying degrees of
resolution and PSWs with higher‐resolution sensors are recommended for use with smaller
companion animals.
Table 2.1 Commonly used calculations for gait analysis parameters.
Variable Example formula
Body weight distribution (%BWD) PVF or Pressure from a single limb

%BWD 100
Total PVF or Pressure froom all limbs
Body weight normalization (%BW) Force experted by a limb Newtons

PVF as a%BW 100
Total weight of the dog Newtons
Percent change (%Change) X2 X1

%Change 100
X1
Symmetry index (SI) XR XL

SI 100
1
XR XL
2
Symmetry ratio (SR) XR

SR 100
XL
Portability and Storage – Many PSW systems can be “rolled‐up” or deconstructed for storage
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and/or transportation. This may be an important consideration for clinicians where dedicated
space is limited.
Kinetic Measurements – PSWs measure foot pressure and while sensor types can vary between
systems, all measure pressure only in the vertical direction. Pressure is related to but not the
same as force, measured with FPs. Clinically, vertical pressure measurements are often evalu-
ated similarly to GRF.
Temporospatial Variables (TSV) – The rapid collection and reporting of TSVs is a major strength
of PSWs. These variables (discussed later in this section) are calculated from the paw strikes
recorded by the PSW.
2.2.5 Pressure-sensitive Walkway Systems: Clinically Reported Values

Kinetic Variables – Pressure (vertical direction only) is the primary kinetic variable recorded with
PSWs (Figure 2.2). Some PSWs (i.e. Tekscan Walkway™) allow clinicians to use pressure measure-
ments to indirectly calculate force (PVF and VI) through a calibration process. Because this method
differs from direct force measurements obtained by FPs, these calculated force values are similar but
not directly comparable to ones obtained from FPs (Lascelles et al. 2006). Clinically, this means that
when evaluating patients (e.g. improved or reduced weight‐bearing), all measurements for compari-
son should be recorded with the same system (FP system or PSW system). How pressure values are
reported varies between PSW systems. Pressure values can be reported as a maximum pressure value
(Tekscan Walkway™) or as a scaled pressure value called a total pressure index (GAIT4Dog®).
Body Weight Distribution (%BWD) – This is calculated from pressure and is automatically cal-
culated by most PSW systems (Table 2.1). For the PSW systems that allow calculation of force
values, those can be used to calculate %BWD. See the FP section for additional information.
Temporospatial Variables (TSV) – These are not kinetic variables because they do not represent
force or pressure. Instead, they describe events related to time (temporo‐) and distance (‐spatial).
For example, stance and swing time are temporal measurement and stride length is a spatial
measurement. Stride velocity and acceleration involve both time and distance. Commonly
reported TSVs are listed below:
Gait Cycle (Stride) Time – The combined value of the stance time + swing time represents the complete
gait cycle of one leg. This occurs between each consecutive footfall (toe‐on to toe‐off to toe‐on).
Stance Time – This is the total time a foot is on the ground during the gait cycle (toe‐on to toe‐off).
This is often displayed as a percentage of the total gait cycle.
Swing Time – This is the total time a foot is off the ground during the gait cycle (toe‐off to toe‐on).
This is often displayed as a percentage of the total gait cycle.
Stride Length – This is the distance between two consecutive footfalls of the same leg. This repre-
sents the distance a foot travels during one complete a gait cycle.
Stride Velocity – This is the velocity (i.e. speed) at which a leg completes a gait cycle.
Stride Acceleration – This is the change in velocity (i.e. speed) between two consecutive strides.
2.2.6 Static or Standing Kinetic Analysis

The previous discussion focused on the more common dynamic kinetic analysis performed
when moving at a walk or trot. However, recently static kinetic analysis or “standing
2.3 Kinematic Analysi 21
weight‐bearing” has gained interest in veterinary medicine with the use of a weight distribution
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platform (WDP) or stance analyzer (Figure 2.1D). Static kinetics is not a new concept and can be
performed with more complex FP and PSW systems. However, dedicated WDP equipment
designed specifically to measure only standing weight‐bearing has entered the veterinary mar-
ket. This equipment is less expensive than complete kinetic systems and is a simple way to record
basic standing weight‐bearing measurements. It consists of a group of four pressure sensors that
are clustered together so that dogs can stand with each of their four paws on the individual pres-
sure sensors. Paw pressure is measured in real time and a computerized software displays the
%BWD in each limb.
Advantages of WDP systems are the ease of use and that minimal skill is required (Phelps et al.
2007). However, like any gait analysis tool, pitfalls during the collection process can affect the
results, such as distractions and head movement, abnormal limb position and posture, removing
or replacing paws during collection or restraint, and subjective acquisition of data only during
times of reduced or improved weight‐bearing. Unfortunately, research regarding these areas as
well as standardized and validated measurement protocols is lacking.
It is important to recognize that the role of standing weight‐bearing measurements in clinical
decision‐making is not well defined in dogs. The clinical relevance of limb off‐loading (e.g. lame-
ness) when standing as compared to moving is not fully understood. Currently, there is limited
published research regarding WDPs and there is only one recent peer‐reviewed publication com-
paring a WDP to a more well‐established kinetic system (PSW) in lame dogs (Clough et al. 2018).
That study demonstrated that a WDP was able to detect an objective lameness in a small and
widely varied population of dogs with various orthopedic conditions. However, the authors cau-
tion that the value of the WDP in dogs with more subtle or severe orthopedic disease is still
unknown. Additionally, they note that the value of a WDP in tracking the clinical progression of
orthopedic disease or therapeutic outcome has yet to be determined. For clinicians who desire to
use a WDP in clinical practice, it is important to recognize these current limitations in our under-
standing of WDPs. Where this equipment fits in clinical practice and more importantly how to
best utilize standing weight‐bearing measurements in patients with clinical disease are still being
explored.
2.3 Kinematic Analysis
Kinematic gait analysis is the study of motion and evaluates motion throughout the complete gait
cycle. Historically, joint angles have been most commonly evaluated and, in the past, this has been
limited to research facilities, universities, and large referral hospitals due to the expensive and
complex equipment. However, with computer and software advancement, this method of analysis
is now more widely available and affordable. This technology can vary greatly from simplistic and
inexpensive to the highly advanced and costly, respectively. With proper technique, any kinematic
systems can provide clinicians with valuable information to aid in the detection and treatment of
musculoskeletal pathologies.
Kinematic data collection in veterinary medicine is focused on evaluating motion in one of two
ways:
1) Motion occurring in a single plane (2D analysis)
2) Motion occurring in multiple planes (3D analysis)
In veterinary medicine, 2D analysis is most common. While 3D analysis provides a more complete
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representation of actual movement, it is complex to perform and requires advanced equipment.

This consideration needs to be accounted for when deciding what is most appropriate in a particu-
lar clinical setting.
2.3.1 Description and Measurement of Joint Motion

In veterinary kinematics, joint flexion and extension are most frequently evaluated, and for appen-
dicular joints, this is where the greatest degree of motion occurs. However, it is important that
clinicians remember that true joint motion occurs in multiple planes (Figure 2.4):
Sagittal Plane – This plane of motion describes joint flexion and extension. It is the most common
plane evaluated and is where the greatest amount of joint motion occurs.
Transverse Plane – This plane of motion describes joint internal rotation and external rotation.
Frontal Plane – This plane of motion describes joint abduction and adduction. Note: this termi-
nology differs from the terminology used for diagnostic imaging (Chapter 10) where this plane
is called dorsal plane.
Figure 2.4 Clinical joint motion in relation to the three planes of motion. Readers should note that the names
of planes used to describe joint motion can differ from those in diagnostic imaging (see also Figure 10.4).
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Box 2.1 Six Degrees of Freedom (6‐DOF) Movement
Joint rotations (3) Joint translations (3)

Flexion and extension Craniocaudal or “craniocaudal translation”
Internal and external rotation Mediolateral or “mediolateral translation”
Abduction and adduction Dorsoventral or “joint distraction”
In order to translate a complex biomechanical process like joint motion into clinically relevant
terms, we must use terminology that is meaningful to researchers and clinicians. Therefore,
joint motion is often discussed using the concept of six degrees of freedom (6‐DOF; Grood and
Suntay 1983). This describes clinical joint motion relative to three axes (x, y, and z) and associ-
ated with these axes are six distinct motions consisting of (3) rotations and (3) translations
(Figure 2.4; Box 2.1).
2.3.2 Kinematic Systems

Two‐Dimensional (2D) Systems – These are single camera systems that allow reliable collection
of motion in a single plane. These systems are simple and inexpensive (<$1000 in most cases).
Consumer grade cameras or even high‐quality cellular phone cameras can be used to capture
video of animals with high contrast spherical markers applied to the skin or coat (e.g. white
markers on a black dog or black markers on a white dog). These markers can then be digitized
by computerized software programs to determine joint or body movement. There are numerous
software programs for 2D kinematics. Kinovea (www.kinovea.org), for example, is a free and
open source program that is easy to use but lacks some of the more advanced and automated
features of paid software. Likewise, MaxTRAQ 2D (Innovision Systems, Inc., Columbiavile,
Michigan, USA) is an easy‐to‐use paid software program for 2D kinematics with many advanced
and automated features that clinicians find useful. Regardless of software, proper camera and
patient positioning is critical because 2D systems can be affected by parallax and perspective
error. Parallax error occurs when the subject moves away from the optical axis of the camera and
perspective error happens when the subject moves in and out of the calibrated plane of motion
(Kirtley 2006). In many cases, these errors can be reduced if clinicians pay careful attention to
camera and subject positioning during data collection. In general, the camera should be placed
at the maximum distance allowable from the subject to provide good resolution and field of
view, perpendicular to the plane interest (e.g. sagittal plane), and positioned at a height that
centers the camera at the level where the markers are to be tracked (Figure 2.5). Additionally,
data should be collected from patients moving along the calibrated plane without deviation
(Figures 2.6 and 2.7). Clinicians wishing for further information on these types of error are
directed to additional resources (Kirtley 2006; Torres 2018).
Three‐Dimensional (3D) Systems – These are multi‐camera systems that allow reliable collec-
tion of three‐dimensional motion. In most cases, these systems consist of specialized cameras
that track reflective markers placed on the skin. Unfortunately, these systems are expensive
(>$100 000 in many cases) and to evaluate true 3D joint motion a more complex marker model
is required. These aspects of 3D systems have restricted their use to research settings. However,
one significant benefit of these systems is that they do not suffer from parallax or perspective
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Camera elevated and projected Camera at level of subject and

downward and not perpendicular perpendicular to the calibrated
to the calibrated plane plane
90°
70°
Altered length measurements True length measurements

Altered joint angles True joint angles
Calibrated plane
Figure 2.5 A possible source of error in 2D kinematics: camera position relative to the subject.
Out-of-plane In-plane Out-of-plane

(near to camera) (far from camera)
Increased length measurements True length measurements Reduced length measurements

(no effect on joint angles) True joint angles (no effect on joint angles)
Calibrated plane
Figure 2.6 A possible source of error in 2D kinematics: subject positioning relative to the calibrated plane
(near‐far).
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Out-of-plane In-plane Out-of-plane

(head toward camera) (head away from camera)
Altered length measurements True length measurements Altered length measurements

Altered joint angels True joint angles Altered joint angels
Calibrated plane
Figure 2.7 A possible source of error in 2D kinematics: subject positioning relative to the calibrated plane
(rotation).
error, as is encountered with 2D systems. Unfortunately, even with technological advancement

and the declining cost of computerized hardware, the price of these systems remains high and
has limited their clinical application. Additionally, the complexity of the 3D models and operat-
ing systems makes every day clinical use challenging.
2.3.3 Kinematic Models

Clinically, kinematic analysis is most commonly performed by placing spherical markers on the
skin over specific areas of the body. The specific pattern in which these markers are placed is called
a kinematic model. The basics of these models and kinematic methods have changed very little for
over 180 years (Decamp 1997; Torres 2018).
Models used with 2D kinematic systems – These are simplistic and easy‐to‐use models focused
on one plane of motion, referred to as “planar” motion. Hence, these models are commonly
called planar models. Their pattern further defines them as linear, linked, or segment models
(Figure 2.8). In veterinary medicine, one of the most widely used 2D kinematic models for dogs
is a full‐body model (Figure 2.9).
Models used with 3D kinematic systems – In general, any model can be used with a 3D kine-
matic system, and historically, simple planar models described above have been used. However,
evaluation of true 3D joint motion requires more complex models, often referred to as rigid body
segment models (Figure 2.8). In the past few years, veterinary research has seen the use of these
models and systems increases. However, they are complex and require a larger number of mark-
ers as well as advanced 3D equipment and training to obtain clinically useful results. Currently,
use in a clinical setting is uncommon in veterinary medicine.
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Linked planar model Segmented planar model Rigid-body segmented model
Three markers for Four markers for Ten markers for

stifle motion stifle motion stifle motion
2D Rotation 2D Rotation and translation 3D Rotation and translation
Rotation: Rotation: Rotation:
• flexion and extension • flexion and extension • flexion and extension
Translation: • internal and external rotation
• craniocaudal translation • abduction and adduction
Translation:
• craniocaudal translation
• mediolateral translation
• dorsoventral translation
Figure 2.8 Comparison of three common kinematic models.
= Marker location Marker locations

= Location of joint angle
Pelvic limb
1. Distolateral aspect of the fifth
metatarsal bone
2. Lateral malleolus of the distal tibia
3. Femorotibial joint, midway
5 6 between the lateral epicondyle of
the femur and the fibular head
4 Shoulder 4. Greater trochanter of the femur
Hip 7 5. Iliac crest
Thoracic limb
3
Stifle 6. Dorsal aspect of the scapular
8 Elbow spine
7. Acromion/greater tubercle of the
2 scapulohumeral joint
Tarsus 8. Lateral epicondyle of the humerus
Carpus 9. Ulnar styoloid process/ulnar
9
carpal bone of the carpus
1
10 10. Distolateral aspect of the fifth
metacarpal bone
Figure 2.9 Common kinematic marker location for a 2D linked planar model.
2.4 Making the Best of Your Gait Data Collectio 27
2.3.4 Other Methods of Kinematic Analysis

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The methods discussed previously are the most common methods used in clinical patients.
However, there are other less common methods used mainly in a research setting that do not
require markers to be placed on the skin of clinical patients:
Radiographic and advanced imaging methods (such as fluoroscopy, computerized tomogra-
phy [CT], and magnetic resonance imaging [MRI]) have been used (mostly in a research setting)
to evaluate kinematics. Some of these methods increase the radiation exposure to patients as
well as personnel. The equipment needed for these methods is not widely available in most clini-
cal practices and is not clinically applicable at this time.
Body‐mounted inertial sensors, called inertial measurement units (IMUs), are used in human
laboratories and have gained interest for use in veterinary patients (Duerr et al. 2016). This
method relies on the attachment of IMUs, which contain accelerometers and gyroscopes, to
provide information on 3D motion. However, attachment of these small devices to the body has
proven difficult in small animal patients and therefore their clinical usefulness at this time is
uncertain.
2.3.5 Kinematic Variables

Although many variables are recorded in veterinary kinematics related to joint motion, the most
commonly evaluated are (Figure 2.3) as follows:
Average Joint Angle – The average or mean joint angle during movement.
Maximum Joint Angle (MAX) – The maximum (e.g. largest) joint angle during movement.
Minimum Joint Angle (MIN) – The minimum (e.g. smallest) joint angle during movement.
Joint Range of Motion (ROM) – The total range of joint motion during movement calculated by
subtracting the minimum joint angle from the maximum.
Percentage of Gait Cycle – Kinematics can evaluate the entire gait cycle and therefore the stance
phase and swing phase are often reported as a percentage of the total gait cycle.
Note: kinematic variables can be reported and evaluated as single point values (e.g. minimum or
maximum joint angle) or as a complete gait waveform.
2.4 Making the Best of Your Gait Data Collection
Clinicians can take important steps to make the best of the gait collection process. Most of these
steps help reduce error in a patient’s gait data by limiting factors that contribute to data variability.
Some factors are difficult to minimize, such as the small trial‐to‐trial or day‐to‐day variations, as
well as the effect of skin motion artifact on kinematic analysis (Torres 2018). However, other fac-
tors discussed below are easier to address.
2.4.1 Habituation
This is the process of acclimating clinical patients to the gait collection process and environment.
Clinicians should allow their patients a period of adjustment in the gait collection area prior to
collecting data. However, the ideal length of time needed for this is not established and may vary
between animals. In most cases, several minutes or more is recommended.
2.4.2 Animal Handlers

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It has been shown that differences in handlers can affect gait data. Therefore, clinicians should try
to limit the number of people who leash walk patients for gait analysis and when possible have the
same person walk an individual patient at each examination time.
2.4.3 Velocity and Acceleration

Changes in movement velocity (e.g. speed) and acceleration have some of the most profound
effects on both kinematic and kinetic gait data. Clinicians should select an acceptable velocity and
acceleration range prior to data collection and only collect trials that conform to that range. Ideal
velocity ranges for walking and trotting may vary between animals of differing sizes. In the author’s
experience, a walking velocity of 0.9–1.2 m/s, a trotting velocity of 1.7–2.1 m/s, and an acceleration
range of −0.5 to 0.5 m/s2 are appropriate for most medium‐ to large‐breed dogs. Information
regarding the merits of wider or narrower velocity ranges for trotting dogs can be found elsewhere
(Hans et al. 2014).
2.4.4 Marker Application

Much of the easily preventable error in kinematic analysis is related to errors in initial marker
placement or marker replacement (Kim et al. 2017; Torres 2018). Clinicians can minimize this by
designating a point person(s) to attach the markers to animals standing in a natural position as
well as establishing consistent protocols for marker placement. Standard marker locations have
been established for most models and many rely on marker application over easily palpable bony
landmarks to help ensure repeatability.
2.4.5 Comparing Averages

For kinetics and kinematics, single gait measurements should not be used for comparison.
Instead, clinicians should compare an average value from repeated measurements. An average
of five measurements or data from five trials are most commonly used for comparison. For PSW
systems where multiple and repeated measurements can occur during one pass, often the
results from five passes are averaged for comparison. Although the clinical benefit of using
more than five passes is unclear, clinicians should avoid using less than three measurements
for comparison.
2.5 Evaluating Gait Data
The appropriate analyses of data in kinetics and in kinematics often rely on similar methods. The
built‐in equipment software programs often can perform data comparison to varying degrees.
However, it is more common that data is exported into a spreadsheet program or a stand‐alone
statistical program for comparison.
In veterinary medicine, single‐point values such as PVF, VI, MAX, MIN, and ROM are most
commonly evaluated (Figure 2.3) and provide clinicians with a single value that is easier to inter-
pret and compare. Other methods may use the entire gait waveform for comparison (Torres 2018).
However, these methods are more complex and time consuming thereby limiting their usefulness
in a clinical setting.
Reference 29
2.5.1 Normalization to Body Weight

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Comparison of kinetic data (PVF, VI, and Pressure) should be performed with data that has been
normalized to an individual’s current body weight at the time of testing. In doing this, values are
expressed as a percentage of body weight (Table 2.1). Often, body weight normalization is per-
formed automatically by the built‐in software. However, some software programs will report data
as both raw and normalized values. The use of normalized values allows clinicians to account for
fluctuations in body weight when comparing different time points as well as provides a means to
compare animals of differing weights and sizes.
2.5.2 Percent Change

The Percent Change from Baseline method is one of the most common ways that patient gait data
is assessed in a clinical setting. It is most often performed by comparing the average of an initial or
“baseline” measurement ( X1 ) to a subsequent measurement ( X2 ). For example, baseline meas-
urements ( X1 ) obtained prior to therapy can be compared to measurements taken at recheck
examinations ( X2 ) to evaluate the clinical changes and/or the effectiveness of therapy. Results are
presented as a percentage. Using the formula in Table 2.1, a (+) percentage indicates an increase
as compared to baseline and a (−) percentage indicates a reduction. Therefore, if a lame dog was
evaluated with kinetic analysis before and after therapy, a (+) percentage change would indicate
an improvement in weight‐bearing following therapy, and a (−) percentage would indicate that the
lameness worsened.
2.5.3 Gait Symmetry

The symmetry of any gait variable (kinetic or kinematic) can be evaluated. This was first introduced
in small animals in the early 1990s and since then is frequently reported (Budsberg et al. 1993). The
most common methods to calculate gait symmetry in veterinary medicine are called a symmetry
index followed by a symmetry ratio (Table 2.1). Many PSW software programs calculate symmetry
ratios. Alternatively, they can be calculated manually by comparing the average value ( X ) from one
limb (front or pelvic) to the opposite limb (front or pelvic). In this way, the animal’s own limbs serve
as an internal control for comparison. Because symmetry ratio and symmetry index calculations
differ, the clinical interpretation of the results is different. However, clinicians should keep in mind
that while it is often assumed that healthy animals are perfectly symmetrical, this is not often the
case. Healthy dogs have been reported to have up to 6% asymmetry between their limbs (Torres
2018). Therefore, clinicians should interpret symmetry indices with great care in clinical patients.
R
eferences
Budsberg, S.C., Jevens, D.J., Brown, J. et al. (1993). Evaluation of limb symmetry indices, using ground
reaction forces in healthy dogs. Am. J. Vet. Res. 54 (10): 1569–1574.
Clough, W.T., Canapp, S.O. Jr., De Taboada, L. et al. (2018). Sensitivity and specificity of a weight
distribution platform for the detection of objective lameness and orthopaedic disease. Vet. Comp.
Orthop. Traumatol. 31 (06): 391–395.
Decamp, C.E. (1997). Kinetic and kinematic gait analysis and the assessment of lameness in the dog.
Vet. Clin. North Am. Small Anim. Pract. 27 (4): 825–840.
Duerr, F.M., Pauls, A., Kawcak, C. et al. (2016). Evaluation of inertial measurement units as a novel
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method for kinematic gait evaluation in dogs. Vet. Comp. Orthop. Traumatol. 29 (6): 475–483.
Grood, E.S. and Suntay, W.J. (1983). A joint coordinate system for the clinical description of three‐
dimensional motions: application to the knee. J. Biomech. Eng. 105 (2): 136–144.
Hans, E.C., Zwarthoed, B., Seliski, J. et al. (2014). Variance associated with subject velocity and trial
repetition during force platform gait analysis in a heterogeneous population of clinically normal
dogs. Vet. J. 202 (3): 498–502.
Kapatkin, A.S., Kim, J.Y., Garcia‐Nolan, T.C. et al. (2014). Modification of the contact area of a
standard force platform and runway for small breed dogs. Vet. Comp. Orthopaed. 27 (4): 257–262.
Kim, S.‐Y., Torres, B.T., Sandberg, G.S., and Budsberg, S.C. (2017). Effect of limb position at the time of
skin marker application on sagittal plane kinematics of the dog. Vet. Comp. Orthop. Traumatol. 30
(06): 438–443.
Kirtley, C. (2006). Clinical Gait Analysis: Theory and Practice. Edinburgh: Elsevier Health Sciences.
Lascelles, B.D., Roe, S.C., Smith, E. et al. (2006). Evaluation of a pressure walkway system for
measurement of vertical limb forces in clinically normal dogs. Am. J. Vet. Res. 67 (2): 277–282.
Phelps, H.A., Ramos, V., Shires, P.K., and Werre, S.R. (2007). The effect of measurement method on
static weight distribution to all legs in dogs using the quadruped biofeedback system. Vet. Comp.
Orthop. Traumatol. 20 (2): 108–112.
Torres, B.T. (2018). Gait analysis. In: Veterinary Surgery: Small Animal (eds. S.A. Johnston and
K. Tobias), 1385–1396. St. Louis: Elsevier.
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The Orthopedic Examination

Dirsko J.F. von Pfeil1,2 and Felix Michael Duerr3
1
Small Animal Surgery Locum, PLLC, Dallas, TX, USA
2
Sirius Veterinary Orthopedic Center, Omaha, NE, USA
3
CO, USA
3.1 Introduction
The orthopedic examination plays a crucial role in determining the source of lameness and appro-
priate diagnostic and therapeutic steps. Orthopedic examination findings should always be inter-
preted in conjunction with the findings from the general physical examination and if available the
myofascial (Chapter 6), rehabilitation (Chapter 5), and neurological examinations (Chapter 4), as
well as subjective (Chapter 1) and objective gait evaluation (Chapter 2). This chapter outlines
essential steps useful in assessing the overall orthopedic health of a dog. Additional information
and more detailed instructions on regional orthopedic examinations are further discussed in the
specific regional chapters contained within this book.
Early diagnosis of musculoskeletal conditions in animals is critical to improve a patient’s
final outcome by instituting appropriate treatment or preventative strategies early in the dis-
ease progression. Hence, at the minimum, a brief orthopedic exam should be performed on
every animal presenting to a veterinary health professional. A thorough orthopedic exam should
be performed on any patient with signs of musculoskeletal abnormalities or if orthopedic treat-
ment interventions are intended. A systematic approach to the orthopedic exam is important to
ensure evaluation of all structures and therefore, the exam should always be performed in the
same order.
3.2 The Orthopedic Examination
The orthopedic examination includes the following steps (Table 3.1):

1) History and signalment
2) Visual exam
3) Subjective gait analysis (Chapter 1)
4) Palpation

32 3 The Orthopedic Examination
Table 3.1 Summary of the components of the orthopedic examination.

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Component Variable Comments
Signalment Breed, age, and sex Inherited dog database can be consulted to determine
likely differential diagnoses (Sargan 2004)
History Onset of lameness To narrow down most likely diagnosis (e.g. geriatric
Inciting cause patient with progressive lameness = higher suspicion of
Progressiveness neoplasia and arthritis)
Response to treatment
Visual Conformational or Off‐loading of limb during standing/at rest indicates
examination anatomical abnormalities affected limb
Limb palpation Bones Possible observations include pain, swelling, and
crepitus (fracture)
Muscles Possible observations include atrophy, pain, and swelling
Joints Possible observations include periarticular swelling,
pain, crepitus, joint effusion, increased or decreased
range of motion, and abnormal end‐feel
Ligaments Possible observations include varus and valgus
instability
3.2.1 History and Signalment

Prior to performing a specific orthopedic examination, the history of lameness, previous diagnos-
tics (radiographs, other imaging, and laboratory tests), previous treatment attempts (medications,
rehabilitation, etc.) and their effect, goals of the owner for their pet, any other systemic disease
present, travel history, vaccination and preventative medications given, diet, and any supplements
administered should be recorded. Whether a pet or a working or sporting dog is examined is also
important since certain conditions have been associated with specific sporting activities, for exam-
ple, supraspinatus tendinopathy in agility dogs (Canapp et al. 2016) or specific orthopedic injuries
in marathon sled dogs (von Pfeil et al. 2015). Additionally, onset, possible causes such as trauma,
timing, and progression of lameness, will help narrowing down the diagnosis. For example, soft
tissue injuries frequently improve or resolve within days. However, an animal presenting with
chronic, progressive lameness is more likely to suffer from diseases such as chronic ligamentous
instability, arthritis, or neoplasia. If the lameness is worse in the morning or after longer periods of
rest, this may indicate degenerative disease. A lameness that improves with exercise is more likely
to be a chronic soft tissue problem or osteoarthritis, whereas a lameness that worsens is more likely
to be related to neoplasia or neurologic disease.
In general, caution is advised when trusting owners’ identification of a lameness. Owners fre-
quently misinterpret a head nod (i.e. identifying the incorrect limb as lame). But owner‐recorded
videos (when available) of the lameness can help the practitioner to identify the affected limb,
particularly if the lameness is inconsistent. Yet, a non‐weight‐bearing lameness can be correctly
identified by owners and hence this information is valuable and needs to be clearly teased out dur-
ing history taking. It is advisable to have owners point out the limb that they believe to be impaired
and specifically ask whether the animal has shown a non‐weight‐bearing lameness. Note that the
term “favoring,” although commonly used to describe a lameness, is somewhat confusing and as
such should be avoided – it is better to use the terms “using less” or “lame.”
3.2 The Orthopedic Examinatio 33
Pertinent questions that should be included in the history are as follows:

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1) Was the inciting cause of the lameness observed?

2) How long has the lameness been observed?
3) What was/is your dog’s activity level before/since the onset of lameness?
4) Has the lameness worsened, stayed the same, or improved?
5) Does the lameness improve or worsen with exercise?
6) Have any diagnostics been performed?
7) What treatment(s) has been initiated (including rest and pharmacologic management) and
what was the response?
Knowing the patient’s signalment and taking a thorough history in combination with knowledge
of predisposed breeds is very useful in establishing a diagnosis. Many patients presenting to the
veterinary health professional for lameness are suffering from inherited diseases. It is therefore
advisable to consider these diseases as highly likely differential diagnoses. Online resources are
available to provide this information for purebred dogs (Sargan 2004). For example, a frequent
diagnosis for an eight‐month‐old Labrador Retriever with a two‐month history of bilateral thoracic
limb lameness is elbow dysplasia (ED) or shoulder osteochondrosis dissecans.
3.2.2 Visual Exam

The distant, visual examination is an important part of the orthopedic exam and many conditions
can be suspected without physical palpation. As mentioned in Chapter 1, dogs will frequently
show off‐loading at a stance clearly indicating the affected limb, which is best observed from a
distance (Video 1.1). During the visual exam, conformational abnormalities such as angular limb
deformities, joint instabilities (e.g. valgus deviation with medial collateral ligament injury of the
carpus), and other osseous deformities can be identified. Periarticular swelling (which may indi-
cate joint effusion or chronic degenerative changes), soft tissue masses or swelling (such as Achilles
tendon swelling; Figure 18.8), or other obvious pathology (such as traumatic digit injuries;
Figure 12.8) can be noted. In shorthaired dogs, muscle atrophy can be visible. Standing joint angles
should be assessed and compared between contralateral limb pairs or to reported normal values
(Milgram et al. 2004) if bilateral abnormalities are present. For example, carpal hyperextension
(Video 13.1) and Achilles tendon rupture (Video 18.1) can be suspected based on the visually
increased joint angles.
3.2.3 Palpation
The examination can be performed with the patient in a standing or recumbent position, using
restraint as needed. However, because restraint affects the ability to interpret subtle responses of
the patient, its usage should be minimized. In general, a combination of standing and recumbent
positions is ideal. It is important to compare contralateral limbs to determine whether detected
abnormalities are normal or pathologic, keeping in mind that many diseases are bilateral. This is
best accomplished during a standing examination – if dogs are unable or unwilling to stand, an
assistant may support the dog’s weight by gently lifting from below the abdomen. The recumbent
position is necessary to perform certain specific tests (e.g. Ortolani) and helpful to allow more
detailed palpation of the affected limb. Recumbent versus standing position may also elicit a differ-
ent response from the animal and as such may be helpful if pain responses are difficult to interpret
in an individual patient.
Following a consistent approach to the orthopedic examination is recommended because doing

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so can avoid omitting important steps during the evaluation and subsequently missing a diagnosis.
A full neurologic examination (Chapter 4) should be performed in any dog suspected to have neu-
rologic disease. However, a few components of the neurologic examination should be included in
every orthopedic examination (i.e. paw replacement, paraspinal palpation, tail lift, and neck range
of motion). The text below, Table 3.2, and Video 3.1 outline the approach to the orthopedic exami-
nation regularly performed by the authors.
Video 3.1:
Complete orthopedic examination.
Starting the orthopedic examination with palpation of the pelvic limbs maintains distance from
the front of the animal, thus permitting an assessment of the patient’s demeanor in a safe manner.
The first step is to evaluate proprioception of both pelvic limbs by performing the paw replacement
test (Video 4.2). If there is uncertainty about which pelvic limb is affected, the examiner can gently
pull back on both legs simultaneously to compare weight‐bearing to identify the impaired leg
(Video 3.1). Subsequently, palpating the pelvic limbs simultaneously (comparing left to right) will
detect any muscle asymmetry, masses, or soft tissue swelling. The tarsus and stifle are also evalu-
ated for presence of joint effusion. Next, the examiner should lift the tail (a pain response may
indicate lumbosacral disease) and then perform paraspinal palpation (in between dorsal spinous
processes and the paraspinal musculature). This is followed by examining neck range of motion
(ventroflexion, dorsoflexion, and lateral movements). The thoracic limbs are palpated in a similar
fashion and compared for any asymmetry (e.g. muscle mass, soft tissue masses, etc.) and evaluated
for joint effusion of the elbow and carpus, ending at the distal limb whereupon proprioceptive test-
ing is performed (e.g. paw replacement test). To identify the lame thoracic limb, legs are lifted
alternatingly while standing over the animal.
Following this general palpation, a more detailed evaluation of the musculoskeletal structures of
the limbs is performed. While the above outlined steps 1–13 (Table 3.2) should be performed in a
standing position (to allow a comparative assessment), the following steps 14–44 may also be per-
formed in lateral recumbency. In general, the detailed palpation consists of long bone palpation
(e.g. evaluation for swelling, heat, pain, and crepitus), muscle palpation (e.g. evaluation for swell-
ing, hypertrophy, atrophy, and pain), collateral ligament assessment (e.g. applying varus/valgus
stress), joint assessment (e.g. performing flexion, extension for all joints, and abduction for shoul-
der and hip joint in addition to evaluation for periarticular swelling, crepitus, joint effusion, and
pain), and specific tests (e.g. drawer motion for cruciate disease). Of important note is that while
the detection of pain is an important feature of determining the source of lameness, it is not neces-
sary to elicit frequently referenced symptoms of pain (e.g. biting and vocalizing) to make this deter-
mination. The authors prefer to use more subtle signs, such as resistance to range of motion, head
turning, licking, widening of the pupillae, swallowing, muscle twitching, or moving away from the
evaluator (during standing exam). This approach maintains a positive relationship with the patient,
facilitating further diagnostics and treatment. Furthermore, it allows to follow a systematic, con-
sistent approach to the orthopedic exam (rather than evaluating the affected limb last as frequently
recommended).
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Table 3.2 Individual steps of the orthopedic examination.
Examination procedure/
Region Step structure Comment
Pelvic limbs 1 Evaluate weight Pulling caudally on the limbs can detect the affected
distribution limb
2 Paw replacement Delayed response indicates neurologic disease
3 Palpation for asymmetry Muscle atrophy can be disuse or neurogenic (i.e.
(muscle mass/soft tissue secondary)
swelling/masses, etc.) Pain, swelling, and masses indicate local pathology
(e.g. trauma, infection, neoplasia, etc.)
4 Tarsal joint effusion Indicates articular disease
5 Stifle joint effusion Indicates articular disease, most frequently cranial
cruciate ligament disease (CCLD)
Spine 6 Tail lift Pain indicates lumbosacral disease
7 Paraspinal palpation Pain indicates neurologic disease
8 Neck range of motion Pain indicates neurologic disease
Thoracic 9 Evaluate weight Lifting up on the limbs can detect the affected limb
limbs distribution
10 Palpation for asymmetry Muscle atrophy can be disuse or neurogenic (i.e.
(muscle mass/soft tissue secondary)
swelling/masses, etc.) Pain, swelling, and masses indicate local pathology
(e.g. trauma, infection, neoplasia, etc.)
11 Elbow joint effusion Indicates articular disease, most frequently ED
12 Carpal joint effusion Indicates articular disease
13 Paw replacement Delayed response indicates neurologic disease
Distal 14 Evaluate nails, webbing, Frequent source of trauma, foreign bodies, etc.
pelvic limb and paw pad
15 PROM of all digits Pain indicates digit pathology – if painful, perform
PROM of individual digit/joints
16 Sesamoid palpation (#2, 7) Pain indicates sesamoid disease
Metatarsals 17 Long bone palpation Pain may indicate neoplasia, fracture
Tarsus 18 PROM Pain, reduced or increased range of motion,
indicates disease of the joint or surrounding soft
tissue structures
19 Varus and valgus stress Instability indicates collateral ligament disruption
20 Achilles tendon insertion Swelling at insertion indicates tendinopathy
Tibia 21 Long bone palpation Pain may indicate neoplasia (proximal and distal
tibia), fracture, and panosteitis
Stifle 22 PROM Pain, reduced or increased range of motion,
tissue structures
24 Evaluate for signs of Palpate for presence of medial buttress, pain on
CCLD hyperextension, and perform drawer and tibial
compression test. Note: effusion (evaluated in step
5) is also an indicator of CCLD
(Continued)
Table 3.2 (Continued)

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Examination procedure/
Region Step structure Comment
25 Assess location of patella Medial luxation generally in extension, lateral in

flexion
Femur 26 Long bone palpation Pain may indicate neoplasia (proximal and distal
femur), fracture, and panosteitis
Hip 27 Hip flexion Indicates pathology of the hip joint or muscle
pathology (e.g. semimembranosus pathology)
28 Hip extension Indicates pathology of the hip or stifle joint,
neurologic disease (e.g. lumbosacral disease), or
muscle pathology (e.g. iliopsoas myopathy)
29 Hip abduction Indicates pathology of the hip joint
Distal 30 Evaluate nails, webbing, Frequent source of trauma, foreign bodies, etc.
thoracic and paw pad
limb
31 PROM of all digits Pain indicates digit pathology – if painful, perform
PROM of individual digit/joints
32 Sesamoid palpation Pain indicates sesamoid disease
(#2, 7)
Metacarpals 33 Long bone palpation Pain may indicate neoplasia, fracture
Carpus 34 PROM Pain, reduced or increased range of motion
tissue structures
36 Flexor carpi ulnaris Swelling at insertion indicates tendinopathy
tendon insertion
Radius 37 Long bone palpation Pain may indicate neoplasia (distal radius), fracture,
and panosteitis
Elbow 38 PROM Pain, reduced or increased range of motion,
tissue structures
40 Campbell’s test Pain indicates medial compartment disease
Humerus 41 Long bone palpation Pain may indicate neoplasia (proximal humerus),
fracture, and panosteitis
Shoulder 42 PROM Pain, reduced or increased range of motion,
tissue structures
43 Shoulder abduction Pain or increased abduction angle indicates
pathology of the medial stabilizers of the shoulder
44 Biceps and supraspinatus Pain during stretching and/or palpation of the
palpation insertion indicates myotendinopathy
Steps 1–13 should be performed in a standing position joint (to allow comparison to the contralateral limb), and
steps 14–44 maybe be performed in either standing or recumbent position.
PROM, passive range of motion, i.e. flexion/extension.
Long bone palpation is important not only in geriatric dogs (to detect potential primary bone
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tumors), but also in any dog because other diseases, such as panosteitis (in younger patients) or
fractures, can be present.
Muscle atrophy is an important indicator of pathology in the affected limb. Neurogenic atrophy is
generally severe and can develop in as little as a week, while disuse atrophy from orthopedic
disease is generally less severe and develops over multiple weeks. Notably, a severely atrophied
leg may not necessarily be the most impaired limb. For example, a dog with chronic left cruciate
disease may acutely rupture the right cruciate ligament which would result in a severe right
pelvic limb lameness but left‐sided muscle atrophy. Measurement of limb circumference to
assess atrophy is subjective and generally performed by palpation or use of a Gulick tape meas-
ure (please refer to Chapter 5 for further details).
Joint crepitus is defined as a grinding or grating sensation or sound that is caused by severe degen-
eration of the joint or intra‐articular fractures. As such, joint disease has to be severe and there-
fore should be radiographically detectable. It is not uncommon to palpate a popping sensation
during elbow flexion‐extension, which can be observed in dogs without radiographic changes.
This should be differentiated from joint crepitus since it is likely due to flexor tendons passing
over the medial epicondyle. Similarly, shoulder abduction may cause a popping noise which is
likely due to cavitation (i.e. the formation of gas bubbles within the joint cavity). Clicking or
popping of tendons over bony prominences and cavitation has been described in people
(Unsworth et al. 1971) but these concepts have not yet been confirmed in dogs. Regardless, the
term (joint) crepitus should be reserved for animals with substantial joint disease.
Specific tests (e.g. testing for cranial drawer, goniometry, Ortolani maneuver, etc.) are crucial to
determine the diagnosis for various conditions. These are described in the individual region
chapters.
3.2.3.1 Pelvic Limb Palpation

The palpation starts with observation and palpation of the distal limb: flexion and extension of all
digits together should be performed to assess if a problem is present, as indicated by signs of dis-
comfort or abnormal anatomy. If an impairment is detected, further evaluation of each individual
digit is performed to assess potential collateral ligament injuries or other pathology. The nails,
webbing, and pads should also be examined for any injuries, foreign bodies, or masses. The sesa-
moid bones are located just distal to the tarsal pad (Figure 12.7) and should be palpated carefully
for swelling and pain. Swelling of the tarsal joint is best felt by palpating the area just proximal to
and on each side of the calcaneus. Because long and short collateral ligaments stabilize the tarsus,
assessment of this joint must include applying varus and valgus stress in flexion and extension.
The insertion of the common calcanean tendon should be evaluated carefully for any swelling or
pain and followed proximally to the musculotendinous junction. The muscles surrounding the
tibia should also be palpated. The stifle should be evaluated for signs of cruciate ligament disease
or patellar luxation. Frequent signs of cruciate disease include joint effusion, medial buttress, pain
on hyperextension, positive drawer (Figure 19.7) and tibial compression (Figure 19.8) test, and a
meniscal click. Medial patellar luxation is diagnosed by extending the stifle while rotating the limb
internally. The thumb of one hand is placed on the lateral aspect of the patella, and the patella is
pushed medially out of the femoropatellar joint. The opposite (i.e. stifle flexion and external rota-
tion while pushing the patella laterally) is performed for lateral patellar luxations. The collateral
ligaments of the stifle should also be evaluated by applying medial and lateral stress in extension.
The tibial and femoral diaphysis should be carefully palpated for any signs of pain to assess for
bone pathology. The muscle groups around the femur should be palpated as for other areas.
Of important note is that pain on hyperextension of the hip joint is not pathognomonic for hip
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dysplasia/arthritis: other diseases, frequently mistaken for hip pathology (because of pain on “hip
extension”), include iliopsoas injury, lumbosacral disease (Chapter 16), and most frequently, cruci-
ate disease. Cruciate disease can be ruled out by palpation of the stifle and evaluation of abduction
of the hip joint. If abduction is not painful, hip pathology is less likely (Figure 20.8). In juvenile
animals, the hip should be evaluated for a positive Ortolani sign (Figure 20.9).
3.2.3.2 Thoracic Limb Palpation

Digital palpation of the thoracic limb is performed as for the pelvic limb. The carpus should be
carefully evaluated for joint effusion. Namely, just below the distal end of the radius, the carpal
joint is easily palpated (Figure 13.3) and any swelling is considered abnormal. Palpation of the
distal radius and proximal humerus is extremely important due to the high incidence of primary
bone tumors in this region. The muscles surrounding the radius and ulna (with particular empha-
sis on the flexor carpi ulnaris muscle; Figure 13.10) should be carefully palpated along with the
distal aspect of the flexor tendons. The elbow should be evaluated for hyperextension, pain during
flexion, joint effusion, and medial compartment palpation (i.e. Campbell’s test; Figure 14.6).
Hyperextension of the joint is performed by pushing cranially at the level of the elbow joint while
keeping the shoulder in a consistent position (i.e. the range of motion of the shoulder should not
change when the elbow is extended, Video 14.2). Pain on flexion can be tested while the animal is
standing by simply flexing the elbow joint and evaluating for symptoms of pain and whether the
dog “moves” away and hops toward the contralateral side (Video 14.2).
The muscles surrounding the humerus should be carefully palpated and the axillary region
should be examined to assess for possible discomfort arising from the brachial plexus. Shoulder
range of motion should be evaluated ideally without performing any range of motion in the elbow,
which is difficult particularly for extension testing. Abduction of the shoulder can be estimated
during stance (Figure 15.7) but accurate abduction angle measurement requires sedation. All
regional shoulder muscles should be carefully palpated and evaluated for a pain response or spasm.
The biceps tendon can be palpated just medial to the greater tubercle (Figure 15.11). The supraspi-
natus insertion tendon is palpated at its attachment to the greater tubercle. Pain can usually be
elicited when palpating and stretching the muscle at the same time (shoulder flexion and elbow
extension). Palpation of the axillary area in older animals is advised to assess for possible brachial
plexus tumors.
3.2.3.3 Other Techniques for Lameness Detection

If the above‐listed examinations do not reveal a source of discomfort, the cause of lameness may
be secondary to muscle injury, neurologic disease, or non‐painful conditions (such as muscle con-
tractures), or because the examiner was unable to locate the painful area, or a result of the dog not
displaying a detectable pain response despite best attempts localizing the source of pain. In such
cases, several examination steps can be taken to identify the source of lameness. Specifically, evalu-
ation of the muscles including myofascial exam and stretching (Chapters 5 and 6) facilitates identi-
fication of myopathies. If no other abnormalities of a specific joint (such as decreased passive
range of motion, see Chapter 5) are identified, all muscles of the affected thoracic limb should be
thoroughly palpated and this should include passive flexibility testing. Neurologic disease that
causes subtle lameness can be difficult to diagnose on palpation; however, a full neurologic exam
may identify neurologic deficits and should therefore be performed (Chapter 4).
In some cases, although a substantial lameness associated with structural musculoskeletal
disease is observed during movement, no obvious pain response is identified during palpation.
Reference 39
For example, dogs with significant elbow pathology (such as coronoid disease or incomplete ossi-
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fication of the humeral condyle) may show no pain response during joint range of motion. This
may be explained by the fact that weight‐bearing causes a much different force than range of
motion (perhaps displacing a coronoid fragment or causing micromotion in the condyle). Therefore,
joint compressions (i.e. manual compression of the joint performed by pushing the distal bone
forming the joint against the stabilized proximal bone) may be an examination method that can
mimic these forces and be utilized in cases when lameness is difficult to localize with routine
palpation techniques.
In horses, flexion tests are used frequently to further isolate the source of a lameness by holding
a joint in flexion for 30–60 seconds and evaluating any worsening of lameness during motion
immediately after its release (Baxter and Stashak 2011). Many normal horses demonstrate a posi-
tive response to flexion tests, which makes interpretation challenging. However, flexion tests have
not been validated as a reliable indicator of musculoskeletal pathology in dogs. Nevertheless, when
performing this test on dogs, a difference between the affected and unaffected side can be helpful
in further narrowing the differential list (i.e. if a difference in response between contralateral limbs
is identified, this suggests that the source of lameness is localizing to the joint and associated soft
tissue structures stretched). In general, dogs will display two possible positive responses to flexion
testing: Some dogs show varying degrees of discomfort when the sustained joint flexion is per-
formed (i.e. in some dogs, it may not be feasible to hold the joint in flexion for 30 seconds), whereas
others show a substantial difference in lameness degree after flexion is released. Again, since this
test has not been validated in dogs, it must be performed in exactly the same manner for both limbs
and even if a difference between sides is identified, the results need to be interpreted with
caution.
R
eferences
Canapp, S.O., Canapp, D.A., Carr, B.J. et al. (2016). Supraspinatus tendinopathy in 327 dogs: a
retrospective study. Veterinary Evidence 1 (3) https://doi.org/10.18849/ve.v1i3.32.
Milgram, J., Slonim, E., Kass, P.H., and Shahar, R. (2004). A radiographic study of joint angles in
standing dogs. Veterinary and Comparative Orthopaedics and Traumatology 17 (2): 82–90.
Sargan, D.R. (2004). Idid: inherited diseases in dogs: web‐based information for canine inherited
disease genetics. Mammalian Genome 15 (6): 503–506.
Unsworth, A., Dowson, D., and Wright, V. (1971). “Cracking joints”. A bioengineering study of
cavitation in the metacarpophalangeal joint. Annals of the Rheumatic Diseases 30 (4): 348–358.
von Pfeil, D.J.F., Lee, J., Thompson, S., and Hinchcliff, K., 2015. Musher and Veterinary Handbook, 3.
Raleigh, NC: International Sled Dog Veterinary Medical Association/Lulu Press.
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The Neurologic Examination

Lisa Bartner
CO, USA
4.1 Introduction
The most common cause of a gait abnormality is orthopedic disease, yet gait irregularities can also
be associated with neurologic causes. Gait abnormalities resulting from neurologic dysfunction
can be broadly categorized into three components that may be observed in combination or as an
isolated component depending on the nervous structures involved: neurogenic lameness, paresis,
and ataxia (Box 4.1).
Neurogenic lameness is attributable to discomfort caused by pathology affecting the nerve roots
and surrounding meninges (e.g. from a lateralized disc herniation). Thus, this is frequently referred
to as “nerve root signature lameness” (Dewey et al. 2016). These patients commonly have a weight‐
bearing lameness, although in more severe cases, the limb may be held up. This lameness can eas-
ily be confused with orthopedic causes of lameness (Video 4.1).
Video 4.1:
Brachial plexus tumor causing neurogenic lameness and partial Horner syndrome.
Paresis describes a partial loss of voluntary movement that is due to disruption of the signal
transmission from either the level of the upper motor neuron (UMN) or lower motor neuron
(LMN). A UMN paresis results from loss of normal signal transmission from higher motor centers
to the LMN and causes the inability to initiate gait voluntarily (i.e. decrease in voluntary move-
ment). An LMN paresis results from loss of normal signal transmission from the LMN to the mus-
cle and causes the inability to support weight (i.e. decrease in muscle “power”). Lesions causing
UMN paresis generally affect multiple limbs, whereas those causing LMN paresis can involve only
a single limb (monoparesis), which is commonly confused with lameness (Figure 4.1). Some texts
use the term weakness synonymously with paresis; however, since systemic conditions can also

42 4 The Neurologic Examination
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Box 4.1 Neurologic Components of Gait Abnormalities
●● Neurogenic lameness (= Nerve root signature lameness)

○○ UMN lesion
■■ Not commonly associated with neurogenic lameness
○○ LMN lesion
■■ = Pathology affecting the afferent (dorsal) nerve root or meninges (=pain)
●● Paresis (= Partial loss of voluntary movement)

○○ UMN lesion (brain, spinal cord: C1–C5, T3–L3)
■■ = Disruption of signal transmission from brain to LMN resulting in inability to initiate
gait voluntarily (= spastic paresis)

■■ = Pathology affecting brain or spinal cord
○○ LMN lesion (spinal cord: C6–T2, L4–S3; nerves, neuromuscular junction, and muscle)
■■ = Disruption of signal transmission from LMN to muscle resulting in inability to sup-
port weight (= flaccid paresis)

■■ = Pathology affecting spinal cord, efferent (ventral) nerve roots, muscles, or neuromus-
cular junction
●● Ataxia (= Incoordination)
○○ UMN lesion
■■ = General proprioceptive (brainstem, spinal cord: C1–5, T3–L3)
■■ = Vestibular
■■ = Cerebellar
○○ LMN lesion
■■ Not associated with ataxia
cause weakness (e.g. profound anemia, electrolyte disturbances, and nutritional deficits); in this
text, paresis will be used when referring to primary neurologic causes.
Ataxia is characterized by uncoordinated movement and originates from within the central
nervous system (CNS). Since it generally affects multiple limbs, it is not commonly confused with
orthopedic causes of lameness.
Animals with neurologic disease may display a combination of neurogenic lameness, paresis,
and/or ataxia. For example, a disc compressing the nerve roots can result in both monoparesis and
neurogenic lameness, which can be explained by involvement of ventral and dorsal nerve roots
(due to their close anatomic proximity), respectively. If the disc herniation is also compressing the
spinal cord white matter, ataxia will be evident caudal to the lesion.
4.2 Neuroanatomy Related to Limb Function
4.2.1 Anatomical Components of the Nervous System

There are three main components of the nervous system: the CNS, peripheral nervous system
(PNS), and autonomic nervous system (ANS). The CNS consists of the brain and spinal cord. The
cell bodies of the neurons are located throughout and synapse on LMNs of the PNS or ANS. The
ANS unconsciously regulates important body functions including the respiratory and circulatory
system and as such is not relevant to lameness. Most causes of lameness or paresis related to the
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Two to three
limbs affected
One thoracic limb and one or

Thoracic limbs abnormal/ Thoracic limbs normal/ both pelvic limbs affected
pelvic limbs normal pelvic limbs abnormal
Pelvic limbs?
Thoracic limbs? Pelvic limbs?
UMN signs LMN signs

(one or both (one or both
pelvic limbs) pelvic limbs)
UMN signs LMN signs UMN signs LMN signs
Lateralized Multifocal spinal

Rare – recheck C6-T2 cord disease
PNS (brachial (1) L4-S3 or
neurologic T3-L3
plexus) (2) PNS
examination
Limbs
affected Brain
Abnormal Yes
Single limb affected mentation,
All four limbs affected cerebellar, or
vestibular ataxia?
No
Thoracic limb Pelvic limb

Pelvic limbs: Pelvic limbs:
UMN signs LMN signs
Monoparesis
LMN signs? LMN signs?

Thoracic limbs? Thoracic limbs?
No LMN signs LMN signs No LMN signs LMN signs

UMN signs LMN signs UMN signs LMN signs
(1) Orthopedic (1) Orthopedic

disease or disease or (1) Generalized
(1) C6-T2 or (1) L4-S3 or PNS or
(2) PNS or (2) PNS or (1) Brainstem or (1) Multifocal or
(2) PNS (2) PNS C6-T2 (2) multifocal
(3) lateralized (3) lateralized (2) C1-5 (2) diffuse disease
C6-T2 L4-S3 spinal cord
disease
Figure 4.1 Diagnostic pathway for neuroanatomic localization of spinal cord lesions based on motor function in the affected limb(s). Lesions causing upper
motor neuron (UMN) paresis generally affect multiple limbs, whereas those causing lower motor neuron (LMN) paresis can involve only a single limb and, hence,
are commonly confused with lameness. PNS, peripheral nervous system; C, cervical, T, thoracic; L, lumbar; S, sacral; and Cd, caudal.
nervous system result from conditions of the PNS although some can involve the CNS (i.e. spinal
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cord). As such, this chapter focuses on these two components and the aspects relevant to canine
lameness. More complete description of the entire neuroanatomy and neurologic conditions are
available (De Lahunta et al. 2015; Dewey and Da Costa 2016).
Nerve cells (neurons) are composed of a cell body and the nerve fibers (axons). The axons are
bundled into either sensory tracts conveying afferent information from peripheral regions to higher
processing centers or motor tracts relaying efferent information from the motor planning centers to
the periphery.
The spinal cord is functionally divided into the following regions, defined by the normal spinal
enlargements (intumescences) in the cervical and lumbar areas: cervical (C1–C5), cervical intu-
mescence (C6–T2), thoracolumbar (T3–L3), lumbar intumescence (L4–S3), and caudal regions
(segments caudal to S3; Figure 4.2). In dogs, the spinal cord ends around the sixth or seventh lum-
bar vertebrae in medium–sized individuals and further caudal (e.g. L7, S1) in dogs of small size.
The PNS consists of the sensory and motor nerves, muscles, and neuromuscular junctions. The
cell bodies of motor neurons are located in the ventral gray matter of the spinal cord, while the cell
bodies of the sensory neurons are located outside the spinal cord in the spinal ganglia. The respec-
tive fibers arise as ventral and dorsal nerve roots on each side of the spinal cord. Thus, the dorsal
roots convey primarily sensory information, while the ventral roots carry motor nerve fibers. The
origin of these nerve roots from the spinal cord defines each spinal cord segment (Figure 4.2).
Motor fibers can be somatic, innervating skeletal (striated) muscle in the PNS, or autonomic,
innervating smooth and cardiac muscle in the ANS. The dorsal and ventral nerve roots fuse at the
level of the intervertebral foramen and form a spinal nerve. Distal to the intervertebral foramen, the
nerve usually splits into a dorsal branch innervating the epaxial muscles and skin, as well as a ven-
tral branch supplying limb muscles and skin.
4.2.2 Functional Components of the Nervous System

Functionally, the nervous system can be divided into the sensory and motor systems. The sensory
system conveys sensory information toward the CNS, while the motor system activates muscles in
the PNS and thereby initiates and controls motion.
4.2.2.1 Motor Systems

Motor neurons are distributed within two motor systems, the UMN and LMN systems, and are
named accordingly. The UMNs are confined entirely within the CNS, while the LMNs originate in
the CNS (ventral grey matter of spinal cord) but the distal portions are located in the periphery.
Hence, the spinal cord connects the UMNs in the CNS to the LMNs in the PNS. The UMNs greatly
influence activity of LMNs so accordingly, the entire function of the CNS is manifested through the
LMN. Thus, the LMNs are the motor effector cells of the PNS. Using the five divisions of the CNS,
the C1–C5 and T3–L3 spinal cord segments are components of the UMN system, and C6–T2 and
L4–S3 are components of the LMN system (Figure 4.2).
Based on the location of a lesion (whether within the LMN or UMN system), specific deficits are
observed which are referred to as UMN or LMN signs (Table 4.1). For example, when the term
UMN disease is used, this refers to the UMN signs produced by diseases of the CNS, specifically
spinal cord white matter and/or brain. The term LMN disease is sometimes used when referring to
diseases of the PNS. However, this can create confusion since the LMNs are the true motor compo-
nent of the PNS while the term PNS also includes the sensory portions (sensory nerves). Thus,
this text will use LMN disease when referring to conditions affecting the motor arm of the PNS
specifically and PNS disease when referring to dysfunction of the entire PNS. The nomenclature
4.2 Neuroanatomy Related to Limb Functio 45
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(A)
(B) (C)
Figure 4.2 Schematic representation of neural organization of (A) spinal cord anatomy and (B, C)
magnification of the lateral and dorsal aspect of the lumbar, and sacral vertebrae and coinciding nervous
tissue. Components of the UMN system (yellow), residing completely within the central nervous system,
include the intracranial structures, C1–C5 and T3–L3 spinal cord segments. The LMN system (purple), with
only cell bodies residing within intumescences of the central nervous system, includes the C6–T2 and
L4–S3 spinal cord segments and the spinal nerves forming the brachial and lumbosacral plexuses. Most
noteworthy, the L4–S3 spinal cord segments (purple) lie within the third to fifth lumbar vertebral bodies.
“neuromuscular disease” is also often used in other texts as yet another synonym for PNS disease
since the muscle and neuromuscular junction are considered part of the PNS.
As a rule, LMN deficits will dominate at the level of a lesion and UMN signs will predominate
caudal to the lesion. Unless the lesion is at an intumescence, the LMN deficits may not be clinically
recognizable. For example, a disc herniation compressing the C3 spinal nerve may cause an LMN
paresis to the group of epaxial muscles innervated by that nerve, which may not be clinically evi-
dent; whereas a disc herniation of the same severity compressing the spinal nerve of C6 would be
more likely to cause LMN paresis to the group of muscles innervated by the radial nerve and result
in a lameness and/or monoparesis of the ipsilateral thoracic limb.
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Table 4.1 Comparison between neuroanatomy and clinical signs from lower motor neuron (LMN)
and upper motor neuron (UMN) lesions.
LMN UMN
Neuroanatomy
Neuroanatomic Peripheral nervous system: spinal cord Central nervous system (cerebral cortex,
origins gray matter (cell bodies) and brainstem basal nuclei, brainstem, and spinal cord
(cranial nerves) white matter)
Spinal cord C6–T2 C1–C5
segments L4–S3 T3–L3
S4–Cd segments
Neuroanatomic Neuron (cell bodies and nerve fibers form Neuron (cell bodies and nerve fibers form
components nerve root, spinal nerve, and named nerve) UMN tracts)
Neuromuscular junction
Muscle
Clinical signs
Quality of paresis Flaccid (i.e. loss of muscle “power”) Spastic (i.e. loss of voluntary movement)
or paralysis
Ataxia type None General proprioceptive (GP)
Posture Crouched stance Normal to slightly crouched
Limbs more centered under the trunk to May vary between base‐wide and base‐
help support weight‐bearing narrow stances
Collapse of limbs when weight‐bearing Limbs may be in an awkward state (e.g.
Ventral neck flexion (generalized crossed over, more toward, or away from
conditions) midline)
Inability to support weight (paresis) Standing on dorsum of the paw
Off‐weighting a limb(s) (nerve pain) (spontaneous knuckling)
Gait Gait characterization: Gait characterization:

●● “Regularly irregular” gait ●● “Irregularly irregular” gait
LMN paresis: UMN paresis and GP ataxiaa:

●● Shortened stride ●● Lengthened stride
●● Nails or foot pads may drag ●● Nails may drag
●● Shuffling gait ●● Stiff
●● ± “Bunny hopping” in pelvic limbs ●● Delayed initiation and protraction phase
●● May prefer to walk rather than stand ●● May vary between base‐wide and base‐
●● Normal initiation phase with narrow gait

shortened protraction phase
●● ± Muscle fasciculations
●● Inability to support weight (paresis)
Neurogenic lameness:
●● Shortened stride
●● Nails or foot pads may drag
●● Unwillingness to support weight

(nerve pain)
Segmental spinal Usually decreased or absent at respective Normal or may be increased caudal to
reflexes anatomic segment (unchanged for others) respective segment
Muscle mass Denervation atrophy within 7–10 days Disuse atrophy after 30 days
(i.e. neurogenic atrophy) Usually mild to moderate; severe with
Usually severe chronicity
4.2 Neuroanatomy Related to Limb Functio 47

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LMN UMN
Muscle tone Decreased to absent Normal to increased

Sensory Perceives noxious stimulus but may Normal or abnormal if there is complete
not be able to withdraw anatomic or functional spinal cord
transection
Postural reaction Normal, delayed, or absent (especially Delayed or absent
deficits those relying on strength, e.g. hopping)
a
UMN paresis and GP ataxia are considered collectively since it is difficult to clinically separate the gait deficits.
C, cervical; Cd, caudal; L, lumbar; LMN, lower motor neuron; PNS, peripheral nervous system; S, sacral; T, thoracic;
UMN, upper motor neuron.
Since the vertebral column grows more rapidly during development than the spinal cord, the
relationship of the spinal cord segments to the vertebrae is altered (Figure 4.2). Paramount to
the LMN system, the C6–T2 spinal cord segments reside within the fifth cervical to the first
thoracic vertebrae, while the L4–S3 segments lie within the third to fifth lumbar vertebral bod-
ies; some individual variability exists between different breeds and dog sizes. This becomes
clinically relevant when determining the expected neurologic dysfunction associated with a
specific lesion location. For example, a lateralized disc herniation at the L4–L5 disc space is
likely to affect the spinal nerve of L4 supplying the femoral nerve. However, if that disc mate-
rial herniated on midline, causing more severe compression to the spinal cord instead of the
nerve, the caudal lumbar spinal cord segments (e.g. L6, L7, and S1) supplying the sciatic nerve
would be impaired.
4.2.2.2 Sensory System

The sensory portions of the nervous system most relevant when diagnosing gait abnormalities
are nociception (also called somatic afferent) and proprioception (specifically general proprio-
ception [GP]).
4.2.2.2.1 Nociception
The nociceptive system has receptors near the body surface that receive their stimuli from the
external environment. The information is conveyed through specialized receptors which include
mechanoreceptor for touch, thermoreceptors for temperature, and nociceptors for noxious stimuli.
In dogs, nociception is most readily evaluated since they are unable to communicate on more sub-
tleties, such as heat.
Nociceptors found in the skin can be activated by pinching the skin, which is useful to localize
neurologic lesions. A dermatome is the region of skin innervated by an individual dorsal spinal
nerve branch (e.g. nerve fibers of C7). These have been mapped in the dog. The cutaneous area is
the total area of skin innervated by a cutaneous nerve (e.g. a specific nerve that originates from two
or more spinal nerves, for example C7–T2 for the radial nerve). Neighboring dermatomes and cuta-
neous areas can overlap but areas do exist where there is no overlap; these are called autonomous
zones. Thus, the autonomous zone is the most specific when localizing lesions.
4.2.2.2.2 Proprioception
The ability to recognize and sense the location of limbs in relation to the rest of the body is called
general proprioception (GP). The neurons of the GP system detect position and movement of
the muscles and joint via specialized mechanoreceptors called proprioceptors. After receptor
stimulation, information entering the spinal cord is either processed directly on LMNs to complete
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a reflex arc (e.g. patellar reflex) or is projected to the brain (i.e. conscious and unconscious proprio-
ception). Clinically, it is difficult to accurately separate unconscious from conscious propriocep-
tion and as such, the term general proprioception is preferred and will be used in this text.
4.3 The Neurologic Examination
The neurologic examination is always performed in combination with a full history and physical
exam. This allows the clinician to first identify clues that are indicative of a neurologic problem
(e.g. worn toe nails indicating proprioceptive deficits; Figure 4.3 and Box 4.2) and then determine
the level and extent of the nervous system dysfunction. Doing so establishes the anatomical diag-
nosis, a critical step in the approach to a neurologic patient.
(A) (B)
Figure 4.3 Toe nail wear commonly seen on the weight-bearing toes in patients with (A) neurologic
disease (white arrow) and (B) normal digits for comparison.
Box 4.2 Clinical Findings Indicating Neurologic Causes of Lameness or Monoparesis
●● Unprovoked, intermittent, or sudden vocalization

●● Focal pain (e.g. nerve root signature)
●● Neurologic deficits:
○○ Paresis or paralysis and ataxia (including knuckling)
○○ Postural reaction deficits
○○ Rapid muscle atrophy
●● Paresis that worsens with activity

●● Other neurologic signs (Horner syndrome with thoracic limb lameness)
●● Uneven nail wear
●● Hyper- or hypoesthesia
●● Lack of orthopedic examination abnormalities
4.3 The Neurologic Examinatio 49
The neurologic examination can be divided into eight parts: (i) mentation status and behavior,
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(ii) posture, (iii) gait, (iv) cranial nerves, (v) postural reactions, (vi) muscle mass and tone,
(vii) spinal reflexes, and (viii) perception of sensory stimuli and pain (Table 4.2). This sequence is
the order which the author feels most logically evaluates the nervous system while considering
patient comfort. However, the specific order is far less important than having a systematic way of
Table 4.2 Components of the neurologic examination and interpretation of the patient with lameness

and/or paresis.
Findings/observations Interpretation
Mentation status and Normal UMN or LMN; some intracranial

behavior Abnormal Intracranial
Posture Neck guarding Cervical pain (muscle, joints, meninges, nerve
root, and bone/disc) or referred (e.g. intracranial)
Kyphosis Congenital or acquired malformation, spinal pain,
Scoliosis and abnormal muscle tone
Lordosis
Head turn Prosencephalon or cervical pain
Head tilt Vestibular or cervical pain
Spontaneous knuckling UMN (GP ataxia)
Gait Lameness Orthopedic or LMN
Paresis/paralysis (general) UMN (spastic or normal) or LMN (flaccid)
Monoparesis/‐paralysis LMN (focal disease)
Hemiparesis/‐paralysis UMN more likely
Paraparesis/‐paralysis UMN or LMN (multifocal)
Tetraparesis/‐paralysis UMN or LMN (generalized)
Ataxia All UMN; cerebellar, vestibular, and/or GP ataxia
Cranial nerves Normal UMN or LMN; some intracranial
Abnormal Brainstem; LMN (CNs VII, IX, X, XII most
common), focal or multifocal (e.g.
polyneuropathy)
Postural reactions Normal Orthopedic disease
Some LMN (e.g. NMJ, muscle, and cauda equina)
Delayed or absent UMN (intracranial or spinal cord), LMN, other
(e.g. sedation and systemic illness)
Muscle mass and Normal tone Orthopedic or UMN
tone Hypertonic UMN
Hypotonic or atonic LMN
Muscle atrophy
Acute; severe LMN (neurogenic)
Chronic; mild, moderate, or Orthopedic or UMN
severe
(Continued)

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Findings/observations Interpretation
Spinal reflexes Normal Orthopedic or UMN; less commonly some LMN

(e.g. muscle or NMJ)
Increased/exaggerated UMN, excitement, pseudohyperreflexia
Clonus UMN
Decreased LMN, limited joint mobility, age‐related (patellar),
and excitement (tense; activation of extensor
muscles)
Absent LMN, limited joint mobility, age‐related (patellar),
and less commonly UMN (i.e. spinal shock or
myelomalacia)
Cutaneous trunci reflex Cutoff: UMN, transverse thoracolumbar spinal
cord
Unilaterally absent: LMN (C8–T1 spinal cord
segments or lateral thoracic nerve), ipsilateral
Bilaterally absent: usually equivocal
Perineal LMN (S1–S3 spinal cord segments or nerves)
Perception of Normal
sensory stimuli and Increased sensitivity Orthopedic or neurologic
pain (hyperesthesia)
Reduced or absent sensitivity Neurologic
(anesthesia)
Reduced nociception Neurologic
(hypalgesia)
Absent nociception Neurologic
(analgesia)
CN, cranial nerves; GP, general proprioceptive; LMN, lower motor neuron; NMJ, neuromuscular junction; UMN,
upper motor neuron.
approaching every neurologic examination. Observation of a patient’s mentation, behavior, and

posture should begin while taking a history and the dog is able to freely move about the room.
Observations should continue throughout the examination to catch subtleties as the patient is
moved from one position to another.
Certain components, for example postural reactions (Box 4.3), should be assessed for any
patient as “screening” tests. For patients presenting with a lameness, Box 4.3 displays the mini-
mal components of the neurologic examination that should be performed. However, if the
patient or history is suggestive of neurologic dysfunction, a full neurologic examination should
be completed.
4.3.1 Mentation Status (Awareness) and Behavior

Mentation is recorded in terms of level of consciousness as alert, dull, obtunded, stuporous, or coma-
tose, and in terms of the content or quality of consciousness (e.g. inappropriate behavior). Since
most neurologic conditions causing a monoparesis or lameness will involve the PNS, mentation
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Box 4.3 Key Components of the Neurologic Examination that Should Be Performed

in a Given Patient
●● All patients:
○○ Gait and posture evaluation
○○ Postural reactions: Proprioceptive placement and hopping
○○ Sensory palpation
○○ Muscle mass and tone
●● Patients with thoracic limb lameness:

○○ Assess for Horner syndrome
○○ Assess for neck pain
○○ Withdrawal reflexes (thoracic and pelvic limb)
○○ Cutaneous trunci reflex
●● Patients with pelvic limb lameness:

○○ Tail lift
○○ Paraspinal palpation
○○ Withdrawal reflexes (thoracic and pelvic limb), patellar reflexes, and anal tone
○○ Perineal reflex
○○ Cutaneous trunci reflex
and behavior should be unaffected unless multiple lesions (e.g. vehicular trauma causing brachial
plexus avulsion and traumatic brain injury) are present.
4.3.2 Posture
The neural organization of gait and posture is complex and involves all levels of the nervous system.
Posture evaluation is a subjective assessment of the position of the head, neck, trunk, and limbs. An
example of an abnormal posture that may be associated with a lameness includes neck guarding.
This term refers to a patient where the head and neck are held in a fixed position, even when walk-
ing around a turn. When thoracic limb paresis accompanies cervical pain, the back may be arched
(kyphosis), and the nose kept close to the ground in an effort to off‐weight the thoracic limbs.
Spontaneous knuckling of a foot (i.e. without an observer flipping the paw), causing the dog to
stand on the dorsum of the paw, is generally caused by proprioceptive deficits, indicating neuro-
logic origin, not orthopedic. Off‐weighting a single limb can be seen with nerve pain (i.e. nerve root
signature), but it can also be seen in orthopedic conditions.
4.3.3 Gait
Initial gait assessment allows the clinician to determine which limb(s) is/are affected and to get an
impression of the nature (i.e. orthopedic versus neurologic), location, extent, and severity of the
lesion. Please refer to Chapter 1 for further details regarding subjective gait analysis.
Specific to the patient with neurologic disease, abnormal gait patterns can be grouped into six
components: (1, 2) two qualities of paresis (UMN and LMN), (3) neurogenic lameness, and (4–6)
three qualities of ataxia (cerebellar, vestibular, and GP). Understanding the difference between
paresis and ataxia is very important to establish a neuroanatomic diagnosis. While ataxia is not
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Box 4.4 Loss of Voluntary Motor Terminology

●● Paresis = partial loss of voluntary motor function (i.e. disruption of UMN signal transmission
or LMN implementation of movement)
●● Plegia/paralysis = complete loss of voluntary motor function (i.e. severe paresis)
○○ Mono‐ = Single limb
○○ Hemi‐ = Thoracic limb and pelvic limb of one side
○○ Tetra‐ = All limbs
○○ Para‐ = Only pelvic limbs
present with LMN dysfunction, it is a key feature localizing to a UMN lesion (Box 4.1). Severe
paresis with complete loss of voluntary movements is termed plegia or paralysis (Box 4.4). The only
difference between paresis and paralysis is the severity of the lesion, and it cannot be used to dif-
ferentiate between UMN and LMN lesions. Further, in a paralyzed patient, ataxia cannot be
assessed.
Paresis, or paralysis, can result from UMN or LMN lesions. UMN lesions disrupt the signal trans-
mission and therefore result in a loss of voluntary movement thus producing a spastic paresis (i.e.
increased muscle tone). LMN lesions disrupt execution of the movement by the muscle due to loss
of muscle power producing a flaccid paresis (i.e. decreased muscle tone). The degree of LMN pare-
sis can range from shortened stride length to partial or complete inability to support weight. If the
animal is ambulatory, the shortened stride length or partial inability to supporting weight can
appear as lameness making the gait in LMN disease similar to that of a patient with orthopedic
disease. Stride length in UMN paresis is typically lengthened due to both delayed initiation and
completion of the protraction (swing) phase. Determining the quality of paresis or paralysis is criti-
cal in differentiating LMN from UMN lesions and is made through evaluating muscle mass, mus-
cle tone, and reflexes.
Gait abnormalities usually result from injury or disease to musculoskeletal components, nerve
roots, or the LMN. As mentioned above, gait abnormalities are more commonly associated with
orthopedic disease and are typically the result of pain or abnormal anatomy. Orthopedic disease is
not usually associated with paresis or paralysis nor should the patient be ataxic. However, gait
abnormalities can occur from neurologic lesions, from pain associated with compression or inflam-
mation of a nerve root, for example from a disc extrusion or a nerve sheath tumor (Video 4.1). This
“neurogenic lameness” is called nerve root signature lameness (i.e. pain from irritation of the nerve
root that is referred down the limb). Signs of nerve root signature vary in severity where some
animals will hold up the limb completely while standing, presumably to minimize stretching of
the irritated nerve, and others show only off‐weighting or a minor weight‐bearing lameness.
Ataxia is a hallmark of UMN disease and does not accompany pure LMN lesions nor orthopedic
diseases. As such, if ataxia is present, the animal has UMN dysfunction. Given the location of the
UMN, ataxia generally affects at least two limbs (unless a severely lateralized lesion is present
which is rare). There are three types of ataxia in veterinary neurology, the name of each indicating
the level of the lesion: cerebellar, vestibular, and GP ataxia. Animals with cerebellar and vestibular
ataxia generally display obvious gait abnormalities in all four limbs (such as hypermetria, base‐
wide gait, or loss of balance), which can be symmetric or asymmetric, respectively. Animals with
GP ataxia can demonstrate various degrees of scuffing and knuckling of the nails or footpads,
limbs crossing midline, stumbling, and a base‐wide or base‐narrow gait (Table 4.1). The swing
phase is prolonged (from loss of inhibition) producing a longer stride than normal and many times,
an overreaching quality is noticed at the end of the swing phase, sometimes described as “soldier
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marching.” If these symptoms are subtle, they may be confused with an orthopedic problem.
In many cases, by observing gait alone, the examiner can determine, not only if a patient has a
gait abnormality due to orthopedic disease or a neurologic lesion but for the latter, whether a UMN
or LMN lesion is present. However, patients with bilateral limb pain (e.g. hip disease or ruptured
cruciate ligaments) may “appear” ataxic, making the distinction challenging. Similarly, some dogs
with marked bilateral paresis due to an LMN lesion can appear uncoordinated, but as a function of
the severity of the paresis limiting the rate and range of foot placement. Gait abnormalities due to
orthopedic disease can also be difficult to differentiate from paresis, especially a monoparesis.
LMN lesions causing paresis are manifested as a gait with a shortened stride length (from inability
to support body weight) or a limb(s) that buckles under the weight of the dog and may be accom-
panied by increased fatigability and decreased muscle tone. In contrast, if the alteration of stride
phases is caused by orthopedic disease, muscle tone is maintained, and fatigability is often not
evident. Orthopedic lameness may also improve after activity, depending on the disease. To decide
if a dog is truly ataxic, using descriptions of cardiac arrhythmias as an analogy for gait can be a
helpful guide. Dogs that are ataxic will have foot placement that is irregularly irregular, implying
neurologic origin. A rhythmic, regularly irregular gait is more consistent with lameness, monopa-
resis (e.g. a nerve sheath tumor affecting the radial nerve), or symmetric paresis (e.g. an interverte-
bral disc herniation in the lumbar intumescence lesion causing paraparesis). The presence of
uneven nail wear (Figure 4.3) supports a nervous system lesion causing paresis and/or ataxia;
orthopedic conditions do not typically have uneven nail wear.
4.3.4 Cranial Nerves

Cranial nerve dysfunction, if present, is a clear indicator of neurologic disease. Of particular
importance to the patient with lameness is evaluation of the patient for evidence of Horner syn-
drome, a disruption of the sympathetic innervation of the eye. This innervation is complex and
involves several neurons. The neurons initially travel from the brainstem to the spinal cord and
synapse on LMNs in the cranial thoracic spinal cord, typically at the level of T1–T3 spinal cord seg-
ments, before redirecting and coursing cranially to provide sympathetic innervation to the eye
(Penderis 2015). Sympathetic stimulation keeps the eyeball positioned normally within the orbit,
widens the palpebral fissure, and dilates the pupils. Disruption of this pathway may result in
Horner syndrome, characterized by retraction of the eye ball (enophthalmos), pupillary constric-
tion (miosis), narrowing of the palpebral fissure (ptosis), and third eyelid protrusion; protrusion of
the third eyelid occurs passively with enophthalmos. The finding of Horner syndrome indicates an
ipsilateral lesion in the nervous system along the sympathetic pathway at any number of locations
of the sympathetic pathway. In a dog presenting with thoracic limb lameness, the finding of Horner
syndrome not only confirms a neurologic lesion but more specifically points to a lesion involving
the first to third thoracic spinal cord segments or LMNs as they exit (e.g. lateralized disc protrusion
or a brachial plexus tumor, Videos 4.1 and 16.1). Commonly, only ipsilateral miosis (i.e. partial
Horner syndrome) is seen with lesions at this level.
4.3.5 Postural Reactions

Postural reactions test the same neurologic pathways already evaluated in gait assessment, namely
the proprioceptive and motor systems. They help identify which limb or limbs is/are affected and
confirm that a nervous system disorder is present. However, since all components of both the CNS
and PNS must be functioning normal to have a normal response, these tests do not provide precise
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localizing information. In this respect, they can detect nervous system dysfunction but are not
specific to localize within a region of the nervous system.
Postural reactions (Figure 4.4 and 4.2) are response tests; they are not spinal reflexes. When per-
forming an initial screening examination, at minimum proprioceptive placement (paw replace-
ment) and hopping should be performed on each patient. If they are normal, the other reactions
(A) (B)
(C) (D)
Figure 4.4 Testing postural reactions using proprioceptive placement (paw replacement) in the
(A) thoracic and (B) pelvic limbs. The examiner places one hand under the sternum or pelvic symphysis to
support the patient’s body weight and maintain a midline center of gravity, while the hand on the same
side as the limb being tested, flips the paw onto its dorsum. Placing a hand under the (C) caudal abdomen
should be avoided since replacement of the paw tends to be less consistent. (D) For placing reactions or the
“paper test,” a sheet of paper or cardboard is placed beneath each of the patient’s limbs beginning in a
neutral weight-bearing position. The paper is then steadily and slowly pulled laterally until the patient
repositions the limb.
are also likely to be normal. In animals where the paw replacement and/or hopping reactions are
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equivocal or difficult to interpret, other postural reactions should be performed. Likewise, if the
nature or the size of the dog precludes accurate assessment of these tests, hemiwalking, for exam-
ple, can be helpful.
Video 4.2:
Neurologic examination – postural reactions.
4.3.5.1 Proprioceptive Positioning and Placing Reaction

During testing of proprioceptive placement, the animal’s weight is supported by the examiner
while the foot is slowly flipped, and the dorsum is gently placed on the ground. The animal should
return the foot to a normal position immediately. Supporting most of the animal’s weight is impor-
tant since this makes it easier to eliminate weakness and orthopedic disease as a reason for a
delayed test. When testing the thoracic limb, the supporting hand is placed under the sternum
(Figure 4.4). More reliable assessment of pelvic limb paw replacement is generally achieved when
a hand is placed ventral and parallel to the pubic symphysis, rather than under the caudal
abdomen.
A similar test, called placing reaction, can be performed by placing the foot on a sheet of card-
board or paper that is slowly pulled laterally (“paper test”). Once an abnormal limb position is
reached, the animal should reposition the foot for normal weight‐bearing. The paw replacement
test is more sensitive for proprioception in the distal extremity, whereas this paper test detects
abnormalities in the proximal limb.
In compressive diseases, abnormalities in proprioceptive placing may be apparent before pare-
sis, because of the superficial position of these pathways. Dogs with PNS disease, on the other
hand, can have normal postural reactions if they still have voluntary motor. They may be too
weak to correct, but if some of the body weight is supported, they can correct normally unlike in
instances of spinal cord lesions, where the animal will be unable to correct even with adequate
support.
Distractions, excitement, or a highly compliant patient can delay paw replacement. In these situ-
ations, hopping reactions should be performed. Dogs with orthopedic disease may appear to have
delayed proprioceptive placing (thought to be due to limb or joint pain that would be associated
with shifting weight or flexing joints) when their body weight is not supported by the examiner. If
orthopedic disease is severe (e.g. femur fracture or severe joint instability) and animals are not
weight‐bearing voluntarily, a lack of correction can be observed even when their body weight is
supported appropriately (Video 4.3). Other factors that can falsely influence results of paw replace-
ment, such as systemic illness or sedation, must be considered during interpretation. Hopping may
be more reliable in these cases.
Video 4.3:
Orthopedic disease mimicking neurologic disease.

4.3.5.2 Hopping Reaction

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The hopping reaction of the thoracic limb is tested with the animal facing in the same direction as
the examiner and one thoracic limb lifted off the ground (Video 4.2). As the weight is increased on
the tested limb, the animal’s ability to maintain full limb extension is observed (evaluating muscle
tone/strength). The patient’s weight is then shifted laterally and the appropriateness of reposition-
ing the foot (i.e. hopping) is interpreted. Important components of the response that are evaluated
include initiation, movement, and support throughout the test. Testing in the pelvic limbs is com-
pleted in a similar fashion but with the examiner facing away from the patient (Video 4.2).
Hopping response testing is more sensitive than other postural reactions, especially when minor
deficits are present. Not only is proprioception tested – indicated by how quickly the patient moves
the limb as the examiner moves the shoulder or hip laterally – but strength and muscle tone are
assessed as the patient bears weight on the limb. Poor initiation of correction suggests sensory defi-
cits (i.e. proprioceptive) while weak follow‐through suggests motor deficits (i.e. paresis).
If pain is a component of the clinical picture, it may affect postural reactions that rely on muscle
strength such as hemiwalking, wheelbarrowing (Video 4.2), and hopping. In these situations, the
results should not be overinterpreted.
4.3.6 Muscle Mass and Tone

Muscle mass will be affected differently depending on the underlying disease. If innervation to the
muscle is compromised, there is disruption in trophic factors and neurogenic (i.e. denervation)
atrophy occurs. These changes take place very rapidly, starting within several hours of injury, and
become most noticeable in 7–10 days. Conversely, mechanical unloading of the muscles, seen with
either musculoskeletal or UMN disease, can cause disuse atrophy. This atrophy occurs very slowly
and becomes apparent only after several weeks to months following onset. Knowing how rapid
muscle atrophy occurred can greatly influence the list of differential diagnoses. For example, rapid
focal muscle atrophy occurring in the thoracic limb with an associated lameness should alert the
clinician to a higher likelihood of a neurogenic origin, such as a nerve sheath tumor.
Muscle tone, along with gait assessment, will help differentiate UMN from LMN lesions. Through
passive manipulation of the limb, the degree of muscle tone is assessed, especially of extensor
muscles. Dysfunction in the UMN system can cause muscle hypertonicity appearing as a spastic
paresis/paralysis; however, normal muscle tone is present frequently. LMN dysfunction causes
muscle hypotonicity and a flaccid paresis/paralysis. Decreased muscle tone is a key feature specifi-
cally localizing to the LMN system.
4.3.7 Spinal Reflexes

Normally during gait and posture, spinal reflexes (also called segmental spinal reflexes) maintain
the limbs in extension to support the animal’s weight. Evaluation of these reflexes should be con-
sidered a continuum of gait evaluation and postural reaction testing; not as a sole entity. Disruption
of sensory input, the associated spinal cord segments, or LMN output will result in decrease or loss
of reflex activity. Spinal reflexes are a dominant factor in differentiating UMN from LMN disease.
A normal sensorium (consciousness) is not required to elicit these reflexes; they will remain intact
as long as the local reflex arc (i.e. the cell bodies and sensory and motor nerves) is intact, even if the
spinal cord cranial to the lesion is completely transected.
Two types of reflexes are evaluated in the limbs (Table 4.3): myotatic and flexor reflexes. Myotatic
reflexes are monosynaptic (two neuron pathways; i.e. one synapse) stretch reflexes and include the
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Table 4.3 Myotatic and flexor reflexes of the thoracic and pelvic limbs.
Spinal cord
Reflex site Reflex name segments Named nerve(s) tested Efferent fibers Normal response
Thoracic limb Flexor C6–T2 Axillary, median, musculocutaneous, Flexor muscles of the shoulder, Shoulder, elbow, and
withdrawal radial, thoracodorsal, suprascapular, and elbow, carpus, and digits carpal flexion
ulnar
Bicepsa C6–C8 Musculocutaneous Biceps muscle group Elbow flexion
Tricepsa C7–T2 Radial Triceps muscle group Elbow extension
Extensor carpi C7–T2 Radial Extensors of the carpus and digits Carpal extension
radialisa
Pelvic limb Flexor L4–S1 Sciatic and femoral Femoral nerve − rectus femoris Hip, stifle, and hock
withdrawal muscle ± psoas muscles flexion
Sciatic nerve − flexor muscles of
the stifle, hock, and digits
Patellar L4–L6 Femoral Quadriceps muscle Stifle extension
Gastrocnemiusa L7–S1 Tibial branch of sciatic Caudal thigh muscles: tarsal Hock extension
extensors and digital flexors
Cranial tibiala L6–S1 Fibular (peroneal) branch of sciatic Tarsal flexors, digital extensors Hock flexion
Anus Perineal S1–S3 and Caudal and Perineal and caudal rectal Caudal nerves − tail depressor Anal sphincter
caudal branches of pudendal muscles Pudendal nerve − anal contraction and tail
sphincter flexion
Skin overlying Cutaneous C8–T1 Lateral thoracic Cutaneous trunci muscles Skin twitch
thoracolumbar truncia
vertebrae
a
Sometimes may not be able to elicit in normal.
0004507087.INDD 57 12/10/2019 1:03:44 PM

extensor carpi radialis, biceps, triceps, patellar, cranial tibial, and gastrocnemius reflexes. The
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flexor (i.e. withdrawal or pedal) reflex of the thoracic and pelvic limb has a multisynaptic (i.e. mul-
tiple neuronal pathways) reflex arc and is the more consistent reflex.
Spinal reflexes are graded on a scale of from 0 to +4: Absence (0) or diminished (1+) reflexes indi-
cate a complete or incomplete lesion, respectively, in the sensory or motor component of the reflex
arc. This would indicate an LMN lesion, although differentiation between lesions of the nerve (neu-
ropathy), neuromuscular junction (junctionopathy), and muscle (myopathy) are not always feasible
based on the reflex assessment. In general, loss of reflexes in one muscle group indicates a neuropa-
thy (e.g. the femoral nerve). Bilateral reflex deficits are more common with a segmental spinal cord
lesion that affects the motor neuron in the gray matter, such as a midline compressive L4–L5 lesion
causing reduced bilateral patellar reflexes. If multiple myotatic reflexes are diminished or absent,
then a spinal cord lesion, polyneuropathy, myopathy, or abnormalities in the neuromuscular junc-
tion may be suspected. Normal (2+), exaggerated (3+), and clonic (4+) reflexes occur when there is
loss of the inhibitory UMN pathways resulting in myotatic reflexes being increased. Increased mus-
cle tone usually accompanies these exaggerated reflexes. Clonus is more often seen in chronic
lesions. Exaggerated reflexes should not be overinterpreted. If gait and postural reactions are nor-
mal, then reflexes are usually normal. If the reflexes appear exaggerated in this case, this is most
likely examiner error or increased muscle tension (e.g. due to patient anxiety).
4.3.7.1 Myotatic (Stretch) Reflexes

A plexor (pleximeter) is used to perform the myotatic reflexes. Generally, the flat surface is used
when striking tendons while the pointed edge is used on muscle bellies. In small or chondrodys-
trophic dogs, the handle can provide a focal contact on tendons. Reflexes will be easiest to interpret
in the relaxed dog lying in lateral recumbency.
4.3.7.1.1 Pelvic Limb Myotatic Reflexes

The patellar (quadriceps) reflex tests are the most reliable myotatic reflex of the pelvic limb. However,
neurologically normal dogs, 10 years of age or older may have reduced or absent patellar reflexes in
one or both limbs (Levine et al. 2002). In these dogs, gait and postural reactions should be normal.
The reflex is performed with the patient lying in lateral recumbency. A supportive hand is placed
under the femur, allowing the stifle to flex slightly. Excessive flexion or extension of the stifle joint
can falsely influence the appearance of the reflex. The patellar ligament is struck crisply using the
flat surface of the plexor and the stifle briskly extends. The normal response is for the stifle to extend.
The cranial tibial and gastrocnemius reflexes are less reliable and therefore less frequently per-
formed. Interpretation of the results should be performed with caution (Lorenz et al. 2011; Dewey
and Da Costa 2016). The cranial tibial reflex is performed with the patient in lateral recumbency,
and the limb is held parallel to the ground while the belly of the cranial tibial muscle is struck with
the plexor, midway along its length. To elicit the gastrocnemius reflex, the metatarsal area is grasped
so that the tibiotarsal joint is held in flexion while the common calcanean tendon is struck with the
pleximeter above the calcaneus.
4.3.7.1.2 Thoracic Limb Myotatic Reflexes

There are no reliable myotatic reflexes for the thoracic limb. The biceps and triceps reflexes are
difficult to elicit and while the extensor carpi radialis reflex can be easily elicited, there is debate of
its value since it can be elicited in limbs with a transected radial nerve. If these reflexes are per-
formed, they should be interpreted with caution and in context with other findings and compared
to the unaffected (if available) limb.
Similar to the pelvic limb, all reflexes of the thoracic limb are performed in lateral recumbency.
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The biceps reflex is elicited by placing an index finger firmly on the tendinous insertion of the biceps
muscle on the radius. While extending the elbow and pulling the thoracic limb caudally, the index
finger is gently struck with the plexor. To elicit the triceps reflex, the antebrachium is held with the
elbow maintained in flexion and rotated slightly outward (elbow abducted). The triceps tendon is
struck with the plexor, just above the olecranon. To elicit the extensor carpi radialis reflex, the ante-
brachium is supported with the elbow and carpus resting passively in flexion. The muscle belly of
the extensor carpi radialis is struck with the pleximeter, just distal to the elbow on the medial aspect.
4.3.7.2 Flexor (Pedal and Withdrawal) Reflexes
In the normal animal, the flexor reflex is meant to serve as protection against noxious stimuli that
would be potentially damaging to the skin. For example, if the animal steps on a sharp object, the
foot is immediately withdrawn even before pain is consciously perceived. The flexor withdrawal
reflex is more complex than myotatic reflexes; because the response involves flexion of all the mus-
cles in the limb, several spinal cord segments are activated. The receptors of the withdrawal reflex
are specialized nociceptors that respond only to noxious stimuli (pressure, heat, and cold). As
such, the stimulus used during reflex testing must be strong enough to discharge these nerves. A
sufficient noxious stimulus applied to a digit should cause the joints to flex (i.e. the limb with-
draws). Which afferent nerve is assessed depends on the specific area of skin being stimulated (for
applicable cutaneous areas, please refer to Table 4.4). The flexor reflex is a spinal reflex and there-
Table 4.4 Cutaneous sensory testing and autonomous zones used in the pelvic and thoracic limbs.
Nerve tested Cutaneous sensation Site used for testing autonomous zone
Thoracic limb
Radial Dorsal surface of the paw Dorsal surface of digits 1, 2, 3, and 4
Dorsal surface of digits 1, 2, 3, and 4
Musculocutaneous Medial aspect of the antebrachium Medial aspect of the antebrachium
Ulnar Caudal and palmar surfaces of the Caudal aspect of the antebrachium
antebrachium and paw; including digit 5 and lateral aspect of digit 5
Median Palmar surface of the paw None exist
Pelvic limb
Lateral cutaneous Craniolateral surface of the thigh Craniolateral surface of the thigh
femoral
Caudal cutaneous Caudal aspect of the proximal thigh Caudal aspect of the proximal thigh
femoral
Genitofemoral Proximal medial surface of the thigh and Proximal medial surface of the thigh
prepuce/vulva and prepuce/vulva
Saphenous Medial aspect stifle to hock Medial aspect; stifle to hock
Digits 1 and 2
Sciatic Caudal aspect of the distal thigh and caudal Caudal aspect of the distal thigh and
surface of the tarsus caudal surface of the tarsus
Tibial Plantar surface of the paw Plantar surface of digits 3, 4, and 5
Plantar surface of digits 3, 4, and 5
Fibular (peroneal) Dorsal surface of the paw Dorsal surface of digits 3, 4, and 5
Dorsal surface of digits 3, 4, and 5
fore requires no activation from the brain. It is critical not to confuse reflex withdrawal with con-
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scious perception (such as vocalizing, head turning, etc.). Withdrawal of the limb is not a behavioral
response; it is merely a reflex and not a sign that nociception is intact. As long as the LMN system
is intact, the flexor reflex will always be present. Testing for the flexor reflex however provides the
clinician the ability to assess two components of the neurologic examination: the reflex arc and
conscious perception of pain (nociception). If the reflex is present and a conscious response is
observed, both are intact.
4.3.7.2.1 Pelvic Limb Flexor Reflex

To test the flexor reflex of the pelvic limb, the limb is extended, and using the fingers, the examiner
pinches the interdigital skin. Both medial and lateral digits, e.g. between digits 2 and 3 and digits 4
and 5, should be tested since they have different cutaneous areas (Table 4.4). The least noxious
stimulus should be used at first but can be slowly increased in intensity if there is no reaction.
Finding the area where the skin becomes thicker at the distal edge and applying the stimulus there
generally yields a more consistent response. If no response is noted, then hemostats can be used by
applying gradually increased pressure of stimulus accordingly, taking care not to damage the skin.
If still no reflex is elicited, hemostats can be repositioned to squeeze across the nail bed, the digit,
and finally the metatarsal or metacarpal bones.
The normal response for this reflex is flexion of the hip, stifle, and hock. Reduced flexion of the
tarsus indicates a lesion in the sciatic nerve, nerve roots of sciatic nerve, or spinal cord segments
(L6–S1); the hips and stifle are flexed normally since the femoral nerve remains intact. Reduced
flexion of all joints indicates a lesion in the L3–S1 spinal cord, the respective nerve roots, or the
femoral and sciatic nerves. An exaggerated reflex indicates a UMN lesion.
4.3.7.2.2 Thoracic Limb Flexor Reflex

The thoracic limb is tested in the same manner as the pelvic, taking the same care to test medial
and lateral digits. The normal response is flexion of the shoulder, elbow, and carpus. Diminished
or absent reflexes indicate a lesion in the C6–T2 spinal cord segments, the respective nerve roots,
or the named nerves. Decreased flexion of the elbow and/or carpus during testing of the with-
drawal reflex indicates deficits in the musculocutaneous and median nerves, respectively. An exag-
gerated reflex would indicate a UMN lesion, occurring either in the C1–C5 spinal cord or caudal
brainstem. However, although this is the most reliable thoracic limb reflex, some dogs with reduced
thoracic limb flexor reflexes can still have a C1–C5 spinal cord lesion and vice versa, where normal
flexor reflexes can be evident when a C6–T2 spinal cord lesion has been confirmed (Forterre et al.
2008).
4.3.7.3 Perineal Reflex

The perineal reflex tests the integrity of the S1–S3 spinal cord segments as well as the caudal nerves.
The skin of the perineum is stimulated using forceps or a cotton‐tip applicator. Both right and left
sides should be tested. This reflex may be diminished in patients that have lesions affecting the
sacral spinal cord or cauda equina, especially if urinary bladder dysfunction is present, for example
degenerative lumbosacral stenosis. The normal response is ipsilateral contraction of the perineum.
4.3.7.4 Cutaneous Trunci (“Panniculus”) Reflex

The cutaneous trunci (previously called panniculus) reflex tests the sensory integrity of all dermato-
mes over the thoracolumbar vertebral column, which are supplied by the dorsal branches of each
spinal nerve in the region. Like cutaneous areas of peripheral nerves, dermatomes are areas of skin
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innervated by one spinal nerve. These sensory nerves synapse on both sides of the cord but pre-
dominantly on the contralateral side, before coursing cranially. Thus, this is a bilateral reflex. The
efferent portion is mediated by the C8–T1 spinal cord segment, the lateral thoracic nerve, and the
cutaneous trunci muscle. As such, this reflex is useful in detecting C8 and T1 spinal cord lesions,
the lateral thoracic nerve, and locating the level of a transverse thoracolumbar spinal cord lesion.
To test this reflex, the dog should be either standing squarely or lying straight in sternal recum-
bency. This reflex is present in the thoracolumbar region but is absent in the cervical and sacral
regions. Testing should begin at the level of the fourth or fifth lumbar vertebra. The skin just lateral
to midline of one side is gently grasped and pinched. Hemostats positioned perpendicular to the
vertebral column work best, especially those with curved tips directed downward. As with the
withdrawal reflex, only enough pressure should be applied to elicit the reflex. The normal response
is bilateral contraction of the skin overlying the cutaneous trunci muscle along the dorsal and lat-
eral trunk. If a normal reflex is elicited caudally, then there is no need to continue cranially; since
the nerves course in a cranial direction, the entire pathway must be intact. If an abnormal reflex
response is encountered, testing up to the level of the first thoracic vertebra is performed and the
location where the reflex becomes normal (cutoff point) is noted. The opposite side is then tested
in the same manner.
Similar to the flexor reflexes, two responses can be observed in the normal patient, a twitch of
the skin and/or a behavioral response. Contraction of the cutaneous trunci muscle indicates the
reflex arc is intact; a behavioral response indicates perception of discomfort. A lateral thoracic
nerve lesion will result in a diminished or absent reflex on the affected side (i.e. LMN dysfunction)
and a transverse spinal cord lesion in the thoracolumbar region will result in a bilateral cutoff
whereby the muscle contraction caudal to the level of a spinal cord lesion (approximately 1–4
spinal segments) will be diminished or absent. Similarly, a lesion affecting the brachial plexus
causes an LMN lesion to the ipsilateral lateral thoracic nerve and results in loss of the ipsilateral
cutaneous trunci reflex. For example, in a patient with a right brachial plexus injury, the muscle
contraction will be elicited only on the left side of the trunk, regardless of where the skin is tested
(Video 16.1).
In some normal animals, a cutaneous trunci reflex will not be elicited. In these circumstances, it
should be interpreted as equivocal since no localizing information can be inferred if there is no
cutoff.
4.3.8 Sensory Testing and Palpation

At this point in the neurologic examination, some information has already been gathered about the
patient’s sensory system, for example during testing of cranial nerves, proprioceptive positioning,
and spinal reflexes. The last portion of the neurologic examination is further evaluation of the
sensory component. This includes nociception (perception of pain), spinal and limb palpation, and
cutaneous sensory testing. To maintain accuracy in localizing the source of pain or abnormal sen-
sation, sensory testing should be completed prior to administering sedation. The age, breed, and
temperament can also influence a patient’s level of response.
4.3.8.1 Nociception
Many publications describe testing for superficial and deep pain by varying the degree of compres-
sion applied to the skin, implying there are different pathways carrying information about each.
In animals, however, one nociceptive pathway predominates (spinothalamic tract) making the dis-
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tinction between deep and superficial pain very difficult. In this text, the term nociception will be
used to infer the patient’s perception of a noxious stimulus.
In patients with severe transverse spinal cord lesions (i.e. paraplegic or tetraplegic), nociception
should only be assessed in limbs that have absent voluntary motor and where the presence of
sensation has not already been established. Any noxious stimulus that elicits a behavioral response
may be used to confirm the presence of pain sensation. Pinching the digit or interdigital webbing
may be adequate in some animals. When a response is more difficult to elicit, hemostats should be
used. If there is no response to a noxious stimulus applied to the toes, then the same stimulus can
be applied to the metacarpal/‐tarsal bones. If there is no motor present in the tail, nociception can
be assessed in a similar caudal to cranial direction.
4.3.8.2 Spinal and Limb Palpation

Palpation of the limbs and vertebral column is performed from distal to proximal and caudal to
cranial, respectively. Palpation should always begin using a light touch to prevent more forceful
than necessary maneuvers near a painful or unstable region, which could be dangerous to the
patient (e.g. unstable vertebral fracture) or the examiner (e.g. aggression provoked from pain or
fear). Details of lumbosacral and cervical palpation are described in the respective Chapters 16
and 21.
It is important to consider that pain assessment is subjective, as well as examiner and patient
dependent. Also, pain can be referred from other sources (e.g. abdominal pathology or intracranial
disease causing spinal hyperesthesia) or transfer to appendicular skeletal structures. For example,
a patient may react or sit when pressure is applied, downward onto the caudal lumbar spine, if
some of this pressure is conveyed onto painful stifle or coxofemoral joints.
4.3.8.3 Cutaneous Sensory Testing

Nervous system lesions typically cause loss of sensation caudal or distal to the lesion, and in many
cases, sensation will be increased at the site of injury. Therefore, the distribution of cutaneous
sensory loss provides great localizing information as lesions can be pinpointed to a specific nerve
or two to three spinal cord segments. For this purpose, areas of increased sensitivity (hyperesthe-
sia), decreased sensation (hypoesthesia, also called hypesthesia), or absent sensation (anesthesia)
are evaluated and mapped out. This concept is also used during the flexor withdrawal and cutane-
ous trunci reflex testing as described above. Similarly, testing can be performed along the other
zones described, such as autonomous zones of the limbs (Figures 4.5). Testing is generally per-
formed using a hemostat (as described above) and is started caudally or distally and advanced
cranially or proximally, respectively. The direction can be reversed to better map the specific point
where decreased sensation transitions to normal sensation. If the patient displays a behavioral
response at any point during the exam, then sensation is present, and giving a more severe stimu-
lus is not necessary.
The autonomous zones most commonly tested in the thoracic limb include the skin of the dorsal
paw for the radial nerve, the medial surface of the antebrachium for the musculocutaneous nerve,
and the caudal surface of the antebrachium for the ulnar nerve (Table 4.4, Figure 4.5). Due to over-
lap from the ulnar nerve, the median nerve does not have an autonomous zone. In the pelvic limb,
sites for testing autonomous zones include the craniolateral surface of the thigh for the lateral
cutaneous femoral nerve, the caudal aspect of the proximal thigh for the caudal cutaneous femoral
nerve, the proximal medial surface of the thigh and prepuce or vulva for the genitofemoral nerve,
4.4 Diagnostic Test 63
(A)
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Dorsal cutaneous branches:

C5 C6 T2 T3
C5 ventral cutaneous Lateral cutaneous

branch branch of T2
Axillary nerve
Brachiocephalic
nerve
Musculocutaneous
nerve
Ulnar nerve
Radial nerve
(B)
Lateral cutenous
femoral nerve
Cutaneous femoral
nerve
Genitofemoral
nerve Sciatic nerve
Saphenous branch of
the femoral nerve
Fibular nerve
Tibial nerve
Figure 4.5 Cutaneous innervation of the (A) thoracic and (B) pelvic limbs: autonomous zones (i.e. areas
innervated by a single nerve; shaded regions) and the recommended sites for testing (red dots) are shown.
the medial surface of the tarsus and stifle for the saphenous nerve (branch of the femoral nerve),
the caudal aspect of the distal thigh and caudal surface of the tarsus for the sciatic nerve, the plan-
tar surface of the paw for the tibial nerve, and the dorsal surface of the paw for the fibular (pero-
neal) nerve. Cutaneous testing in the cervical region is unreliable in localizing lesions (Table 4.4,
Figure 4.5).
4.4 Diagnostic Tests
The division between musculoskeletal and neurologic disorders is not always straightforward.
Nonetheless, this distinction is important since the diagnostic approaches and therapeutic plans
can vary considerably depending on the cause. To add further confusion, the same patient may
have both orthopedic and neurologic disease. Some patients presenting early in a neurologic
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disease process, such as a nerve sheath tumor, may only display lameness as a sole deficit, mak-
ing differentiation from orthopedic disease very difficult. Typically, orthopedic causes are easiest
to exclude first with an orthopedic examination, and if any identified abnormalities are nonex-
planatory or no abnormalities are found, neurodiagnostics (e.g. neuroimaging) are then
pursued.
General considerations regarding diagnostic imaging technologies are discussed in Chapter 10.
Multiple abnormalities may be found on neuroimaging, and the clinician will need to determine
their clinical significance. Any abnormality needs to be interpreted in light of the clinical history
and corroborated with the neurologic examination.
4.4.1 Survey Radiographs

Orthogonal spinal radiographs can be used to assess vertebral structures, intervertebral disc spaces,
and intervertebral foramina. To accomplish ideal positioning, sedation is generally advised.
Mineralized intervertebral discs may be evident in the foramen or canal and occasionally neoplas-
tic lesions can cause enlargement of the intervertebral foramen from pressure atrophy. Bone lysis
due to discospondylitis or neoplasia may also be seen, depending on chronicity.
4.4.2 Myelography
Myelography is an imaging examination where contrast material is injected into the subarachnoid
space followed by either radiographs or computed tomography (CT). The images, called myelo-
gram, can provide information on the spinal canal, spinal cord, meninges, subarachnoid space,
and nerve roots. It is helpful in detecting extramedullary compressive lesions, but it is frequently
not useful in identifying intramedullary, foraminal, nerve root, or nerve lesions.
4.4.3 Computed Tomography

CT has the advantage of being a fast imaging modality but does have limitations regarding its ability
to diagnose neurologic lesions. Similar to myelography, CT is useful in detecting compressive
extramedullary lesions, such as mineralized intervertebral discs. However, compared to magnetic
resonance imaging (MRI), CT images provide limited information on the nerves and intramedullary
diseases, such as neoplasia and fibrocartilaginous emboli (FCE). If a herniated intervertebral disc is
not mineralized, it will not be easily detectable on CT. CT can be combined with myelography and/
or an intravenous contrast agent to increase the diagnostic accuracy.
4.4.4 Magnetic Resonance Imaging

MRI is the imaging modality of choice for the CNS and PNS. MRI is valuable in identifying inflam-
mation or regions of edema, which signify pathology. Structural lesions (such as intervertebral disc
herniation), soft tissue proliferation secondary to discospondylitis or spondylomyelopathy, neopla-
sia, and intramedullary pathology (e.g. FCE) are also detectable by MRI. Intravenous contrast can
be administered and may accentuate some lesions, especially those outside of, or disruptive to, the
blood–brain barrier, e.g. certain neoplasms, meningitis, and discospondylitis.
Reference 65
4.4.5 Electrodiagnostic Examination

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Electrodiagnostic studies assess the integrity of muscles and nerves through recording action
potentials. The two most commonly performed electrodiagnostic studies include electromyogra-
phy (EMG), which measures spontaneous electrical activity of muscles, and nerve conduction
velocity (NCV), which evaluates the function of a motor or sensory nerve by measuring the veloc-
ity of an evoked action potential along its length. General anesthesia is required for most electro-
diagnostic tests to minimize both movement artifacts and patient discomfort. A detailed
discussion of electrodiagnostic testing can be found in the literature (Cuddon 2002; Dickinson
and Lecouteur 2002).
Collectively, electrodiagnostic studies are useful screening tests to confirm dysfunction in the
muscle or nerve. Although these tests do not diagnose specific PNS disorders, because orthopedic
disease will not cause abnormalities on electrodiagnostic studies, they can aid in distinguishing if
equivocal signs of lameness (e.g. pain or atrophy) are caused by neurologic or orthopedic disease.
For example, if muscle atrophy is present, EMG will be normal if the cause is disuse atrophy rather
than neurogenic. Thus, the distribution of abnormalities can be mapped out through testing of
specific muscles and nerves, the results of which guide additional testing needed, like muscle and
nerve biopsies, so that only tissue from abnormal regions is collected.
4.4.6 Cerebrospinal Fluid Analysis

Cerebrospinal fluid (CSF) is contained in the ventricular system and subarachnoid space, where it
bathes the brain and spinal cord, including nerve roots. It is produced in the ventricles by the cho-
roid plexus and ependymal cells as well as the brain tissue.
Analysis of CSF often contributes to a diagnosis but rarely gives a specific diagnosis, much like
abnormal complete blood count (CBC) or serum chemistry results. Thus, it is very sensitive for
detecting CNS disease but in most cases, it is not very specific. Indications for CSF collection
include any disease affecting the brain, a spinal cord lesion not definitively diagnosed on advanced
imaging, and lesions suspected to affect the spinal nerve roots (radiculopathies), which are the
only portion of the PNS still enclosed in meninges.
Collection of CSF is performed either from the cerebellomedullary or lumbar cistern; typically, the
location that is nearest or caudal to the suspected location is selected. A normal CSF does not
exclude neurologic disease. For example, if a disease process does not involve the meninges, it may
not be evident on CSF analysis. Descriptions of how to perform and interpret CSF fluid analysis
can be found elsewhere (Di Terlizzi and Platt 2009; Dewey and Da Costa 2016).
R
eferences
Cuddon, P.A. (2002). Electrophysiology in neuromuscular disease. Vet Clin North Am Small Anim
Pract 32 (1): 31–62.
De Lahunta, A., Glass, E., and Kent, M. (2015). Veterinary Neuroanatomy and Clinical Neurology. St.
Louis: Elsevier.
Dewey, C.W. and Da Costa, R.C. (2016). Practical Guide to Canine and Feline Neurology. Hoboken:
Wiley‐Blackwell.
Dewey, C.W., Da Costa, R.C., and Thomas, W.B. (2016). Performing the neurologic examination. In:
Practical Guide to Canine and Feline Neurology, 3e (eds. C.W. Dewey and R.C. Da Costa), 92–137.
Hoboken: Wiley‐Blackwell.
Di Terlizzi, R. and Platt, S.R. (2009). The function, composition and analysis of cerebrospinal fluid in
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companion animals: Part II—Analysis. Vet J 180 (1): 15–32.

Dickinson, P.J. and Lecouteur, R.A. (2002). Muscle and nerve biopsy. Vet Clin North Am Small Anim
Pract 32 (1): 63–102.
Forterre, F., Konar, M., Tomek, A. et al. (2008). Accuracy of the withdrawal reflex for localization of the
site of cervical disk herniation in dogs: 35 cases (2004‐2007). J Am Vet Med Assoc 232 (4): 559–563.
Levine, J.M., Hillman, R.B., Erb, H.N., and De Lahunta, A. (2002). The influence of age on patellar
reflex response in the dog. J Vet Intern Med 16 (3): 244–246.
Lorenz, M.D., Coates, J.R., and Kent, M. (2011). Handbook of Veterinary Neurology. St. Louis: Elsevier/
Saunders.
Penderis, J. (2015). Diagnosis of Horner’s syndrome in dogs and cats. In Practice 37 (3): 107–119.
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The Rehabilitation Examination

Sasha Foster
James L. Voss Veterinary Teaching Hospital, Colorado State University, Fort Collins, CO, USA
5.1 Introduction
Canine rehabilitation modifies human physical therapy evaluation and treatment techniques
into the canine model with the goal of improving functional outcomes for patients. Mobility
depends on the health and quality of many tissues, from the deepest part of the joint, the articu-
lar cartilage, to the superficial muscles, fascia, and skin. When tissues are injured, these attrib-
utes deteriorate which may produce painful and abnormal function. For example, if cartilage is
no longer smooth and pliable, joint surface movement becomes restricted; this in turn may
shorten the joint capsule, leading to secondary tightening of muscles, which may then cause
weakness and atrophy. What rehabilitation brings to the lameness exam is the ability to clini-
cally differentiate which tissues (e.g. joint, muscle, ligament, and fascia), based on their normal
and abnormal attributes, may be contributing to lameness. The evaluation techniques used to
clinically differentiate these tissues are subjective, manual evaluation techniques consisting of
(i) passive range of motion (PROM), (ii) joint play, (iii) flexibility testing, (iv) strength testing,
and (v) special tests (Box 5.1). The latter entail specific maneuvers that evaluate a specific condi-
tion (such as cranial drawer for cruciate ligament instability). This chapter will focus on the first
four components of the rehabilitation exam (please refer Chapters 12–22 for special tests regard-
ing individual regions).
When completing manual therapy evaluations, the available scientific evidence needs to be con-
sidered before determining a diagnosis and establishing a treatment plan. Only few canine studies
exist to support the use of manual evaluation techniques, such as PROM and limb circumference
evaluation (Millis and Ciuperca 2015). Even studies in people (who have the capacity to communi-
cate pain to an evaluator) show that the reliability of manual evaluation techniques is variable
(May et al. 2010). Yet, results of manual therapy evaluation can be useful to the evaluator to develop
and further define a differential diagnosis list, particularly regarding muscle injuries. Nonetheless,
the systematic application of established diagnostics such as radiographs, ultrasound, CT, and MRI

68 5 The Rehabilitation Examination
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Box 5.1 Components of the Rehabilitation Exam
1) Passive Range of Motion (PROM)

a) End-feel
b) Osteokinematics (goniometry)
2) Joint Play
a) Arthrokinematics
3) Flexibility
a) Passive flexibility (muscle stretching)
b) Myofascial exam (Chapter 6)
4) Strength
a) Canine Muscle Test (C-MT)
5) Special tests (see Chapters 12–22 for specific regions)
continues to be the gold standard for determining the underlying cause of lameness. Therefore, if
diagnostics are not available, care should be taken when using clinical exam findings for the purpose of
treatment planning.
5.2 Passive Range of Motion
PROM testing comprises the foundation of the rehabilitation manual evaluation for thepurpose
of determining if osteokinematic abnormalities contribute to a canine patient’s lameness.
Osteokinematics describe the movement between two bone segments (i.e. flexion and extension,
abduction and adduction, and external and internal rotation of a joint). PROM testing includes two
components that provide important pieces of clinical information: (i) the subjective description of
the end‐feel and (ii) the objective goniometric measurement. End‐feel is the subjective description
of the sensation that the observer experiences at the end of joint range of motion (i.e. the “end‐feel
limiting structure” of the joint). The end‐feel provides the tester with information about which
tissues should be evaluated further (Figure 5.1), while the goniometric measurements determines
if PROM is normal, restricted, or excessive.
Various classifications, terminology, and descriptions have been used to describe different end‐
feel observations (Petersen and Hayes 2000; Marcellin‐Little and Levine 2015). The purpose of
assessing end‐feel is to determine which tissue type may be allowing excessive PROM or restricting
it. Some end‐feels can be normal or pathologic, depending on the joint and the point at which dur-
ing motion they are observed (Table 5.1 and Figure 5.2). As such, the observer needs to be aware of
the normal end‐feels for each joint (Table 5.2). If PROM testing detects an abnormal amount of
motion (decreased or increased) between the two bone segments, the type of end‐feel may indicate
which tissues are causing this finding and isolate those that require further evaluation as seen in
Figure 5.1. With the end‐feel in mind, the objective goniometric measurement is taken to deter-
mine if range of motion is normal. Reference ranges are available (Figure 5.3, Tables 5.3 and 5.4)
but because they may vary between breeds (Thomas et al. 2006; Hady et al. 2015), the contralateral
limb should be used for comparison (if unaffected).
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Passive range of motion (PROM) end-feels
Subjective end-feel during PROM

End-feel
Muscle Tissue
Capsular Elastic Bony approximation Empty
spasm
restricting
motion
Tissue
Muscle/ Unable to
Joint capsule Muscle pain Bone Soft tissues
tendon recoil determine
palpatory
Test joint Test muscle Test muscle

Next
step
play flexibility flexibility

diagnostic
procedure
Indicated
Musculoskeletal Musculoskeletal Musculoskeletal Radiographs, Variable –

FNA/ultrasound
ultrasound, MRI, ultrasound, MRI, ultrasound, MRI, CT, etc. determine
etc. etc. etc. source of pain
Figure 5.1 Diagnostic suggestions based on the observed end-feel during passive range of motion.
Table 5.1 Description of end-feels with normal and abnormal examples.

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Example
End-feel Description normal Example abnormal
Capsular Firm and yielding: joint capsule Shoulder and Loss of hip extension PROM with
restricts motion and resistance is hip extension hip osteoarthritis
not abrupt
Elastic Yielding with recoil: muscle and Tarsal flexion Patellar tendonitis, carpal
tendons restrict motion hyperextension
Bony Hard and unyielding: bone Elbow Advanced elbow osteoarthritis, loss
restricts motion and resistance is extension (or of elbow flexion, and extension
abrupt capsular) PROM
Muscle spasm Resistance with pain and visual None Myotendinopathies
and palpable muscle spasm:
muscle pain restricts motion
Tissue Soft tissue limits motion Shoulder or Large lipoma interfering with
approximation stifle flexion motion
Empty No end‐feel noted: unable to None Intra‐articular fracture, unable to
determine end‐feel due to pain evaluate
(A) (B)
Elastic Bony
(C) (D)
Capsular Spasm
Figure 5.2 Illustration of selected end-feels: (A) an elastic end-feel describes the sensation that is
observed when muscle or tendon are limiting range of motion, for example, with a supraspinatus
tendinopathy; (B) a bony end-feel can be observed if severe osteophyte production in an arthritic joint is
reducing range of motion; (C) similarly, a capsular end-feel may be observed with osteoarthritis; however,
the limiting tissue in this case is the thickened capsule rather than osteophytes; (D) muscle spasm end-feel
limits range of motion because of muscle pain.
5.2 Passive Range of Motio 71
Table 5.2 Normal passive range of motion (PROM) limiting structures and end-feel description (used by author)
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for the major canine joints.
Joint PROM Normal end-feel Normal limiting structure
Shoulder extension Capsular Joint capsule

Shoulder flexion Tissue approximation Triceps muscle group on body wall
Elbow extension Capsular/bony Joint capsule/oblique ligament
Elbow flexion Tissue approximation Carpal extensor muscle group on biceps brachii muscle
Carpus extension Elastic Carpal flexor muscle group
Carpus flexion Capsular Joint capsule
Hip extension Capsular Joint capsule
Hip flexion Tissue approximation Quadriceps muscle group on body wall
Stifle extension Capsular Cranial cruciate ligament
Stifle flexion Tissue approximation Gastrocnemius on hamstring muscle group
Tarsal extension Capsular Joint capsule
Tarsal flexion Elastic Gastrocnemius stretch
Canine thoracic limb goniometry Canine pelvic limb goniometry
[44 ± 6 (50 ± 2)] ~45°

~50° [47 ± 6 (57 ± 2)]
[155 ± 6 (162 ± 3)] ~160°
~160° [159 ± 6 (165 ± 2)]
[25 ± 4 (36 ± 2)] ~30° ~35° [33 ± 7 (42 ± 2)]
~155° [153 ± 4 (162 ± 3)]

[155 ± 5 (165 ± 2)] ~160°
~35° [34 ± 6 (32 ± 2)] [30 ± 8 (39 ± 2)] ~35°
[149 ± 6 (164 ± 2)] ~155°
~200° [198 ± 4 (196 ± 2)]
Figure 5.3 Rounded approximation (in bold) of published angles (goniometry) and normal measurements
of the canine thoracic and pelvic limb. Bracketed reference values of the mean (±SD) measurements are
provided for German Shepherd Dogs followed by those for Labrador Retrievers, in parentheses. Source:
Adapted from Thomas et al. (2006).
Table 5.3 PROM and flexibility testing for the thoracic limb.

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Joint Normal PROM Muscle(s) inhibiting Flexibility testing
Shoulder Flexion (47–57°) Supraspinatus Shoulder flexion

Biceps brachii Shoulder flexion and elbow
extension
Extension Deltoids Shoulder extension, adduction, and
(159–165°) internal rotation
Infraspinatus Shoulder flexion or extensiona,
adduction, and internal rotation
Latissimus dorsi/teres Shoulder extension, abduction, and
major/deep pectoralis external rotation
Triceps long head Shoulder extension and elbow flexion
Abduction Subscapularis Shoulder abduction or shoulder
(30–32°) flexion with external rotation
Superficial pectoralis Shoulder abduction
Elbow Flexion (25–36°) Triceps long head Shoulder extension and elbow
flexion
Extension Biceps brachii Shoulder flexion and elbow
(155–165°) extension
Carpus Flexion (32–34°) Common and lateral Elbow extension, carpus flexion,
digital extensor digit flexion
Extensor carpi radialis Elbow extension and carpus flexion
Extension Flexor carpi radialis Carpus extension
(196–198°) Flexor carpi ulnaris Elbow flexion and carpus extension
(humeral head)
Digits (thoracic) Flexion (N/A) Common and lateral Elbow extension, carpus flexion,
digital extensor and digit flexion
Extension (N/A) Superficial digital flexor Elbow flexion, carpus extension,
and proximal interphalangeal joint
extension
Deep digital flexor Elbow flexion, carpus extension,
and distal interphalangeal joint
extension
Normal goniometric measurements for each joint are outlined in the second column, the “inhibiting” muscle (i.e.
muscle that could decrease the PROM measurements) in the third column, and the joint positions to stretch the
muscle are outlined in the fourth column. If the observer detects decreased PROM, an elastic end‐feel and/or pain
while performing goniometric measurements, flexibility testing of the “inhibiting” muscles should be performed.
The normal PROM measurements are the mean measurements described for German Shepherd Dogs and Labrador
Retrievers. Source: Adapted from Thomas et al. (2006).
a
Depending on the position of the shoulder joint, this muscle can be an extensor or flexor and as such flexibility
testing should also include both.
Table 5.4 PROM and flexibility testing for the pelvic limb (see Table 5.3 for column descriptions and how
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to use this table).
Joint Normal PROM Muscle(s) inhibiting Flexibility testing
Hip Flexion Deep and middle gluteal Hip flexion and adduction
(44–50°) Superficial gluteal and Hip adduction
piriformis
Extension Sartorius, cranial head, and Hip extension and stifle flexion
(155–162°) rectus femoris
Iliopsoas Lumbar spine extension, ventral pelvic tilt,
hip extension, and hip internal rotation
Abduction Pectineus and adductor Hip abduction
(N/A)
Stifle Flexion Quadriceps complex Stifle flexion
(33–42°) Sartorius, cranial head, and Hip extension and stifle flexion
rectus femoris
Extension Biceps femoris Hip flexion, adduction, internal rotation,
(153–162°) and stifle extension and tarsal flexion
Semitendinosus Hip flexion, external rotation, and stifle
extension and tarsal flexion
Semimembranosus Hip flexion, slight abduction, and stifle
extension
Gracilis Hip flexion, abduction (greater degree than
semimembranosus), external rotation, and
stifle extension and tarsal flexion
Tarsus Flexion Gastrocnemius Stifle extension and tarsal flexion
(30–39°)
Extension Long digital extensor Stifle flexion, tarsal extension, and digit
(149–164°) flexion
Cranial tibialis Tarsal extension
Digits Flexion (N/A) Long digital extensor Stifle flexion, tarsal extension, and distal
(pelvic) interphalangeal joint flexion
Extension Superficial digital flexor Tarsal flexion and proximal
(N/A) interphalangeal joint extension
Deep digital flexor Tarsal flexion and distal interphalangeal
joint extension
5.2.1 How to Perform Passive Range of Motion Testing

PROM testing is a skill set that requires basic knowledge of joint osteokinematics, awareness of
muscle origins and insertions, manual handling skills, and correct choice and use of a goniometer.
A frequently neglected factor causing incorrect PROM angles is improper positioning of the limb.
PROM testing should be an evaluation of the motion between two bone segments, avoiding the
influence of muscle tension across the joint. This can be accomplished by placing all muscles that
surround the joint, especially muscles that cross more than one joint, in a slacked (non‐taut) position.
Knowledge of muscle anatomy and function is crucial to accomplish this task. However, as a rule
when testing flexion PROM, the proximal and distal joints should be positioned in flexion; when
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(B)
(A)
(C)
Figure 5.4 Flexibility versus PROM of the hamstrings/stifle joint: when testing stifle extension PROM and
end-feel, the muscles resisting stifle extension (i.e. the hamstring group) must be on slack to eliminate their
influence on osteokinematic end-feel and goniometric measurements. This is accomplished by positioning
the hip in extension. If the hip is placed in flexion, flexibility of the hamstrings is tested. This concept is
illustrated using the semimembranosus muscle as an example (this muscle has two bellies: the cranial belly,
a hip extender and the caudal belly, a hip extender and stifle flexor). Given that flexibility testing means
performing the opposite joint motion of the concentric contraction of a muscle, if (A) the hip is placed in
flexion and the stifle in extension, the flexibility of both semimembranosus bellies is evaluated. If (B) all
joints are placed in extension PROM of the stifle and hip joint can be accurately measured, since both
bellies are on slack. If (C) the hip and stifle are placed in flexion, the flexibility of the cranial
semimembranosus belly only is tested.
testing extension, the joints should be positioned in extension. For example, when testing stifle
extension and osteokinematic end‐feel, the tester must place the hamstring muscle group on slack
(i.e. by extending the hip joint). If this is not performed, hamstring flexibility, rather than PROM
of the stifle joint, is tested (Figure 5.4). PROM testing positions for all major joints, current pub-
lished measurements and flexibility testing positions for the common muscles that may influence
PROM at each joint can be found in Tables 5.3 and 5.4.
It is important to note that there are ranges of motion where single‐joint muscles cannot be
placed on slack – this will always influence subjective end‐feel and objective goniometric
measurements. For example, both the supraspinatus and biceps brachii muscles cross the cranial
aspect of the shoulder joint (i.e. act as shoulder extenders). However, the supraspinatus is unable
to be placed on slack when testing flexion PROM of the shoulder joint because it crosses only a
single joint. The biceps brachii, on the other hand, can be placed on slack by flexing the elbow dur-
ing shoulder flexion PROM testing. Similarly, other muscles that cross multiple joints such as the
humeral head of the flexor carpi ulnaris and the gastrocnemius cannot be placed on slack when
testing for PROM of carpus extension or tarsal flexion, respectively.
The second confounding factor in PROM testing is improper use and placement of the universal
goniometer. Steps necessary to perform accurate goniometry are outlined in Figure 5.5 and
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Step 1
Move joint through ROM
• Identify joint center
• Identify landmarks
Step 2
Place limb in testing position

• = all joints flexed if testing flexion
• = all joints extended if testing extension
Step 3
Place the goniometer

• Stationary arm on proximal bone segment
• Center of goniometer over center of joint
• Motion arm on distal bone segment
Step 4
Add overpressure
• Identify maximum motion
• Measure angle
Figure 5.5 Passive range of motion (PROM) for carpus extension is completed in a series of four steps. First,
the patient is relaxed in lateral recumbency and the joint is moved through range of motion to identify the
joint center and landmarks. Second, the limb is positioned for testing by placing the multi-joint muscles on
slack; in this, this case by ensuring the elbow is extended and the subjective end-feel is determined. Third, the
goniometer is placed over the joint with the stationary arm on the proximal bone, the axis on the point of
rotation of the joint, and the mobile arm on the distal bone. Fourth, with the goniometer in place, the joint is
moved into the testing range of motion applying overpressure at end range to achieve full range of motion of
the joint.
reviously published landmarks for goniometer positioning (Jaegger et al. 2002; Freund et al.
p
2016) should be considered to standardize goniometric measurements (Table 5.5). In veterinary
medicine, all PROM measurements should be measured on the flexion side of the joint (i.e. on the
cranial aspect for the elbow, hip, and tarsus, and on the caudal aspect for the shoulder, carpus, and
stifle; Figure 5.3). Current evidence suggests that canine goniometric measurements are more
accurate when using a universal goniometer compared to digital, electronic, and smart phone
devices/apps (Thomas et al. 2006; Freund et al. 2016).
PROM testing of the peripheral limbs can be completed with the patient in a standing or recum-
bent position, but only if they are performed consistently when measurements between time
points are compared. If the patient reacts to any of the testing positions while standing, or if the
tester subjectively feels hypo‐ or hypermobility in any joint, PROM testing with the patient in lat-
eral recumbency is indicated. This position will allow the antigravity muscles to relax. The muscles
Table 5.5 Previously published landmarks for placement of goniometer arms.

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Stationary (=proximal) arm Motion (=distal) arm
Distal landmark Proximal landmark Distal landmark Proximal landmark
Shoulder Spine of scapula Lateral epicondyle of Insertion of the

the humerus infraspinatus
muscle on the
greater tubercle of
the humerus
Elbow Lateral epicondyle of Insertion of the Cranial to caudal Lateral epicondyle
the humerus infraspinatus muscle midpoint of the of the humerus
on the greater antebrachium at the
tubercle of the level of the ulnar
humerus styloid process
Carpus Cranial to caudal Lateral epicondyle of Long axis of metacarpal bones III and IV
midpoint of the the humerus
antebrachium at the
level of the ulnar
styloid process
Hip Tuber sacrale Tuber ischiadicum Lateral epicondyle of Greater trochanter
the femur
Stifle Lateral epicondyle of Greater trochanter Lateral malleolus of Craniocaudal
the femur the fibula midpoint of the
proximal aspect of
the tibia at the level
of the tibial crest
Tarsus Lateral malleolus Craniocaudal Long axis of metatarsal bones III and IV
midpoint of the
proximal aspect of the
tibia at the level of the
tibial crest
Source: Adapted from Jaegger et al. (2002) and Freund et al. (2016).
will therefore have less of an influence on the PROM evaluation. Also, it is important to note that
PROM testing in a standing position must be differentiated from measuring standing angles; the
latter has recently been described and evaluates the posture of a dog rather than range of motion
of a joint (Sabanci and Ocal 2018).
5.2.2 How to Interpret Passive Range of Motion Testing

PROM testing determines whether joint range of motion is abnormal and which tissue type
restricts range of motion. This information can be helpful in determining appropriate subsequent
diagnostic steps. For example, when testing a patient’s shoulder extension PROM, if the end‐feel
is elastic and the PROM goniometric measurement is 140°, the observer should conclude that
PROM may be decreased because of muscle pathology (as indicated by the elastic end‐feel;
Table 5.1). Several muscles limit shoulder extension (Table 5.3), including the latissimus dorsi,
5.3 Joint Pla 77
teres major, deep pectoralis, deltoids, infraspinatus, and the long head of the triceps. Flexibility
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testing of these muscles and thorough evaluation for pain should then be performed. These
findings may then lead the tester to determine that further diagnostics (e.g. ultrasound) of the
area may be indicated (Figure 5.1).
5.3 Joint Play
While testing range of motion is commonly taught in veterinary school, testing of motion within
the joint is only taught for very specific examples (such as “cranial drawer” motion with rupture of
the cranial cruciate ligament). These small amplitude movements at the level of the joint are
defined as arthrokinematics, joint play, or accessory motions. The concept of arthrokinematic testing
has been described for assessment of the canine spine, where it is known as the chiropractic
evaluation (Taylor and Romano 1999). Although there is a lack of research supporting the use of
chiropractic evaluations and treatments in veterinary medicine (Rome and Mckibbin 2011), there
are several examples of arthrokinematic assessments being applied in veterinary orthopedics.
Such examples include the testing for hip laxity (Ortolani maneuver; Chapter 20) and evaluation
of cranial or caudal drawer motion of the stifle. While these examples are well‐known applications
of arthrokinematics in small animal orthopedics, the rehabilitation exam aims to use the same
concept to identify more subtle abnormalities for all joints. In other words, the chiropractic exami-
nation includes arthrokinematic evaluation of the spine, whereas joint play is the arthrokinematic
evaluation of appendicular joints.
When goniometric measurements are increased or decreased, further evaluation of joint arthro-
kinematics is warranted. PROM tests osteokinematic motion, whereas joint play (i.e. arthrokine-
matics) tests the subjective quality and quantity of movement between two articular surfaces
(Figure 5.6). Joint play occurs between two joint surfaces and may include a combination of three
primary types of motion: rolling, spinning and gliding (sliding) which can be associated with spe-
cific osteokinematic motions. For example, carpus extension and carpus flexion PROM are associ-
ated with the carpal bones gliding caudally and cranially respectively on the radius and ulna. If
carpus PROM measurement is abnormal, further evaluation of joint play of the carpal bones on the
radius and ulna is indicated.
Because the primary PROM limitations diagnosed during canine lameness exam are the
osteokinematic motions of flexion and extension, the remainder of this section is devoted to fur-
ther rehabilitation manual evaluation of the joint play gliding which is associated with these spe-
cific motions. However, the same concepts also apply for evaluating the motion of abduction and
adduction.
5.3.1 How to Perform Joint Play Testing

Joint play testing is the subjective evaluation of two components of arthrokinematics – the quality
and quantity of motion. This test is passive and should be completed with the dog resting in lateral
recumbency. The testing joint should be placed in a neutral position (approximately midrange
between end range flexion and extension) slacking the joint capsule and ligaments to allow the
distal joint surface to glide on the proximal surface with the least interference from these joint
stabilizing structures. To prepare to test joint play, the tester manually stabilizes the proximal bone
as close to the joint surface as possible without painfully compressing soft tissues. To initiate the
(A) (B)
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Osteokinematic motion: Rolling

gross movements of
bones at joints
Arthrokinematic motion:
small amplitude motions
of bones at joint surface
(C) (D)
Cranial
Medial
Spinning Gliding
Lateral
Caudal
Figure 5.6 Osteokinematics and arthrokinematics are related to each other and are used to accurately
assess and describe joint range of motion. (A) Osteokinematics describe the gross movements of bones as
manifested at the joint by a change in joint angle (e.g. flexion and extension through range of motion).
Arthrokinematics describe small changes at the level of the joint surface itself (e.g. accessory motions).
Arthrokinematic motions include (B) rolling, which is a rotary movement (i.e. one bone is “rolling” off the
other which would for example cause flexion of the shoulder); (C) spinning, which is also a rotary
movement, however rather than rolling one bone is “spinning” on the other like a top, causing internal or
external rotation; and (D) gliding or sliding, which is a translatory movement that can happen in four
directions (i.e. one bone gliding on the other which may be part of normal range of motion or pathologic,
such as a drawer motion).
test, the tester manually mobilizes the distal bone (again, as close to the joint as possible) parallel
to the proximal bone joint surface in one direction at a time – cranially, caudally, medially, and
laterally. As the distal surface of the joint is gliding on the proximal surface, the tester feels for joint
surface quality and notes descriptions such as crepitus or pain (Cookson and Kent 1979). Since this
testing is subjective, it is ideal for the tester to compare findings to the contralateral, unaffected
joint. If no unaffected joint is available, breed‐to‐breed comparison may be considered. This infor-
mation can then be used to determine if the joint surface quality is normal and if the joint surface
gliding motion is restricted or excessive.
5.4 Flexibility Testin 79
5.3.2 How to Interpret Joint Play Testing

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Joint play testing determines the quality and quantity of joint surface gliding motion. In addition
to PROM testing, this information can be helpful in determining appropriate subsequent
diagnostic steps. For example, if shoulder flexion PROM is restricted with a capsular end feel, joint
play evaluation is indicated. If joint play in the medial direction is increased, disruption of the
medial shoulder stabilizers (i.e. the medial glenohumeral ligament and subscapularis muscle) is
suspected. If joint play in the cranial direction is abnormal, then pathology of the cranial structures
is suspected (e.g. the supraspinatus and biceps brachii muscles). A decrease in cranial glide may
indicate adaptive shortening of the biceps brachii muscle. On the other hand, an increase in cra-
nial glide may be noted with complete disruption of the biceps brachii muscle. These observations
may aid in selecting appropriate further diagnostics (e.g. sedated examination, MRI and/or ultra-
sound). This concept can be applied to any joint; knowledge of the common diseases affecting the
region helps dictate the most appropriate next diagnostic step. For example, if carpus extension
PROM end‐feel is elastic (i.e. normal) but the goniometric measurement is 215° (i.e. increased),
further evaluation with joint play testing is indicated. If the amount of glide is excessive, indicating
the carpal bones move beyond normal arthrokinematic motion, the observer may consider diag-
nostics for joint hypermobility (e.g. stress radiographs of the carpus).
5.4 Flexibility Testing
Flexibility testing is evaluation of muscle extensibility, in other words, the ability of the muscle to
stretch or passively elongate when an external manual force is applied. This flexibility testing is
generally combined with the myofascial exam (Chapter 6). Flexibility testing is an evaluation of
the passive extensibility of the contractile and connective tissue components of the muscle. The
purpose of flexibility testing is to determine whether flexibility is increased (e.g. indicating a rup-
ture), decreased (e.g. indicating a contracture), or normal and whether it is painful (e.g. indicating
inflammation). The answer to these questions may lead the tester to determine that further diag-
nostics of a specific muscle or muscle groups may be needed (e.g. ultrasound).
Flexibility testing is frequently confused with PROM testing. The difference between the two
tests lies in the positioning of the entire limb. For PROM, the goal is to put muscles on slack (to
isolate the joint), whereas for flexibility testing the goal is to stretch the muscles to isolate them.
Unfortunately, this is not possible for single‐joint muscles; however, the concept becomes clear
with the example of two‐joint muscles (Figure 5.4).
During the rehabilitation evaluation, flexibility testing is indicated in three instances: (i) PROM
is normal; (ii) PROM is limited with an elastic or muscle spasm end‐feel; or (iii) PROM is excessive
with an elastic or muscle spasm end‐feel.
If PROM is normal, flexibility testing is completed to determine if a muscle is contributing to the
lameness and if so, to what extent the muscle may be injured. An example is lameness due to acute
tenosynovitis of the biceps brachii muscle for which PROM of shoulder flexion may be normal (i.e.
shoulder flexion with the elbow flexed to place the biceps brachii on slack), but flexibility testing
of the biceps brachii (i.e. shoulder flexion with elbow extension placing the bicep brachii on taut)
is decreased and painful.
In the second instance, if PROM is limited with an elastic or muscle spasm end‐feel, flexibility
testing is completed to determine which muscle is contributing to the abnormal PROM. An exam-
ple is supraspinatus tendinopathy for which PROM shoulder flexion has an elastic end‐feel (the
normal end‐feel should be “tissue approximation”; Table 5.1 and Figure 5.2) and the tester can
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palpate and see muscle spasms during testing. In this instance, because the supraspinatus is a sin-
gle‐joint muscle, the PROM position and the stretched position are the same; the tester would
further evaluate the muscle for pathology by direct palpation (Chapter 6).
In the third instance, if PROM is excessive with an elastic or muscle spasm end‐feel, flexibility
testing is completed to determine which muscles are injured. For example, when tarsal hyperflex-
ion is observed, flexibility testing of the tarsal extensor muscles (e.g. gastrocnemius) should be
completed to determine which muscles may be contributing to the excessive PROM and to what
extent they are injured as described in the first instance above.
5.4.1 How to Perform Flexibility Testing

To test flexibility of a specific muscle, the patient should be placed in lateral recumbency and
relaxed. The observer needs to be familiar with the origin (the most proximal aspect) of the muscle
as well as the insertion (the most distal aspect) of the muscle. The observer then manually stabilizes
the bone on which the origin of the muscle is located and slowly guides the insertion of the muscle
away from the origin placing the muscle on a passive stretch (i.e. performing the opposite joint
motion as a concentric contraction would elicit; Figure 5.4). While holding the stretch, the observer
notes the amount of flexibility (in comparison to the contralateral side), the patient’s response to
flexibility (e.g. pain and pulling away), and the body’s response to flexibility (e.g. muscle spasms).
While goniometric normal values have been described for PROM testing, such values have not
been described for flexibility testing in dogs. To use goniometric measurements for flexibility test-
ing, the joint angle of the muscle origin must remain static while the tester is measuring the inser-
tion joint angle. For example, when measuring flexibility of the gastrocnemius muscle with a
goniometer, the joint angle of the stifle must remain consistent during the test, as well as from one
test to another (e.g. maintaining that the stifle is positioned and held at 140° while tarsal flexion is
measured each time). Because goniometric measurements of muscle flexibility have not been eval-
uated in the canine model, in clinical practice, the degree of flexibility is most commonly com-
pared to the other limb.
5.4.2 How to Interpret Flexibility Testing

Flexibility testing is completed to determine if a muscle is contributing to lameness and if so, to what
extent the muscle may be injured. A minor muscle injury may have associated normal to mildly
decreased flexibility with pain and muscle spasm. For instance, in the earlier example of acute teno-
synovitis of the biceps brachii muscle, PROM of shoulder flexion may be normal, but flexibility of the
biceps brachii is decreased and painful. In comparison, a moderate muscle injury may produce
increased flexibility due to fiber disruption with associated pain and muscle spasm. An example is
lameness due to a partial biceps brachii rupture for which PROM of shoulder flexion may be normal,
but flexibility of the biceps brachii is excessive with pain and muscle spasms. Flexibility testing after
a severe muscle injury may result in extreme flexibility without pain due to absent of intact muscle
fibers. For example, PROM of shoulder flexion due to a complete biceps brachii rupture may be nor-
mal, but flexibility of the biceps brachii is grossly excessive and pain free. Findings such as these from
flexibility testing can be used to determine specifically which muscle and to what extent it may be
injured, which may assist with developing a diagnostics plan (e.g. ultrasound).
5.5 Strength Testin 81
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(B)
Figure 5.7 (A) The Gulick tape measure is used to

measure limb circumference. (B) The device
contains a 4-oz spring-loaded tension indicator
that allows the tester to standardize the amount of
(A) tension applied. The appropriate tension is applied
when one red bead is visible (white arrow).
5.5 Strength Testing
Whereas flexibility testing evaluates the passive extensibility, or stretch of a muscle, strength test-
ing evaluates the force‐producing capacity of the muscle to determine if weakness is contributing
to lameness. Strength testing can only tell the tester if the muscle is strong or weak, not the under-
lying reason why. If the evaluator finds muscle weakness during the strength test, further diagnos-
tics to determine the cause should be pursued.
Prior to strength testing, the quantity of muscle bulk should be estimated to determine if muscle
atrophy has occurred, even though muscle circumference is not necessarily directly correlated
with muscle strength. Muscle mass can be estimated by direct palpation or by measuring the limb
circumference with a Gulick tape measure. Direct palpation certainly is subjective, and several
authors have also called into question the validity and reliability of Gulick measurements. Namely,
the ability to replicate positioning of the tape measure on the limb (particularly from one session
to another), hair regrowth (if used during convalescence from surgery), and systemic weight gain
or loss is a factor that influences these measurements (Smith et al. 2013; Bascuñán et al. 2016).
Therefore, the clinician should understand the correct use of a Gulick device and take note of the
area measured to improve the accuracy of subsequent measurements (Figure 5.7).
5.5.1 How to Perform Strength Testing

Strength testing in people is performed using validated tests, such as the manual muscle test
(MMT) to determine hip extensor muscle strength (Perry et al. 2004). These tests rely on commu-
nication with the patient (e.g. asking the patient to maintain a certain joint or limb position while
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(A) (B)
(C) (D)
Figure 5.8 Canine Muscle Test (C-MT): to test strength, the contralateral limb is lifted off the ground and
the patient is observed for signs of breaking the isometric hold for approximately 30 seconds. This is first
performed on a flat surface, and if the patient can maintain the isometric standing position, the front or
pelvic limbs are placed on a box and the test is then repeated. For example, for thoracic limb strength testing,
the tester lifts (A) the contralateral thoracic limb while the patient is standing on a flat surface; or (B) the
pelvic limbs are placed on a box. Similarly, for testing of pelvic limb strength, the patient is first observed
while (C) lifting the contralateral hind limb on a flat surface before (D) placing the thoracic limbs on a box.
manual forces are applied), which are difficult to duplicate in dogs. The Canine Muscle Test (C‐
MT; Figure 5.8) developed by the author evaluates strength by observing the ability of a limb to
maintain a static standing position, when the contralateral limb is lifted off the ground (similar to
the first phase of testing postural reactions with the hopping test; Chapter 4). To differentiate dif-
ferent degrees of strength, the test is completed in two different standing positions, first on the
floor and then on an incline (i.e. the limbs that are not evaluated on an approximately elbow height
box) whereby both are scored on a 0–5 scale (Box 5.2).
5.5.2 How to Interpret Strength Testing

The results of strength testing provide the tester with general information about the degree of
muscle weakness and with specific information about which areas are most affected. Generalized
weakness (from systemic causes) is expected to affect all limbs equally, while osteoarthritis would
only affect the diseased limb. Weakness in the absence of decreased PROM or flexibility is more
Reference 83
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Box 5.2 Canine Muscle Test (C-MT) Scores
Scoring of the patient’s ability to maintain a standing position of the tested limb (i.e. the limb
on the ground) for approximately 30 seconds when the contralateral limb is lifted (i.e. the abil-
ity to isometrically brace against gravity):
●● 5 (Normal) = Able to maintain on an incline
●● 4 (Good) = Able to maintain on an incline, but shows compensation*
●● 3 (Fair) = Able to maintain on neutral ground
●● 2 (Poor) = Able to maintain on neutral ground, but shows compensation*
●● 1 (Trace) = Failure to maintain on neutral ground
●● 0 (Zero) = Non-weight-bearing on tested limb on neutral ground
* Compensation is defined as breaking the isometric hold by shifting weight to another limb, failing to maintain the
standing position or muscle trembling.
likely to be associated with a neurological cause. Weakness in the presence of decreased PROM or
flexibility may be related to each other. For example, hip osteoarthritis is associated with muscle
weakness in people (Loureiro et al. 2013). A similar finding has been observed in dogs by the
author and seen as a strength score of 2 and a hip drop during the C‐MT. This may be due to hip
joint pain and gluteal muscle weakness secondary to decreased joint range of motion (since a mus-
cle weakens when it cannot contract through the full range of motion). In this instance, specific
diagnostics of the gluteal muscle group may not be indicated, but the strength score will be benefi-
cial for the purpose of rehabilitation treatment planning and monitoring. Specific areas of weak-
ness can be used to develop more specialized diagnostic plans. For example, the evaluator can look
for particular signs that indicate pelvic limb weakness such as a pelvic drop (gluteal weakness),
increased tarsal flexion angle (Achilles complex weakness), and digital pads directed forward
(deep digital flexor weakness). If increased tarsal flexion is noted during the C‐MT, the tester
would go on to further evaluate the tarsal extenders with flexibility testing and palpation. Findings
from these specific muscle evaluations can be used to determine which diagnostics may be benefi-
cial for determining the underlying cause of lameness (e.g. ultrasound).
R
eferences
Bascuñán, A.L., Kieves, N., Goh, C. et al. (2016). Evaluation of factors influencing thigh circumference
measurement in dogs. Veterinary Evidence 1 (2) https://www.veterinaryevidence.org/index.php/ve/
article/view/33.
Cookson, J.C. and Kent, B.E. (1979). Orthopedic manual therapy – an overview. Part I: the extremities.
Physical Therapy 59 (2): 136–146.
Freund, K.A., Kieves, N.R., Hart, J.L. et al. (2016). Assessment of novel digital and smartphone goniometers
for measurement of canine stifle joint angles. American Journal of Veterinary Research 77 (7): 749–755.
Hady, L.L., Fosgate, G.T., and Weh, J.M. (2015). Comparison of range of motion in Labrador Retrievers
and Border Collies. Journal of Veterinary Medicine and Animal Health 7 (4): 122–127.
Jaegger, G., Marcellin‐Little, D.J., and Levine, D. (2002). Reliability of goniometry in Labrador
Retrievers. American Journal of Veterinary Research 63 (7): 979–986.
Loureiro, A., Mills, P.M., and Barrett, R.S. (2013). Muscle weakness in hip osteoarthritis: a systematic
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review. Arthritis Care & Research 65 (3): 340–352.

Marcellin‐Little, D.J. and Levine, D. (2015). Principles and application of range of motion and
stretching in companion animals. The Veterinary Clinics of North America. Small Animal Practice 45
(1): 57–72.
May, S., Chance‐Larsen, K., Littlewood, C. et al. (2010). Reliability of physical examination tests used
in the assessment of patients with shoulder problems: a systematic review. Physiotherapy 96 (3):
179–190.
Millis, D.L. and Ciuperca, I.A. (2015). Evidence for canine rehabilitation and physical therapy. The
Veterinary Clinics of North America. Small Animal Practice 45 (1): 1–27.
Perry, J., Weiss, W.B., Burnfield, J.M., and Gronley, J.K. (2004). The supine hip extensor manual muscle
test: a reliability and validity study. Archives of Physical Medicine and Rehabilitation 85 (8): 1345–1350.
Petersen, C.M. and Hayes, K.W. (2000). Construct validity of Cyriax’s selective tension examination:
association of end‐feels with pain at the knee and shoulder. The Journal of Orthopaedic and Sports
Physical Therapy 30 (9): 512–527.
Rome, P.L. and Mckibbin, M. (2011). Review of chiropractic veterinary science: an emerging profession
with somatic and somatovisceral anecdotal histories. Chiropractic Journal of Australia 41 (4):
127–139.
Sabanci, S.S. and Ocal, M.K. (2018). Categorization of the pelvic limb standing posture in nine breeds
of dogs. Anatomia, Histologia, Embryologia 47 (1): 58–63.
Smith, T.J., Baltzer, W.I., Jelinski, S.E., and Salinardi, B.J. (2013). Inter‐ and intratester reliability of
anthropometric assessment of limb circumference in Labrador Retrievers. Veterinary Surgery 42 (3):
316–321.
Taylor, L.L. and Romano, L. (1999). Veterinary chiropractic. The Canadian Veterinary Journal 40 (10):
732–735.
Thomas, T.M., Marcellin‐Little, D.J., Roe, S.C. et al. (2006). Comparison of measurements obtained by
use of an electrogoniometer and a universal plastic goniometer for the assessment of joint motion in
dogs. American Journal of Veterinary Research 67 (12): 1974–1979.
85
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The Myofascial Examination

Rick Wall1,2
1
Animal Clinics of The Woodlands, The Woodlands, TX, USA
2
Center for Veterinary Pain Management and Rehabilitation, The Woodlands, TX, USA
6.1 Introduction
Myofascial pain syndrome (MPS) is defined as muscle, sensory, motor, and autonomic nervous
system symptoms caused by stimulation of myofascial trigger points (MTPs; Stecco et al. 2013).
Because many definitions exist for MPS, so as to avoid confusion, within this chapter, the defini-
tion of MPS will be used to describe a form of myalgia that is characterized by the presence of
MTPs. MPS is a common cause of pain and disability in people (Weller et al. 2018) and lameness
associated with canine MPS has been reported by several authors (Janssens 1991, 1992; Frank
1999; Wall 2014). Yet, identification and treatment of MPS is not commonly performed in veteri-
nary practice.
A simple definition of myofascial examination would be examination of muscles for pain and
dysfunction. More specifically it could be defined as the examination of skeletal muscle to identify
MTPs. The goal of this chapter is to provide the current status of knowledge and an introduction
to the myofascial examination.
6.2 Characteristics of Myofascial Trigger Points
In human healthcare, MTPs are defined as discrete, focal, hyperirritable spots located in a taut
band of skeletal muscle (Alvarez and Rockwell 2002). These spots are painful when pressed and
have been associated with referred pain, motor dysfunction, and autonomic phenomena. As such,
MTPs have been described to have three major characteristics: sensory, motor, and autonomic.
The sensory component includes local pain, referred pain, as well as both peripheral and central
sensitization. The muscle pain or myalgia associated with MTPs is described in people as diffuse
and is difficult to localize with defined referred pain patterns. A common referred pain pattern
found in people is pain down the back of the thigh and calf from MTPs in the caudal portion of the
deep gluteal muscle.
The motor component includes the development of the taut band within the muscle, a local
twitch response, and muscle weakness:

86 6 The Myofascial Examination
The taut band is a localized, linear, discrete band of hardened muscle within the softer,
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homogeneous muscle that runs parallel to muscle fibers. The MTP is located within the taut
band and is what distinguishes it from other painful areas within muscle. The contractile
properties of this group of taut fibers is not the result of alpha motor neuron initiating activ-
ity at the motor endplate (like in muscle spasm), but rather due to intrinsic causes. Taut
bands result in muscle shortening and reduced joint range of motion.
The local twitch response is an additional motor component of the MTP. It is a unique
spinal cord reflex resulting in a rapid contraction of the taut band following manual stimu-
lation via direct palpation or insertion of a needle (Gerwin 2010). The presence of a local
twitch response can serve as validation of the presence of a MTP.
Weakness is recognized in muscles with MTPs. This weakness is without muscle atrophy
and is not related to neuropathy or myopathy. Weakness is often rapidly reversed following
inactivation of the MTP suggesting that weakness from MTPs is due to inhibition of muscle
activation. A MTP in one muscle can also inhibit effort or contractile forces in another mus-
cle, suggesting a central inhibition process (Gerwin 2010). Additional motor or muscle dys-
function from MTPs is the result of disordered muscle recruitment or activation patterns in
muscles during movement or specific action.
In people, several conditions such as coryza, lacrimation, salivation, changes in skin tem-
perature, piloerection, and erythema have been identified as autonomic manifestations of
myofascial pain (Lavelle et al. 2007). However, such conditions remain difficult to observe
in the canine patient.
6.3 Etiology and Pathophysiology of Myofascial Trigger Points
The etiology as to the formation of the taut bands and MTPs is unknown. However, the Integrated
Trigger Point Hypothesis postulates that muscle injury leads to motor end plate dysfunction and
excessive release of acetylcholine. This excessive release of acetylcholine results in extended
release of calcium from the sarcolemma resulting in sarcomere shortening and sustained muscle
fiber contraction (Gerwin 2010; Wall 2014). This sarcomere shortening has been observed histo-
pathologically (Simons and Stolov 1976).
More recently the role of fascia and hyaluronic acid in the pathophysiology of MTPs has been
theorized. The muscle fascia receives innervation with both mechanoreceptors that detect changes
in length and tension as well as nociception. Hyaluronic acid is present in abundance in the body’s
connective tissues and serves as a lubricant and reservoir for electrolytes and nutrients. However,
alterations in the conformation of hyaluronic acid can result in adhesion rather than lubrication.
It has been proposed that increased temperature and massage may allow reversal of the pathologic
configurations of hyaluronic acid (Stecco et al. 2013).
Other possible mechanisms that have been suggested to cause muscle injury and the develop-
ment of MTPs and MPS are thought to be related to muscle overload or stress due to direct trauma,
unaccustomed eccentric contractions, eccentric contractions in unconditioned muscle, or maxi-
mal or submaximal concentric contractions (Wall 2014; Gerwin 2016). MTPs can be observed in
limbs that are not primarily affected as well as in muscles of the affected limb that are overused.
An example would be the formation of MTPs in the coxofemoral flexors of the affected limb in
dogs that are non‐weight‐bearing due to cranial cruciate ligament rupture. These dogs maintain
the non‐weight‐bearing posture by continuous flexion of the coxofemoral joint. The muscles that
6.4 The Myofascial Examinatio 87
induce flexion of the coxofemoral joint are therefore required to continuously contract, which may
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result in the metabolic overload and the formation of MTPs (please refer to the MPS patterns below
for more detail).
6.4 The Myofascial Examination
Myopathies are a frequent cause of lameness, yet, examination of the muscles for pain and/or dys-
function is not generally part of the standard physical, orthopedic, or neurologic examination in the
canine. In the author’s opinion, it is imperative that the myofascial examination be included in any
lameness workup to avoid missing a source of lameness and allowing for appropriate treatment.
Anatomical understanding as to the functional muscle units (i.e. muscles that activate a joint) of
a joint is crucial and can assist in examination for additional areas of pain and dysfunction.
Identification of taut bands and hypersensitive MTPs within muscle is an acquired skill that
requires practice and an understanding of muscular anatomy, especially muscle fiber direction.
The myofascial examination begins in the examination room, usually with the patient standing.
This portion of the examination is to identify areas of myalgia and patterns (Table 6.1). The myo-
fascial examination is not completely separate from the orthopedic examination but rather compli-
mentary to it. Once the areas of myalgia have been identified, examination of the muscles in a
relaxed state is preferred. This portion of the examination is usually performed with the patient in
a lateral recumbent position.
There are two basic palpation techniques (Figure 6.1) employed in a myofascial examination
(Wall 2014):
●● Flat palpation: Examination by finger pressure across muscle fibers in a perpendicular direction
to the muscle fibers while compressing them against a firm underlying structure such as bone.
This technique is employed for muscles such as the supraspinatus, infraspinatus, and psoas
major.
●● Pincer palpation: Examination of a part of a muscle by holding it in a pincer grasp between the
thumb and fingers. Groups of muscle fibers are rolled between the tips of the digits to detect taut
bands. This technique is used for muscles such as the triceps, sartorius, and tensor fasciae latae.
Table 6.1 Common myofascial pain syndrome patterns.
Clinical problem Clinical exam findings MTP locations
Chronic CCLD or slow recovery post‐ Non‐weight‐bearing or Stifle flexors, extenders, and
Tibial Plateau Leveling Osteotomy limited weight bearing in adductors as well as in thoracic
(TPLO) or Femoral Head and Neck surgical limb limb due to weight shifting
Ostectomy (FHO)
C6–T2 lesion Neurologic signs typical Triceps and any muscles
for radiculopathy innervated by the innervated
nerve
Hip dysplasia Weight‐bearing lameness Pectineus, gluteal musculature, and
hip flexors as well as in thoracic
limb due to weight shifting
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(A) (C)
(B) (D)
Figure 6.1 Palpation techniques for myofascial examination. Palpation is performed initially while the
patient is (A, C) standing but examination of the muscle in the relaxed state requires palpation in (B, D)
lateral recumbency. (A, B) Pincer palpation is used for muscles that are distant from an underlying firm
structure. (C, D) Flat palpation is used for muscles that can be compressed against a firm underlying
structure (e.g. bone).
Palpation of an MTP in the canine can result in a pain response (such as vocalization and/or with-
drawal) as pressure is applied. Therefore, when performing the myofascial examination, the use of
an assistant to provide gentle patient restraint is recommended. With experience, palpation tech-
niques to locate MTPs require less pressure and produce minimal to no patient response.
6.5 Myofascial Pain Syndrome Patterns Associated with Lameness
MTPs are categorized as “active” MTP and “latent (passive)” MTP (Shah and Gilliams 2008). Active
MTPs spontaneously produce pain whereas latent MTPs only produce pain when examined by
palpation. However, with the exception of pain, all other MTP characteristics are shared by active
and latent MTPs. This is of clinical importance since latent trigger points also cause muscle short-
ening and the other above‐described changes and thereby affect function (Janssens 1991).
6.6 Clinical Significanc 89
MPS has been categorized as primary (unrelated to other medical conditions) or secondary
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(associated with a comorbid medical condition; Weller et al. 2018). An acute muscle strain injury
that results in the formation of MTPs is an example of the former, whereas an example of the latter
includes the formation of MTPs in the functional unit muscles secondary to any articular dysfunc-
tion (Table 6.1).
Chronic cranial cruciate ligament disease (CCLD) is a good example of secondary MPS in the
functional muscle units. In this scenario, the functional muscle units are those that flex and extend
the stifle joint. Pelvic limb muscles that assist in stifle extension include the cranial head of the
sartorius, tensor fasciae latae, rectus femoris, and the vastus group. Predominant stifle flexors
include the semitendinosus, semimembranosus, biceps femoris, and gastrocnemius. Additionally,
these muscles provide dynamic stabilization and the demand placed upon them may be increased
due to the deficiency in static joint stabilization. Careful evaluation of these muscles for evidence
of taut bands and MTPs should be performed in dogs with CCLD. MTPs can also be found in the
gracilis and adductor due to their attempts to counter the slight pelvic limb abduction seen with
CCLD as described by Tashman et al. (2004). Severity of MPS is directly related to the chronicity
and severity of the CCLD.
Articular dysfunction of the coxofemoral joint related to hip dysplasia can also lead to MTP for-
mation in its functional muscle units. The pectineus muscle in particular can become exquisitely
painful and taut. Myalgia in this small muscle is almost always the result of articular disturbance
and mechanical overload of the muscle due to its attempt to counter the subluxation of the femoral
head. Other muscles that may show MTPs include the gluteal muscles and hip flexors including
the iliopsoas, and iliocostalis lumborum near its origination.
Pelvic limb disorders, both orthopedic and neurologic, can result in increased distribution of
body weight to the thoracic limbs. The formation of MTPs in the triceps, infraspinatus, supraspi-
natus, deltoids, latissimus dorsi, in the region of its fusion with the teres major, and/or serratus
ventralis can be observed. The more chronic and severe the pelvic limb problem(s) are the more
profound the MPS in the muscles described above.
MTPs can also be related to radiculopathy, such as thoracic limb lameness related to structural,
compressive lesions of the C6–T2 region. Clinically MTPs can be observed in any of the muscles
receiving innervation from an irritated spinal nerve(s). A pattern of increased development of
MTPs in the triceps on the affected side in a C6–T2 radiculopathy is often observed.
6.6 Clinical Significance
MPS and MTPs in human healthcare are not without their skeptics and critics: A critical literature
review published in 2014 dismissed MPS and MTP concepts and hypotheses (Quintner et al. 2015).
However, in this author’s opinion, Quintner et al. (2015) provided a biased review and failed to
review current literature. In contrast, the rather lengthy published response of Dommerholt and
Gerwin (2015) based on more current scientific advances supported the concepts of MPS and MTP.
This controversy is in part due to the reliance upon palpation and pain responses when diagnos-
ing MPS. Further research is needed to clearly answer the clinical implications of MPS and MTP
in people and dogs. However, the use of ultrasound and magnetic resonance elastography offers a
method for more objective identification of MTPs (Gerwin 2016). For example, recent research
utilizing MRI has confirmed the presence of taut bands in people but also showed that they are
overestimated by clinicians (Chen et al. 2016).
Muscle pain and dysfunction resulting from the presence of MTPs should be considered in
canine lameness as a potential cause (primary MPS) and/or a finding (secondary MPS) associated
with a comorbid issue(s). In primary MPS, the localization of pain and dysfunction causing lame-
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ness will not be properly identified without a myofascial examination. As such, the diagnosis may
be missed and appropriate treatment may not be initiated. Secondary MPS is highly prevalent in
both people and dogs affected by any orthopedic condition or recovering from orthopedic and/or
neurologic surgeries as described above.
Many treatment options for MPS have been described (Gerwin 2016). For example, treatment
with dry needling has been shown to benefit patients with secondary MPS (Janssens 1991; Espejo‐
Antunez et al. 2017). It has also been successfully used to improve comfort after total knee arthro-
plasty in people (Mayoral et al. 2013). While there is still some controversy about the use in
veterinary medicine, a better understanding of the patterns of myalgia and dysfunction associated
secondary MPS may assist in localization of the primary issue as well as identification of additional
areas for therapeutic intervention.
It is important to understand that common imaging modalities (radiography as well as standard
ultrasound) are unable to diagnose MTPs. This in turn may place fault with a lesion that is not the
real etiology (but can be identified with these diagnostic means).
R
eferences
Alvarez, D.J. and Rockwell, P.G. (2002). Trigger points diagnosis and management. American Family
Physician 65 (4): 653–660.
Chen, Q., Wang, H.‐J., Gay, R.E. et al. (2016). Quantification of myofascial taut bands. Archives of
Physical Medicine and Rehabilitation 97 (1): 67–73.
Dommerholt, J. and Gerwin, R.D. (2015). A critical evaluation of Quintner et al.: missing the point.
Journal of Bodywork and Movement Therapies 19 (2): 193–204.
Espejo‐Antunez, L., Tejeda, J.F., Albornoz‐Cabello, M. et al. (2017). Dry needling in the management
of myofascial trigger points: a systematic review of randomized controlled trials. Complementary
Therapies in Medicine 33: 46–57.
Frank, E.M. (1999). Myofascial trigger point diagnostic criteria in the dog. Journal of Musculoskeletal
Pain 7 (1–2): 231–237.
Gerwin, R.D. (2010). Myofascial pain syndrome. In: Muscle Pain: Diagnosis and Treatment (eds.
S. Mense and R.D. Gerwin), 15–83. Berlin: Springer.
Gerwin, R.D. (2016). Myofascial trigger point pain syndromes. Seminars in Neurology 36 (5): 469–473.
Janssens, L.A. (1991). Trigger points in 48 dogs with myofascial pain syndromes. Veterinary Surgery 20
(4): 274–278.
Janssens, L.A. (1992). Trigger point therapy. Problems in Veterinary Medicine 4 (1): 117–124.
Lavelle, E.D., Lavelle, W., and Smith, H.S. (2007). Myofascial trigger points. Anesthesiology Clinics 25
(4): 841–851. vii–viii.
Mayoral, O., Salvat, I., Martin, M.T. et al. (2013). Efficacy of myofascial trigger point dry needling in
the prevention of pain after total knee arthroplasty: a randomized, double‐blinded, placebo‐
controlled trial. Evidence‐based Complementary and Alternative Medicine 2013: 694941.
Quintner, J.L., Bove, G.M., and Cohen, M.L. (2015). A critical evaluation of the trigger point
phenomenon. Rheumatology (Oxford) 54 (3): 392–399.
Shah, J.P. and Gilliams, E.A. (2008). Uncovering the biochemical milieu of myofascial trigger points
using in vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome.
Journal of Bodywork and Movement Therapies 12 (4): 371–384.
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in canine muscle. American Journal of Physical Medicine 55 (2): 65–88.

Stecco, A., Gesi, M., Stecco, C., and Stern, R. (2013). Fascial components of the myofascial pain
syndrome. Current Pain and Headache Reports 17 (8): 352.
Tashman, S., Anderst, W., Kolowich, P. et al. (2004). Kinematics of the acl‐deficient canine knee during
gait: serial changes over two years. Journal of Orthopaedic Research 22 (5): 931–941.
Wall, R. (2014). Introduction to myofascial trigger points in dogs. Topics in Companion Animal
Medicine 29 (2): 43–48.
Weller, J.L., Comeau, D., and Otis, J.A.D. (2018). Myofascial pain. Seminars in Neurology 38 (6):
640–643.
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Part II
Diagnostic Techniques
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Arthrocentesis Technique
Bryan T. Torres1 and Felix Michael Duerr2
1
2
Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University,
7.1 Introduction
Joints are complex structures that can allow varying degrees of motion. Fibrous joints (e.g. tibi-
ofibular joint) and cartilaginous joints (e.g. pubic symphysis) offer little to no motion and have no
joint cavity. However, synovial or diarthrodial (freely movable) joints (e.g. hip joint) allow wide
degrees of motion and have fluid‐filled joint cavities. This fluid, called synovial fluid, is a protein‐
rich ultrafiltrate of plasma and plays an important role in joint health. It contains hyaluronic acid,
sugars, electrolytes, and enzymes that help provide nutrition to intra‐articular structures, aid in
joint lubrication, and act as a shock absorber during joint motion. By sampling it, clinicians can
glean valuable information on the health of a joint or the presence and type of pathology
(Chapter 9). Fluid evaluation is indicated for various clinical presentations (e.g. Box 7.1) and can
also be used to gauge a patient’s response to therapy. Despite the relative simplicity in obtaining
synovial fluid samples by arthrocentesis (i.e. joint tap), this diagnostic tool remains underutilized
in veterinary medicine.
Box 7.1 Principal Indications for Arthrocentesis

When to consider arthrocentesis?
●● Joint effusion or swelling
●● Joint pain
●● Lameness (e.g. shifting leg and unexplained lameness)
●● Altered gait or limb function
●● Fever of unknown origin
●● Generalized pain and weakness
●● Suspected sepsis

96 7 Arthrocentesis Technique
7.2 Risks and Contraindications
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Generally, there is little risk with appropriately performed arthrocentesis; however, iatrogenic
damage to the joint and joint sepsis are possible complications. The overall incidence of joint sepsis
after arthrocentesis and intra‐articular administration of medications in horses has been reported
to be less than 0.1% or 1 case per 1279 injections (Steel et al. 2013), but this has not been studied in
dogs. To avoid the risk of contamination, arthrocentesis should not be performed when any
evidence of infection/pyoderma is present in the area. Additionally, arthrocentesis should be
performed under sterile conditions and with appropriate restraint/sedation.
7.3 Restraint
We recommend that sedation be used to ensure that the best synovial fluid samples are obtained in
a pain‐free manner that reduces patient stress during the procedure. There are anecdotal reports of
performing canine joint taps without any or with only mild sedation using topical lidocaine–
prilocaine cream (EMLA); however, these creams require 30–60 minutes of contact time (van
Oostrom and Knowles 2018). Although joint taps are commonly performed without sedation in
horses, canine joints are much smaller, and sedation helps reduce iatrogenic damage to the joint
structures. Clinicians should choose a sedation method that they are comfortable with, provide
adequate analgesia for the procedure, and minimize patient motion to ensure atraumatic aspira-
tion of joint fluid. Please refer to Chapter 8 for specific sedation recommendation when joint fluid
aspiration is combined with diagnostic joint anesthesia (e.g. joint block).
7.4 Site Preparation
All arthrocentesis sites should undergo a standard aseptic preparation process prior to acquiring a syno-
vial sample. The goal of the aseptic skin preparation is to reduce gross contamination as well as the
transient bacterial flora on the skin. Hair should be removed (clipped) from an area of approximately
5 cm × 5 cm (for a medium‐sized dog) prior to cleaning and aseptic preparation. The size of the prepared
site may vary by joint, size of dog, and/or clinician preference. The removal of hair helps reduce tissue
contamination during arthrocentesis in horses; however, Wahl et al. (2012) found that angled insertion
of the needle (at 45° to the skin) through unclipped hair results in the least amount of hair (not tissue)
contamination. Additionally, the authors of this study suggested that hair debris is more likely to con-
tain bacteria and cause sepsis and, therefore, recommended that (for horses) hair clipping may not be
beneficial. However, since this has not yet been studied in dogs, when performing arthrocentesis on
dogs, we recommend clipping hair prior to cleaning and aseptically preparing the insertion site.
7.5 Equipment
The equipment needed for arthrocentesis is readily available in most clinical environments. Sterile
disposable syringes and hypodermic needles of varying sizes will be needed along with sterile
gloves, glass slides for evaluation, culture medium (ideally pediatric blood culture flasks), hair
clippers, and sterile preparation materials. General recommendations are listed in Table 7.1.
When selecting needles, clinicians should remember that joint fluid is viscous and smaller bore
needles (e.g. 25 g) can make aspiration difficult. However, larger gauge needles appear to be associ-
ated with an increased risk of contamination (Waxman et al. 2015). Therefore, needle size should
7.5 Equipmen 97
Table 7.1 Supplies required for performing arthrocentesis.

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Arthrocentesis supplies
Sedation ●● Sedation and monitoring supplies and equipment
Site preparation ●● Hair clippers

●● Sterile scrub solution and alcohol
●● Sterile gauze
●● Sterile gloves
Needles ●● Small dogs and cats = 25–22 g needles; 5/8″ to 1″ length

●● Medium to large dogs = 22–20 g needles; 1–1.5″ length
●● Giant‐breed dogs = may require spinal needle; 2.5″ length
Syringes ●● Sterile disposable syringes

○○ Small dogs and cats = 1–3 ml
○○ Medium‐ to Giant‐breed dogs = 3–6 ml
Sample submission supplies ●● Glass slides (and slide mailer) for

○○ submission of freshly prepared smears
●● Pediatric blood culture flasks for

a
○○ obtaining bacterial culture and sensitivity
●● Ethylenediaminetetraacetic acid (EDTA) blood tubes (purple or

lavender top tubes)b for
○○ total nucleated cell count
○○ cytology
○○ total protein (if not underfilled)
●● Sterile, no additive blood tubes (red top glass tubes)c for

○○ biochemical analytes (lactate, glucose, and total protein)
○○ mucin clot test (rarely indicated)

a
○○ obtaining bacterial culture and sensitivity
b,c
●● Heparin blood tubes (green top) for
○○ mucin clot test (rarely indicated)
○○ total nucleated cell count
○○ total protein (if not underfilled)
a
Pediatric blood culture flasks are preferred (over culturette swabs or red top tubes) particularly if >0.5 ml of
synovial fluid is available to increase the chances of obtaining a successful culture result. If large amounts of
sample are available, cultures should be submitted in blood culture flasks and red top tubes (Chapter 9).
b
Small volume (pediatric) heparin and EDTA tubes are recommended to reduce dilutional effects that may lead to
testing errors.
c
Unless EDTA blood tubes are unavailable, heparin blood tubes are generally not utilized. Please note that heparin
tubes cannot be used for cytology.
not only be appropriate to the animal and joint, but also chosen with care to minimize the potential
for iatrogenic trauma, to permit easy collection of joint fluid in as few attempts as necessary, and
to ensure samples are free of blood contaminant.
The use of spinal needles with the stylet inserted is controversial (e.g. for hip and shoulder joint
aspiration in large dogs), since some studies have suggested that it may result in increased con-
tamination due to the hairs getting stuck in between the space of the stylet and needle (Adams
et al. 2010; Wahl et al. 2012). To reduce the risk of contamination with arthrocentesis, Wahl et al.
(2012) recommend using regular, disposable hypodermic needles. However, the tip of these nee-
dles is more oblique than the tip of a spinal needle (Wahl et al. 2012) and thus may not enter the
lumen of the joint completely in smaller joints. For this reason, some authors recommend using a
spinal needle for small joints (Degner 2014).
7.6 Approaches
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The approach that clinicians use to perform arthrocentesis of different joints can vary and has been
described by numerous authors (Clements 2006; Degner 2014). The following section/images
describe some of the more common approaches as well as our preferred methods for obtaining
joint fluid from appendicular joints. Recommended patient positioning, needle placement, and
structures to avoid are summarized in Table 7.2.
Table 7.2 Summary of arthrocentesis recommendations and structures to avoid by region.
Area Patient positioning Needle placement Structures to avoid Figure
Carpus Lateral recumbency with the From cranial, just Cephalic and Figure 7.1
(radiocarpal target joint/limb up below the palpable accessory cephalic
joint) distal radius vein
Elbow Medial aspiration Figure 7.2
Lateral recumbency with the From medial, distal, Ulnar nerve
target joint/limb down and caudal to the
medial epicondyle
Caudal aspiration
Lateral recumbency with the From lateral, in None
target joint/limb up between the lateral
epicondylar crest and
anconeal process
Shoulder Lateral recumbency with the Lateral aspiration Figure 7.3
target joint/limb up
From lateral, just Suprascapular
below (or slightly nerve
caudal to) the
acromion process
Cranial aspiration
From cranial, just Biceps tendon (if
medial or lateral to medial to greater
the greater tubercle tubercle)
Tarsus Lateral recumbency with the Cranial aspiration Figure 7.4
(tibiotarsal target joint/limb up
joint)
From lateral, just Cranial branch of
medial and cranial to lateral saphenous
the lateral malleolus vein
Caudal aspiration
From lateral, caudal Caudal branch of
to the lateral lateral saphenous
malleolus/distal tibia vein
Stifle Lateral recumbency with the From cranial, medial, Meniscus Figure 7.5
target joint/limb up or dorsal or lateral to patellar
recumbency with the target tendon
joint/limb facing the
clinician
Hip Lateral recumbency with the From lateral, just Sciatic nerve Figure 7.6
target joint/limb up proximal to greater
trochanter
7.6 Approache 99
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(A) (B)
Figure 7.1 Carpus: (A) aspirate the radiocarpal joint by palpating the distal end of the radius and inserting
the needle in a craniocaudal direction; (B) aspirate the middle carpal joint by inserting the needle in
between either the second and third or third and fourth carpal bones.
7.6.1 Carpus
The antebrachiocarpal (radiocarpal) joint is one of the most frequently aspirated joints.
Arthrocentesis can be performed by flexing the carpus to increase the joint space and improve
needle access. The joint space can be palpated cranially at the distal end of the radius (a depression
should reveal the landmark for the radiocarpal joint and will identify the site for needle insertion).
The needle should be inserted from the cranial aspect of the joint and aligned perpendicular to the
joint surface (Figure 7.1A and Video 7.1). Arthrocentesis of the middle carpal joint (Figure 7.1B) is
performed between the second and third or third and fourth carpal bones. However, joint fluid
may not always be obtained and therefore aspiration of this joint is less commonly performed.
Clinicians should take care to palpate and avoid the cephalic and accessory cephalic vein when
performing arthrocentesis of this joint.
Video 7.1:
Procedural details for aspiration of the carpal joint.
7.6.2 Elbow
It is the authors’ preference to aspirate the elbow joint from a straight medial direction. If signifi-
cant effusion is present, aspiration in a craniolateral direction at the caudal joint may also be per-
formed. For medial aspiration (Figure 7.2A and Video 7.2), the patient should be placed in lateral
recumbency with the affected limb down on the table. The elbow should be “opened” up by gently
levering it over a towel while extending the joint. The ulnar nerve should be palpated prior to
inserting the needle (which can easily be found just caudal to the epicondyle). The needle should
be inserted at the level below the epicondyle and slightly caudal to this area – NOTE: in a medium‐
sized dog, the location will be a little less than 1 cm distal and caudal to the medial epicondyle.
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(B)
(A) (C)
Figure 7.2 Elbow: (A) aspirate the elbow joint by inserting the needle in a straight medio‐lateral direction
at a location distal and caudal to the medial epicondyle (which can easily be palpated); (B) to identify the
joint space location, imagine an equidistant triangle with the medial epicondyle (blue dot) and the caudal
aspect of the epicondylar ridge (orange dot) as the two palpable landmarks, whereby the tip of the triangle
then identifies the location of the arthrocentesis point (green dot); (C) for caudal aspiration, the needle is
inserted in a distomedial direction along the long axis of the ulna.
Video 7.2:
Procedural details for aspiration of the elbow joint.
For caudal aspiration (Figure 7.2C), the joint is held in a flexed or neutral position and the needle
is inserted alongside the olecranon and angled cranially. The needle is placed at the proximal level
of the olecranon, medial to the lateral epicondyle (i.e. between the lateral epicondylar crest and
anconeal process), and inserted in a distomedial direction along the long axis of the ulna.
7.6.3 Shoulder
The shoulder joint is most frequently aspirated laterally in an area below the acromion but can also
be aspirated from a cranial and caudal location. Regardless of aspiration location, the patient
should be placed in lateral recumbency with the affected shoulder up. It sometimes is helpful to
distend the joint by pulling the distal limb away from the body; however, a neutral position typically
provides good access.
For lateral aspiration (Figure 7.3A and Video 7.3), the needle should be inserted just below the
acromion process in most dogs. In larger dogs, placement may be slightly caudal to the acromion
process. The needle should be directed in a straight mediolateral direction, in a manner that is
perpendicular to the skin. If the joint is not penetrated, a slightly more distoproximal angle should
be attempted. Clinicians should be aware that acromion anatomy may differ in some dogs affecting
its shape and position and making joint aspiration challenging. Radiographs of the joint and evalu-
7.6 Approache 101
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(A) (B)
Figure 7.3 Shoulder: (A) aspirate the shoulder joint by inserting the needle just below the acromion
process in a straight lateromedial direction; (B) alternatively, the joint can also be aspirated by inserting the
needle laterally or medially to the greater tubercle in a caudal direction.
ation of the bony anatomy may be beneficial (to assess the location of the acromion process in
relation to the joint space).
For cranial aspiration (Figure 7.3B), palpate the greater tubercle and insert the needle in a caudal
direction either medial or lateral to this structure. If the needle is inserted medially to the greater
tubercle, the biceps tendon should be palpated and avoided during insertion of the needle.
Video 7.3:
Procedural details for aspiration of the shoulder joint.
7.6.4 Tarsus
The tibiotarsal joint is the most frequently aspirated joint of the tarsus and is generally aspirated
from the cranial or caudal aspect of the joint, approaching from either the medial or lateral side.
The authors prefer the lateral aspect since it is easier to access. Aspiration of the cranial aspect of
the joint (Figure 7.4A and Video 7.4) is done with the tarsus in slight extension and the needle is
inserted into the joint space in a dorsomedial direction beginning at a point just medial and cranial
to the lateral malleolus (distal fibula). Aspiration of the caudal aspect of the joint (Figure 7.4B) is
done with the tarsus in slight flexion and the needle is inserted into the joint space by beginning
needle insertion parallel to the calcaneus with insertion in a craniomedial direction. The tarsus is
a small joint and often a smaller gauge needle may be more appropriate. It is also important to
remember that the cranial and caudal branches of the saphenous vein are located laterally. If pal-
pable, care should be taken to avoid the vein during aspiration. Thorough palpation of joint/land-
marks, prior to aspiration, during range of motion is advised.
Figure 7.4 Tarsus: (A) aspirate the tarsal

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joint cranially by inserting the needle in a

dorsomedial direction beginning at a
point just medial and cranial to the
lateral malleolus, or (B) caudally by
inserting the needle in a craniomedial
direction.
(A) (B)
Video 7.4:
Procedural details for aspiration of the tarsal joint.
7.6.5 Stifle
The stifle is a large joint that can be aspirated in several ways, depending on clinician preference.
It is aspirated either medially (Figure 7.5A and Video 7.5) or laterally (Figure 7.5B) to the patellar
tendon. Some clinicians prefer to insert the needle through the central portion of the patellar liga-
ment and one of the authors (BT) has not noticed any adverse events using this approach. In all
cases, the joint is held in mild flexion. If aspiration is to occur medial or lateral to the patellar ten-
don, it may help to palpate the femoral condyle and the joint pouch and push fluid from the side
opposite of where aspiration is to occur. Aspiration is performed by first locating the point for
needle insertion, which is typically halfway between the patella and the tibial tuberosity. The nee-
dle is then inserted in a craniocaudal direction and angled toward the intercondylar space of the
distal femur. A longer (1.5″) needle is ideal for the stifle. Due to the fat pad, joint fluid may be dif-
ficult to aspirate particularly in a normal joint because it contains little joint fluid.
Video 7.5:
Procedural details for aspiration of the stifle joint.
7.6.6 Hip
The coxofemoral joint is most commonly aspirated from the lateral side of the body. The limb is
placed in slight abduction and the joint is identified by palpating the greater trochanter (illustrated
in Figure 7.6). A long needle should be used and inserted just proximal to the greater trochanter at
7.6 Approache 103
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(A) (B)
Figure 7.5 Stifle: aspirate the stifle joint by inserting the needle (A) medially or (B) laterally to the patellar
tendon angled towards the intercondylar space of the distal femur.
Figure 7.6 Hip: aspirate the hip joint by inserting the needle just proximal to the greater trochanter at an
angle that is perpendicular to the long axis of the femur.
an angle that is perpendicular to the long axis of the femur (Video 7.6). If straight insertion does
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not allow for joint aspiration, the needle should be redirected slightly ventrally. Alternatively, the
needle may be inserted cranially to the greater trochanter at ~45° angling caudomedially.
Positioning the needle caudal to the greater trochanter or angling the needle toward the caudal
aspect of the acetabulum should be avoided to prevent iatrogenic trauma to the sciatic nerve.
Ventral aspiration has been described but is rarely performed.
Video 7.6:
Procedural details for aspiration of the hip joint.
R
eferences
Adams, S.B., Moore, G.E., Elrashidy, M. et al. (2010). Effect of needle size and type, reuse of needles,
insertion speed, and removal of hair on contamination of joints with tissue debris and hair after
arthrocentesis. Veterinary Surgery 39 (6): 667–673.
Clements, D. (2006). Arthrocentesis and synovial fluid analysis in dogs and cats. In Practice 28 (5):
256–262.
Degner, D.A. (2014). Arthrocentesis in dogs. Clinician’s Brief. https://www.cliniciansbrief.com/article/
arthrocentesis‐dogs (accessed 31 January 2019).
Steel, C.M., Pannirselvam, R.R., and Anderson, G.A. (2013). Risk of septic arthritis after intra‐articular
medication: a study of 16,624 injections in Thoroughbred racehorses. Australian Veterinary Journal
91 (7): 268–273.
Van Oostrom, H. and Knowles, T.G. (2018). The clinical efficacy of EMLA cream for intravenous
catheter placement in client‐owned dogs. Veterinary Anaesthesia and Analgesia 45 (5): 604–608.
Wahl, K., Adams, S.B., and Moore, G.E. (2012). Contamination of joints with tissue debris and hair
after arthrocentesis: the effect of needle insertion angle, spinal needle gauge, and insertion of spinal
needles with and without a stylet. Veterinary Surgery 41 (3): 391–398.
Waxman, S.J., Adams, S.B., and Moore, G.E. (2015). Effect of needle brand, needle bevel grind, and
silicone lubrication on contamination of joints with tissue and hair debris after arthrocentesis.
Veterinary Surgery 44 (3): 373–378.
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Diagnostic Joint Anesthesia

Bryan T. Torres1 and Felix Michael Duerr2
1
2
Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
8.1 Introduction
The use of intra‐articular anesthetic agents to aid in the diagnosis of lameness has been long estab-
lished in equine veterinary medicine (Dyson 1986). However, within the past few years, there has
been an increased interest in employing diagnostic joint anesthesia (DJA) or “joint blocks” as a
diagnostic tool in small animals to aid clinicians in pinpointing the source of lameness (Van Vynckt
et al. 2012a). Principles of DJA are outlined in Box 8.1.
8.2 Patient Selection
In general, any dog with an unidentifiable source of lameness may benefit from DJA. Particularly
if advanced diagnostics (such as CT/MRI) are not readily available, DJA may be helpful to justify
that such diagnostics are indicated. If DJA results in a positive response, it allows the clinician to
determine the injected joint as the most likely source of lameness. If DJA results in a negative
response, it places other differential diagnoses higher on the list. As is true in horses, DJA aims to
identify the joint responsible for a lameness rather than provide a specific diagnosis. This approach
can be clinically useful in the following scenarios:
●● Patients presenting with a lameness that is thought to be joint related, but the physical exam and
available diagnostics are not definitive (e.g. a dog with suspected elbow dysplasia that shows no
pain on examination and radiographs only show minor/no abnormalities). In this scenario, a
positive DJA result (of the elbow joint) may aid to confirm the elbow as the source of lameness.
●● Patients presenting with a lameness and multiple joints show abnormalities (e.g. a dog with
shoulder and elbow osteoarthritis). In this scenario, a positive DJA result (of the elbow or shoul-
der joint) may aid to confirm the elbow or shoulder as the source of lameness.
●● Patients presenting with a lameness and multiple detected abnormalities (e.g. a dog with shoul-
der osteoarthritis and possible axillary pain). In this scenario, a negative DJA result (of the
shoulder joint) may aid to confirm that further diagnostics (such as MRI) investigating a possible
neurologic reason (such as brachial plexus tumor) for the lameness is indicated. On the other
hand, a positive result would confirm the shoulder as the source of lameness.

106 8 Diagnostic Joint Anesthesia
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Box 8.1 Principals of Diagnostic Joint Anesthesia (DJA)
●● Use only for patients with obvious lameness.

●● Use sedation protocol A for stressed/anxious animals and A or B for calm animals.
●● Use 2% mepivacaine (20 mg/ml Carbocaine®) at 1.5 mg/kg. A total dose of 5 mg/kg per dog
and 4 ml/joint should not be exceeded.
●● A 20% improvement in lameness is considered a positive response.
●● Ideally objective gait analysis is used to evaluate response.
●● False-negative and false-positive (due to diffusion of anesthetic or pain modulating effects
of sedation) results are possible.
The most common joints where DJA has been applied to aid in lameness diagnosis have been in
the thoracic limb (Van Vynckt et al. 2012b, 2013). This is understandable due to the frequent dif-
ficulty in isolating the location and cause of thoracic limb lameness (as compared to pelvic limb
problems). However, DJA has also been used in all major canine pelvic limb joints (Van Vynckt
et al. 2012a). The utility of DJA as a diagnostic aid should not be underestimated as the sensitivity
and specificity of DJA has been shown to be up to 90 and 100%, respectively (Van Vynckt et al.
2012a). Therefore, the use of this technique can be a valuable clinical tool. However, as with many
diagnostic tests, understanding the potential limitation is critical. Most importantly, false‐negative
results have been reported in approximately 10% of dogs. Furthermore, in dogs with more subtle
lameness, the clinical interpretation of DJA is challenging due to the less significant degree of
improvement seen and the potential effects of sedation on lameness. However, in dogs with more
moderate‐to‐severe lameness, the degree of improvement after DJA is often more dramatic and
this makes clinical interpretation easier. Clinicians should consider these factors when performing
DJA as a diagnostic test and when evaluating the treatment response.
8.3 Sedation Protocols
While routinely performed in horses, we do not recommend performing DJA without sedation in
dogs. Sedation ensures a pain‐free, atraumatic joint injection, in a manner that reduces patient
stress during the procedure (Chapter 7). General anesthesia should not be performed because this
technique is employed as a diagnostic tool and patients are required to walk prior to and after injec-
tion to evaluate the efficacy of treatment.
Because DJA is a diagnostic test, unlike arthrocentesis, the choice of sedative agent(s) is a more
important clinical consideration. Ideally, an effective sedative, that also allows quick ambulation
and does not affect lameness interpretation, is used. Unfortunately, our understanding on how
sedative agents affect lameness in dogs (positive or negative) and ultimately how they may influ-
ence our clinical interpretation of DJA is limited. Currently, only one study has evaluated the effect
sedative agents have on lameness in dogs (Van Vynckt et al. 2011); it evaluated the two sedation
protocols outlined below and found both to be suitable for use with DJA:
8.3.1 Sedation Protocol A: Sedation with an α₂-Adrenergic Receptor Agonist

This protocol is based on one of the most common and familiar methods of sedation in small ani-
mal medicine. The clinical benefits include rapid and effective sedation as well as sedation reversal
8.3 Sedation Protocol 107
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Box 8.2 DJA Protocol A
●● Step 1 – Sedative agent is administered intravenously – dexmedetomidine (0.5 mg/ml) given

IV at a dose of 250 mcg/m2.
●● Step 2 – Intra-articular anesthetic is instilled in the target joint.
●● Step 3 – Reversal agent is administered intramuscularly immediately after intra-articular anes-
thetic is administered – atipamezole (5.0 mg/ml) is administered IM at a volume (ml) that is
the same as the preceding dose volume of dexmedetomidine.
●● Step 4 – Lameness evaluation is performed seven minutes after reversal agent (atipamezole)
is administered.
with an antagonist agent. These aspects make it well suited for DJA. Available studies were per-
formed with medetomidine; however, currently clinicians in North America are more likely to
have access to dexmedetomidine. The recommended steps for DJA with an α₂‐adrenergic receptor
agonist are listed in Box 8.2.
8.3.2 Sedation Protocol B: Sedation with a Neuroleptanalgesic and Opiate

The use of acepromazine with an opiate has also been investigated and serves as a good option for
use with DJA. This method of sedation is used for light‐to‐moderate sedation and analgesia while
still allowing the patient to ambulate. Since sedation is less effective, more physical restraint was
needed in one study (Van Vynckt et al. 2012b). Therefore, we prefer to use protocol A unless there
are contraindications for the use of an α₂‐adrenergic receptor agonist. Unlike sedation protocol A,
there is no reversal agent administered. It is possible that stressed or anxious animals may require
a higher sedative dose; however, Van Vynckt et al. (2012b) found the dose range in the steps listed
in Box 8.3 suitable for DJA.
Currently, our understanding of how other sedatives affect lameness in dogs is limited to the
protocols discussed above. It is possible that other protocols (such as use of Propofol or local anes-
thetics in addition to sedation) may be equally useful. However, the degree of effect and more
importantly a means to account for that effect in our clinical interpretation is lacking. For example,
if a local anesthetic is used, it could result in a change in lameness because of diffusion (and pro-
viding local anesthesia) into the extra‐articular structures. This is not to say that other sedatives or
combinations of sedatives are not appropriate for DJA, just that their effect on lameness interpreta-
tion is currently unknown. Therefore, it is recommended that clinicians use the tested and studied
methods.
Box 8.3 DJA Protocol B
●● Step 1 – Sedative agent is administered intravenously – acepromazine (0.01–0.02 mg/kg IV)

and methadone (0.1–0.2 mg/kg IV).
●● Step 2 – Intra-articular anesthetic is instilled in the target joint.
●● Step 3 – Lameness evaluation is performed two minutes after intra-articular anesthetic is
administered.
8.4 Intra-articular Anesthetic Instillation

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The basic principles (including patient positing and preparation) used with arthrocentesis (Chapter 7)
apply when using DJA. However, given the possibility of performing injections into normal joints,
great attention to detail is required to avoid iatrogenic trauma to the joint. Ultrasound‐guided injec-
tions may help improve the accuracy of injections and reduce trauma to the cartilage. A technique
description for canine ultrasound‐guided injection of the coxofemoral joint is available (Bergamino
et al. 2015). Ultrasound guidance allows to place the needle more superficially in the joint, thereby
causing less trauma. Furthermore, confirmation of placement of the anesthetic into the joint can be
confirmed by observing distention of the joint capsule. If ultrasound guidance is not available, prior
to instilling the anesthetic agent, joint fluid should be aspirated to confirm the location of the needle.
In the case that joint fluid is unable to be aspirated, the needle should be slightly withdrawn, redi-
rected, and aspiration attempted again. If joint fluid still cannot be aspirated, then careful instillation
of the anesthetic agent can be performed. This should be done gradually and with great care to
ensure that no resistance is met during instillation. If the needle is correctly located in the joint space,
regardless of the aspiration of joint fluid, there should be no resistance met upon instillation of the
anesthetic agent. Following instillation of the anesthetic agent, the joint flexion and extension should
be performed to distribute the anesthetic throughout the joint (Van Vynckt et al. 2012a).
Because it is widely available and has a preferred safety profile for intra‐articular use, 2% mepiv-
acaine (i.e. 20 mg/ml Carbocaine®) is the recommended anesthetic agent for DJA in dogs. The use
of lidocaine or bupivacaine for DJA is not recommended at this time as they may cause more local
irritation when compared to mepivacaine (Van Vynckt et al. 2010). The recommended dose is
1.5 mg/kg instilled into a single joint (approximately 1–4 ml). A total dose of 5 mg/kg per dog and a
total volume of 4 ml should not be exceeded (Van Vynckt et al. 2010, 2012a).
8.5 Lameness Evaluation and Interpreting the Effect

of Diagnostic Joint Anesthesia
The localization of lameness to a specific joint with DJA is based on a change in lameness following
instillation of the anesthetic. A positive response is when lameness improves, and a negative response
is when the lameness is unchanged or worsens. Various grading scales are available, as described in
Chapter 1. Currently available research used an 11‐point numerical rating scale (with 0 = no lame-
ness and 10 = non‐weight‐bearing) and a change of 2 scores was considered a positive response. As
such, an approximately 20% improvement in degree of lameness should be used if other scoring
systems are used. Ideally, objective gait analysis (Chapter 2) is used before and after DJA.
Lameness evaluation is recommended to begin seven minutes after the reversal agent is admin-
istered if an α₂‐adrenergic receptor agonist is administered (Protocol A) for sedation (Figure 8.1).
If a neuroleptanalgesia with an opioid is administered (Protocol B), then it is recommended that
evaluation begins two minutes after the anesthetic agent is instilled. Regardless of sedation proto-
col, dogs should be evaluated at frequent intervals. The dogs should be walked continuously for the
first five minutes after the initial evaluation. If an improvement in lameness is not seen during that
time period, then repeat evaluations should be performed approximately every 5 minutes for a
maximum of 30 minutes after injection (Van Vynckt et al. 2011, 2012a). An improvement in lame-
ness at any time point during those 30 minutes is considered a positive response. The use of video
recordings may aid in lameness evaluation by providing an ability to compare time points as well
as providing material for secondary observers, if needed.
8.5 Lameness Evaluation and Interpreting the Effect of Diagnostic Joint Anesthesi 109
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Perform DJA
using sedation Walk patient
Patient Protocol B for five minutes
Moderate-high does not
tolerate continuously
grade lameness α -agonist
thought to be
Assess change Assess change
joint related DJA in lameness after in lameness after
indicated? two minutes No five minutes
Perform DJA Assess

using sedation change in At least 20% At least 20%
lameness
Protocol A after seven improvement in improvement in
minutes lameness? lameness?
Yes No
Yes
Assess Assess change in
Joint IS source of At least 20% change in
lameness until 30
lameness
lameness improvement in every five minutes after
Yes lameness? minutes injection
Positive
response No
False negative Negative

10% of cases
response response
Joint is NOT
Consider: source of lameness
• Was DJA performed 90% of cases
correctly?
• Was DJA protocol
followed? True negative
Perform additional response
diagnostics of the
instilled joints
Perform X-rays,
CT, MRI, and Perform X-rays, CT, Perform additional
MRI, arthroscopy, diagnostics of
arthroscopy
other joints
scintigraphy, and
DJA of other joints
Specific
diagnosis
Figure 8.1 Decision tree for determining DJA protocol and interpretation of lameness assessment.
Both protocols outlined above were found to have the potential to influence lameness and
thereby DJA interpretation. Van Vynckt et al. (2011) evaluated the influence of sedation on dogs
with lameness (without performing DJA) and found that most dogs (72% for protocol A and 80%
for protocol B) experienced no change in lameness due to sedation. However, sedation lead to a
worsening of lameness by 1–2 grades in up to 20% of lame dogs (20% for protocol A and 12% for
protocol B) and an improvement by 1 grade in 8% (for both groups). In general, lameness may
become more obvious in anxious dogs (since the sedation results in them relaxing and being less
distracted by the unfamiliar environment) while the pain modulation associated with the sedation
may improve the lameness in less anxious dogs. Based on these findings, it is recommended that a
positive response to DJA be interpreted only when lameness improves by two or more grades
(using an 11‐point scale).
DJA has been reported to be 100% specific and 90% sensitive for the identification of joint pain
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and lameness: Van Vynckt et al. (2012a) performed DJA in almost 200 dogs with thoracic or pelvic
limb lameness that was thought to be joint related. In that study, all dogs who received DJA in a
painful joint showed an improvement in lameness (100% specificity). Therefore, a positive response
clearly indicates that the infused joint is painful and contributing to the observed lameness.
However, 10% of lame dogs with a negative response to DJA (i.e. unchanged or worsening of the
lameness) were actually false negatives, meaning that the joint was the source of lameness based
on other diagnostics performed. Therefore, a negative response only indicates a 90% certainty that
the joint infused is non‐painful and not the source of lameness. As such, a negative response does
not completely rule out the treated joint as the source of pain and lameness in all cases. Negative
results should therefore be interpreted with caution and additional diagnostics should be utilized
if the clinician is suspicious that the result may be a false‐negative (rather than true negative)
result (Figure 8.1). Alternatively, additional joints can be tested using DJA. It is also possible that
specific joint disorders or pathology (such as pain originating from subchondral bone with intact
cartilage or severe arthritis) may be less responsive to DJA (Dyson 1986; Van Vynckt et al. 2010).
As mentioned above, a slight improvement in lameness may be attributed to the pain‐modulat-
ing effects of the sedation. While this response may be considered a false‐positive response, Van
Vynckt et al. (2012a) reported no false‐positive responses when using an improvement in lameness
by approximately 20% as the cutoff. While this has not been reported in dog studies, leakage of
anesthetic to surrounding extra‐articular structures as well as errors in lameness interpretation are
other reasons for false‐positive results in horses (Jordana et al. 2016).
References
Bergamino, C., Etienne, A.L., and Busoni, V. (2015). Developing a technique for ultrasound‐guided
injection of the adult canine hip. Veterinary Radiology and Ultrasound 56 (4): 456–461.
Dyson, S. (1986). Problems associated with the interpretation of the results of regional and intra‐
articular anaesthesia in the horse. Veterinary Record 118 (15): 419–422.
Jordana, M., Martens, A., Duchateau, L. et al. (2016). Diffusion of mepivacaine to adjacent synovial
structures after intrasynovial analgesia of the digital flexor tendon sheath. Equine Veterinary Journal
48 (3): 326–330.
Van Vynckt, D., Polis, I., Verschooten, F., and Ryssen, V.B. (2010). A review of the human and
veterinary literature on local anaesthetics and their intraarticular use. Veterinary and Comparative
Orthopaedics and Traumatology 23 (04): 225–230.
Van Vynckt, D., Samoy, Y., Mosselmans, L. et al. (2012a). The use of intra‐articular anesthesia as a
diagnostic tool in canine lameness. Vlaams Diergeneeskundig Tijdschrift 81 (5): 290–297.
Van Vynckt, D., Samoy, Y., Polis, I. et al. (2011). Evaluation of two sedation protocols for use before
diagnostic intra‐articular anaesthesia in lame dogs. Journal of Small Animal Practice 52 (12):
638–644.
Van Vynckt, D., Verhoeven, G., Samoy, Y. et al. (2013). Anaesthetic arthrography of the shoulder joint
in dogs. Veterinary and Comparative Orthopaedics and Traumatology 26 (04): 291–297.
Van Vynckt, D., Verhoeven, G., Saunders, J. et al. (2012b). Diagnostic intra‐articular anaesthesia of the
elbow in dogs with medial coronoid disease. Veterinary and Comparative Orthopaedics and
Traumatology 25 (4): 307–313.
111
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Joint Fluid Analysis and Collection Considerations

Adam Harris and Kelly Santangelo
Department of Microbiology, Immunology, and Pathology, College of Veterinary Medicine and Biomedical Sciences,
Colorado State University, Fort Collins, CO, USA
9.1 Introduction
Synovial fluid is a viscous substance produced and contained within diarthrodial (i.e. freely mov-
able) joints. Synovial fluid analysis is a valuable tool used to diagnose and monitor primary and
secondary articular joint disorders. Information gained from cytological evaluation of synovial
fluid is most helpful when combined with patient history, physical exam, imaging findings, and
other laboratory data, such as bacterial culture and serology. For procedural details of arthrocente-
sis, please refer to Chapter 7.
9.2 Sample Submission and Prioritization of Diagnostic Tests
Pre‐analytical errors involving sample collection and specimen handling can vastly alter results. In
general, synovial fluid should be shipped at 4 °C and delivered within 24 hours. Fresh smears made
at the time of collection are best for maintaining cellular morphology. If cytology is a primary out-
come but adequate smears cannot be made by the referring clinician at the time of sample aspira-
tion, smears should be made at the clinical pathology laboratory from samples stored in
ethylenediaminetetraacetic acid (EDTA) tubes. Heparinized samples will not adequately preserve
mammalian cell architecture.
Between 0.01 and 1 ml of synovial fluid may be aspirated from non‐pathologic joints of dogs,
with larger joints normally containing more fluid for sampling. As little as a single drop of joint
fluid can be considered within normal limits, particularly in small‐breed dogs. Joint pathology
often increases joint fluid volume and clinicians should be suspicious of pathology in cases where
the aspirated volume is >1 ml (Clements 2006). Given that aspiration of synovial fluid can yield
variable amounts, allocation of the available sample for priority of diagnostic tests is important
(Figure 9.1) and should be made considering the most likely differential diagnoses. If adequate
joint fluid is retrieved, submission of the sample as direct smears, in EDTA tubes (purple or laven-
der tubes), sterile no‐additive tubes (red top glass tubes), and blood culture flasks (if culture is
indicated) are recommended.

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Assess amount of synovial fluid
Normal to
No fluid
increased
<0.1 ml 0.1–0.5 ml >0.5 ml
Use ultrasound
guidance or
Cytology
attempt alternative
approach Make fresh smear Make fresh smear Make fresh smear
to joint
(see Chapter7)
TNCC, TP,
cytospin
EDTA tube* EDTA tube*
and
(purple top) (purple top)
No fluid analysis
possible
Culture
Flush hub fluid into Flush hub fluid into At least 0.5 ml in
blood culture flask** blood culture flask** blood culture flask
and lactate
glucose,
Culture,
No additive tube
(red top)***
Figure 9.1 Algorithm for the prioritization of sample for synovial fluid. Due to the limited amount of joint fluid sample available, the clinician must prioritize
allocation of the available sample. [*Most automated hematology analyzers require a minimum of 200 μl to process the sample submitted. If there is limited
sample, the reader is encouraged to use the appropriate size EDTA tube, which generally requires submission in a pediatric/small tube. Submission in the
appropriate size tube is critical because inappropriate anticoagulant to sample ratios can cause erroneous results. **If limited sample is available and an
infectious etiology is suspected, some labs suggest submitting the capped needle directly to the diagnostic laboratory. Please contact the lab beforehand to
ensure this is possible and provide instructions to flush the needle hub using sterile technique prior to processing cultures. Alternatively, the content of the
syringe may be sterilely flushed into the culture media. ***If sufficient sample is available, red top tubes should be used to collect the additional sample. Further
tests such as a secondary culture (in addition to the culture from the blood culture flask), mucin clot test, and biochemical analytes (such as lactate, glucose, and
total protein) may be performed. Please contact the reference laboratory to ensure that use of these latter assays is available and validated for synovial fluid.]
9.3 Gross, Biochemical, and Cytologic Examinatio 113
9.3 Gross, Biochemical, and Cytologic Examination

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Joint fluid analysis and evaluation typically involve assessment of gross appearance, protein con-
centration, total nucleated cell count (TNCC), and cytologic interpretation. Other biochemical
parameters, such as glucose and lactate, can also be measured but the availability of these tests
may vary from laboratory to laboratory. A summary of typical findings in non‐affected canine
joints and general interpretation guidelines are provided in Figure 9.2 and Table 9.1.
9.3.1 Gross Appearance

Gross appearance of synovial fluid assesses turbidity, color (particularly regarding the presence of
blood), viscosity, and the amount of volume sampled from each joint. In healthy patients, joint
fluid is typically clear and pale yellow, as well as thick and viscous. While these characteristics will
be determined by the laboratory, it is also helpful to note such qualities at the time of sample col-
lection. Viscosity can be evaluated empirically by forming a string of synovial fluid between the
tips of the fingers, but this is only recommended to be performed in cases with ample amount of
sample. A fingertip stretch distance of ~2–3 cm is generally considered appropriate viscosity.
Recording the presence or absence of blood is particularly helpful to the clinical pathologist for
distinguishing blood contamination due to sample collection from overt hemorrhage.
9.3.2 Protein Concentration

While protein concentrations are typically estimated using a refractometer, automated chemistry
measurements and electrophoresis have also been used to determine and/or characterize such.
However, some laboratories will not perform automated protein concentration analyses on joint
fluids if the fluid is too viscous. When using a refractometer, it is important to note that the pres-
ence of other solutes in the fluid may affect the measurement of protein concentration, as does
underfilling EDTA tubes or aspirating joints previously treated with intra‐articular injections.
Therefore, it is critical to use appropriately sized EDTA tubes due to the possibility of erroneous
results secondary to EDTA dilution when tubes are underfilled. Alternatively, if sufficient sample
is available, red top tubes can be used to measure protein concentrations.
Normal protein levels in synovial fluid are between 1.5 and 3.0 g/dl (MacWilliams and Friedrichs
2003). In disease states or when there is inadvertent sampling of blood, protein concentrations can
begin to rise and approach levels similar to serum or plasma.
9.3.3 Total Nucleated Cell Counts

TNCCs are typically performed by an automated analyzer, most often on samples collected into
EDTA. TNCCs within synovial fluid are predominately composed of white blood cells. However,
other nucleated cells may also be included in the analyzer count as part of the TNCC (e.g. synovio-
cytes, nucleated red blood cells, neoplastic cells, etc.) making cytological analysis in addition to the
TNCC imperative. If an analyzer is not available, or the amount of synovial fluid retrieved is insuf-
ficient to process through an analyzer, hemocytometers or direct smears can be used to assess cel-
lularity. If a direct smear is used to estimate cellularity, the average number of cells per 40×
objective high‐power field over 10 fields can be multiplied by 1000 to yield an approximate number
of cells per microliter. However, the evaluator should be aware that visual estimates are less
accurate than automated methods. The viscosity of joint fluid can make estimation of cellularity
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protein
Total
1.5–3.0 g/dL >3.0 g/dL
nucleated
cell count
<3 000 3 000–5 000 3 000–100 000
Total
cells/μl cells/μl cells/μl
Neutrophils
<10% <10% 10–99%
%
Mononuclear
cells
80–90% 80–90% <80%
% Color
Pale, yellow Slightly cloudly Red/pink Cloudy
Cytology
Predominantly Predominantly
degenerate non-degenerate
neutrophils neutrophils
Diagnosis
Hemarthrosis/
Normal Osteoarthritis/ blood Infectious Immune
trauma contamination mediated
Figure 9.2 Guidelines for interpretation of synovial fluid samples. Please note that the provided interpretation is based on most commonly
observed values for each disease and individual patients may not fit within these guidelines. Refer to Table 9.1 for further details on normal values
and percentage of cell distribution.
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Table 9.1 Typical joint fluid analysis findings associated with normal and diseased joints.
Protein
Category Subtype Appearance Volume concentration (g/dl) Mucin clot TNCC % Neutrophils % Mononuclear cells
Normal N/A Clear, pale Normal 1.5–3.0 Good <3 000 <10 80–90
yellow
Nonsuppurative Osteoarthritis Slightly Reduced, >3.0 Fair to poor 3 000–5 000 <10 80–90
and trauma cloudy and normal, or
red (trauma) increased
Suppurative Infectious and Cloudy and Increased >3.0 Fair to very 3 000–100 000 20–99 0–80
immune- turbid poor
mediated
Neoplastic Highly variable – cytology primarily used as the differentiating feature
TNCC, total nucleated cell count (cells/μl).
0004507092.INDD 115 12/10/2019 1:16:36 PM

116 9 Joint Fluid Analysis and Collection Considerations
difficult and, therefore, direct smears have been recommended to be assessed using broader cate-
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gories such as normal, mild‐moderately increased, or markedly increased (Dusick et al. 2014).
Nevertheless, if an automated analyzer is not available, it is important to obtain or estimate a
TNCC as this can be used to determine response to treatment.
Normal canine joints typically have a TNCC of less than 3000 cells/μl. TNCCs in pathologic
joints will vary depending on the underlying pathological cause. Suppurative arthropathies often
yield the highest cell counts, which have been reported to range from >3 000 to >100 000 cells/μl
(MacWilliams and Friedrichs 2003). Nonsuppurative arthropathies typically do not exceed
10 000 cells/μl and most often range from 3 000 to 5 000 cells/μl.
9.3.4 Cytological Analysis

Cytologic analysis of joint fluid is typically performed by evaluating direct smears. If smears prepared
by the clinician at the time of collection are adequate, these will be utilized for interpretation. Many
laboratories will often also prepare their own direct smears and cytospin preparations using sample
from the EDTA tubes; the latter slides can be helpful for distinguishing cellular morphology or charac-
teristics not obvious on direct smears. Slides are generally evaluated microscopically using 10× and
100× objectives to confirm automated TNCCs, provide a differential cell count, and assess cell morphol-
ogy and/or inclusions. Direct smear preparations of synovial fluid in healthy patients typically have a
dense eosinophilic stippled background (Figure 9.3). Cells may align in a linear fashion, commonly
referred to as “windrowing,” due to the viscosity of joint fluid (Figure 9.4A, B). High protein content can
also result in dense preparations, which make it challenging to determine cellular morphology, cellular-
ity, and the presence of infectious agents. The thinnest portions of the slide and/or cytospin slides are
best for cellular evaluation. The number of red blood cells and the presence of platelets/platelet clumps
should be noted as this can indicate increases of WBC proportions due to blood contamination.
Cells frequently seen on cytologic evaluation of normal joints include large and small mononu-
clear cells, synovial lining cells (i.e. synoviocytes), and rare‐to‐occasional neutrophils (Figure 9.3).
Large mononuclear cells are the predominate cell population identified in healthy joints and com-
pose approximately 90% of cells identified. On cytological evaluation, it can be difficult to differenti-
ate synovial macrophages from synoviocytes, which is why the term “large mononuclear cells” is
used. Large mononuclear cells are typically identified by their amount of blue grey to deeply baso-
philic cytoplasm, vacuolization, cytoplasmic inclusions, and the size of their nucleus (approximately
1.0×–1.5× the size of a neutrophil). Synoviocytes can have a similar morphology as macrophages and
have a round to spindle shape, with round‐to‐ovoid nuclei, and a moderate amount of basophilic
cytoplasm. Small mononuclear cells are usually representative of the lymphocyte population pre-
sent. They are identified by a thin rim of cytoplasm, an absence of cytoplasmic vacuolization, and a
nucleus that is round and approximately 0.5–1.0× the size of a neutrophil (Figure 9.3B). Nondegenerate
neutrophils are readily identified by their segmented nucleus and clear, granular cytoplasm
(Figure 9.5E). Of note, in the absence of blood contamination, neutrophil numbers will be low; how-
ever, if blood contamination is present, the number will increase. As mentioned above, it can be
challenging to differentiate cell types in dense cytological preparations, so in some cases, cytospin
preparations or dilution of the sample might be required to fully assess cellular morphology.
9.3.5 Mucin Clot Test

The mucin clot test is a semiquantitative assessment of the hyaluronic acid content in synovial
fluid. The test estimates the ability of the synovial fluid to form a clot after the addition of acetic
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(A) (B)
(C) (D)
(E) (F)
Figure 9.3 Representative examples of the appearance of the cells found in (A–D) normal joint fluid
versus (E, F) mononuclear inflammation in joint fluid from a dog with osteoarthritis. Predominantly (b) large
and (c) small mononuclear cells and occasional blood cells, such as (a) neutrophils and (e) red blood cells
are present; (d) protein crescents are artifactual folds in the background material indicating a normal
content of protein and other solutes (e.g. hyaluronic acid) found within synovial fluid. Note the stippled
eosinophilic background, which is typical of proteinaceous samples such as synovial fluid, as well as the
increased number of large (b) mononuclear cells, in a (E) low-power versus a (F) high-power field of view.
Magnification: (A, B, F): 100×; (C, E): 10×; (D): 20× objective.
acid. It should be performed on samples that have been collected in no additive (red top glass
tubes) or heparin tubes, as EDTA can hinder clot formation. Fluid from non‐pathologic joints
forms a clot rapidly after the addition of the acetic acid. In contrast, pathologic or inflamed
joints typically have delayed or poor clot formation. However, because quantitative data for
interpretation of the mucin clot test is lacking, the results should be interpreted together with
other clinical findings (Clements 2006).
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(A) (B)
(C) (D)
(E) (F)
Figure 9.4 Representative examples (A–F) of the appearance of the joint fluid from canine patients with
immune-mediated polyarthritis (IMPA): (A, B) note the increased number of (a) nondegenerate neutrophils
relative to (b) red blood cells and the non-pathologic windrowing pattern that can occur with viscous fluid
samples such as joint fluid; (C, D) samples showing (c) ragocytes seen with IMPA; care should be taken to
distinguish ragocytes from neutrophils containing phagocytized bacteria (see also Figure 9.3C); (D, E)
cytoprep samples clearly illustrating the high number of (a) nondegenerate neutrophils typically seen with
IMPA; (E, F) samples showing (d) lupus erythematous cells seen with IMPA. Magnification: (A): 10×; (B): 50×;
(E): 100× objective; (C, D, F): 100× objective digitally magnified.
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(A) (B)
(C) (D)
(E) (F)
Figure 9.5 Representative examples of the appearance of the joint fluid from canine patients with (A, B)
hemarthrosis, (C–E) septic arthritis, and (F) synovial sarcoma: (A) erythrophagia and (B) hematoidin crystals
(both indicated by black arrows) in large mononuclear cells seen in joint fluid of dogs with hemarthrosis;
(C, D) samples showing representative images of intracytoplasmic bacteria in (a) neutrophils present in a
synovial fluid sample from a dog with septic arthritis. Note the high number of (b) nondegenerate to (c)
degenerate neutrophils present; (E) sample collage illustrating the difference between (c) degenerate and
(b) nondegenerate neutrophils: nondegenerate neutrophils maintain their shape and segmented nuclei
while degenerate neutrophils lose their segmented nucleus and display cellular swelling. The
glycosaminoglycan background of this image is diluted and a few (d) ruptured cells are present; (F) sample
showing cell features consistent with a diagnosis of synovial sarcoma: wispy cytoplasmic borders, cells are
loosely aggregated together or individualized, moderate anisocytosis and anisokaryosis and multiple
prominent nucleoli. The bright eosinophilic cytoplasmic granules are compatible with a secretory product.
Magnification: (A, B, C, D): 100× objective; (E, F): 100× objective digitally magnified.
9.4 Canine Arthropathies

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9.4.1 Suppurative Arthropathies

An increased proportion of nondegenerate to degenerate neutrophils above what is suspected to be
due to blood contamination is indicative of suppurative inflammation. Specifically, neutrophil per-
centages are considered increased when above 10% of the total nucleated cells. However, in many
cases, they are even higher, often between 20 and 99% (MacWilliams and Friedrichs 2003).
Hemorrhage may accompany suppurative arthropathies, making the source contributing to neu-
trophil numbers difficult to discern. The two forms of suppurative inflammation include immune‐
mediated and infectious arthropathies. Differentiating these two forms can be difficult as cytologic
features can be similar (Table 9.1). The presence of degenerate neutrophils is suspicious for an
underlying infectious etiology. However, caution should be used when relying on the presence of
degenerate neutrophils in synovial fluid since neutrophils can deteriorate rapidly once in fluid or
tissue due to their short life span. As neutrophils decline, they can acquire cytologic features, such
as swollen nuclei and basophilic cytoplasm, that overlap with the appearance of true degenerate
neutrophils.
9.4.1.1 Immune-mediated
Immune‐mediated joint disease is a common cause for suppurative polyarthritis in canine patients.
Since immune‐mediated polyarthritis (IMPA) generally affects multiple joints, samples from sev-
eral joints, particularly the carpi and tarsi, should be collected and evaluated. Cytologic evaluation
typically reveals a predominance of nondegenerate neutrophils. Ragocytes and lupus erythema-
tous (LE) cells are indicative of IMPA (Figure 9.4) but are not commonly observed and should not
be relied on for diagnosis of an immune‐mediated process.
9.4.1.2 Infectious
Microscopic interpretation of infected joints reveals mildly to markedly increased TNCCs that are
primarily composed of nondegenerate and degenerate neutrophils. While degenerate neutrophils
are one feature of septic arthritis, some patients may not display many of these cells and septic
arthritis should not be ruled out in these instances (Marchevsky and Read 1999; Mielke et al. 2018).
Similarly, infectious agents are uncommonly identified on cytology (Figure 9.5C, D) and cultures
are also only positive in about 50% of the cases (Scharf et al. 2015; Mielke et al. 2018). Therefore,
infectious arthritis can mimic immune‐mediated polyarthritis on cytology and correlation with
clinical signs and careful classification of neutrophils as degenerate or nondegenerate is recom-
mended before initiating treatment.
Obtaining a culture in cases of suspected infection is crucial for establishing a diagnosis and
enabling selection of appropriate antibiotics. Therefore, every attempt should be made to facilitate
a successful culture result in these scenarios. The use of blood culture media is recommended to
increase sensitivity and the likelihood of obtaining a positive result (Montgomery et al. 1989;
Miller et al. 2018). Unfortunately, the smallest blood culture medium flasks available (pediatric
blood culture flasks, which are generally used in veterinary medicine) still require at least 0.5 ml of
fluid. If too little synovial fluid is available for culture via direct ejection into the blood culture
flask, yield can be maximized by sterilely flushing the culture media back and forth between the
collection needle and culture bottle to remove as much of the sample from the needle/hub as pos-
sible. Alternatively, the hub of a capped needle can be submitted to some diagnostic laboratories,
with instructions to flush the sample. However, submission in the blood culture bottle is preferred
9.4 Canine Arthropathie 121
due to the potential for desiccation when submitted in the syringe/needle. It is important to note
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that the sensitivity for a true positive result can decrease with small sample volumes (i.e. if less
than 0.5 ml are used in a blood culture flask). On the other hand, use of a culturette swab as the
single method of culture is least likely to produce a positive culture result and therefore should be
avoided (Font‐Vizcarra et al. 2010).
Blood culture flasks are available with and without antibiotic‐binding resin. In general, and par-
ticularly in situations where an animal is receiving antibiotics, use of resin‐containing media is
advised to reduce the activity of antibiotics previously administered to the patient (Lorenzo‐
Figueras et al. 2006). If excessive amounts of fluid are available (such as frequently seen in septic
arthritis), culture from a red top tube in addition to the blood culture flask is ideal since blood
culture flasks have a higher propensity for contamination. As such, matching culture results from
both the red top and blood culture flask cultures provides greater confidence in the diagnosis.
Culturing of the synovial membrane has not been shown to be superior to synovial fluid and,
therefore, likely does not justify the additional cost and potential morbidity associated with the
sample collection procedure (Montgomery et al. 1989).
Infectious agents (bacteria, rickettsial, fungal, protozoal, or viral) typically require additional
specific tests (i.e. culture or genetic isolation) to diagnose. Many agents can infect joints either via
direct penetration or the hematogenous route (Martinez and Santangelo 2017). Some organisms,
such as Borrelia burgdorferi, may not necessarily cause synovial infections, but disease is typically
thought to be due to immune complex deposition, resulting in polyarthritis (Littman et al. 2018).
Additional diagnostics, such as the measurement of lactate and glucose in synovial fluid, as well
as serum C‐reactive protein, have shown promise for including or excluding septic arthritis if cytol-
ogy, culture, and clinical signs are not conclusive (Proot et al. 2015; Hillström et al. 2016). Further
work is warranted to validate use of these tests for diagnosing septic arthritis, particularly given a
lack of knowledge regarding how other musculoskeletal and non‐musculoskeletal conditions may
affect the test results. It should be noted that, prior to adopting these or any other novel assays
clinically, each individual diagnostic laboratory will need to confirm assay sensitivity and specific-
ity for synovial fluid on the designated high‐throughput or point‐of‐care instrument, determine
in‐house reference intervals, and validate their own diagnostic cutoffs.
9.4.2 Nonsuppurative Arthropathies

9.4.2.1 Mononuclear Inflammation
Mild to moderately increased TNCCs with predominantly large mononuclear cells are typically
due to either degenerate joint disease, such as osteoarthritis, or trauma. Both conditions can result
in increased populations of large mononuclear cells, typically both synoviocytes and macrophages,
within the synovial fluid. Investigation into clinical history and additional diagnostic information
is crucial for interpreting synovial fluid that shows increased nuclear cellularity due to large mono-
nuclear cells. If trauma is suspected, evidence of previous or acute hemorrhage and/or other frag-
ments of surrounding structures such as cartilage or bone might also be visualized on cytological
examination.
Foreign body reactions can induce mononuclear‐to‐mixed inflammation, the latter of which
may contain neutrophils, lymphocytes, and/or plasma cells. Pseudogout (deposition of calcium
pyrophosphate crystals in articular cartilage), while very rare in dogs, can cause acute arthritic
clinical signs and is associated with a mixed inflammatory response composed of mononuclear
cells and neutrophilic inflammation. A distinguishing feature of pseudogout is the presence of
variably sized square‐to‐rhomboid‐shaped crystals (Forsyth et al. 2007).
9.4.2.2 Hemarthrosis
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True hemarthrosis, defined as hemorrhage within the synovial space, can be difficult to differenti-
ate from inadvertent blood contamination. Therefore, the clinician should communicate any dif-
ficulties encountered during sample collection or irregular amounts of blood seen during aspiration
to the laboratory. Joint fluid associated with true hemarthrosis is typically homogeneously pink/
orange/red. Cytological evaluation reveals an increased density of red blood cells, a dilute glycosa-
minoglycan background, increased hemosiderin laden and erythrophagocytic macrophages, and,
if chronic, hematoidin crystals (Figure 9.5). Erythrophagocytic macrophages are macrophages
with erythrocytes in their cytoplasm. Hemosiderin is an iron storage complex that forms within
macrophages as erythrocytes are being broken down. The pigment granules on Wrights–Giemsa
staining appear dark blue green to almost black and can vary between very fine to globular within
the cytoplasm. Special stains to identify iron (i.e. Prussian blue) can be performed to identify
hemosiderin from other pigment granules. Hematoidin crystals are breakdown products of biliru-
bin that crystalize to form diamond‐to‐rectangular‐shaped light brown‐gold refractile crystals. Of
note, macrophages are capable of phagocytizing erythrocytes post‐collection and within collection
tubes. Therefore, it is crucial to make fresh smears at the time of collection to discern in vivo from
in vitro erythrophagia. The presence of hemosiderin and hematoidin is more definitive for true
hemorrhage because they take longer to form and suggest chronicity. Possible differentials for
patients with hemarthrosis include trauma, coagulation disorders (hemophiliacs versus anticoag-
ulants), or any condition that disrupts blood supply and causes hemorrhage (i.e. neoplasia).
9.4.3 Neoplasia
All cell populations within the joint organ have the potential to become neoplastic. Diagnosis of a
neoplastic disorder can be reached by combining the clinical picture with the cytological findings.
Establishing a diagnosis based on synovial fluid analysis can be difficult; neoplastic synovial fluid is
highly variable in cellular and protein composition and can appear similar to any of the other cate-
gories described above. It is the presence of cells that display atypia and criteria of malignancy that
should alert the evaluator to consider neoplastic differentials (e.g. synovial cell sarcoma in
Figure 9.5F). Ancillary diagnostics, such as biopsy, immunocytochemistry or immunohistochemis-
try, and/or flow cytometry, are typically required to reach a definitive diagnosis, as multiple types of
sarcomas have similar morphological feature. Additionally, other tumor tissue types, such as carci-
nomas and lymphomas, have been reported to metastasize or localize to synovial tissue and fluid.
References
Clements, D. (2006). Arthrocentesis and synovial fluid analysis in dogs and cats. In Practice 28 (5):
256–262.
Dusick, A., Young, K.M., and Muir, P. (2014). Relationship between automated total nucleated cell
count and enumeration of cells on direct smears of canine synovial fluid. Vet. J. 202 (3): 550–554.
Font‐Vizcarra, L., Garcia, S., Martinez‐Pastor, J.C. et al. (2010). Blood culture flasks for culturing
synovial fluid in prosthetic joint infections. Clin. Orthop. Relat. Res. 468 (8): 2238–2243.
Forsyth, S.F., Thompson, K.G., and Donald, J.J. (2007). Possible pseudogout in two dogs. J. Small Anim.
Pract. 48 (3): 174–176.
Hillström, A., Bylin, J., Hagman, R. et al. (2016). Measurement of serum C‐reactive protein
concentration for discriminating between suppurative arthritis and osteoarthritis in dogs. BMC Vet.
Res. 12 (1): 240.
Reference 123
Littman, M.P., Gerber, B., Goldstein, R.E. et al. (2018). ACVIM consensus update on Lyme borreliosis
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in dogs and cats. J. Vet. Intern. Med. 32 (3): 887–903.

Lorenzo‐Figueras, M., Pusterla, N., Byrne, B.A., and Samitz, E.M. (2006). In vitro evaluation of three
bacterial culture systems for the recovery of Escherichia coli from equine blood. Am. J. Vet. Res. 67
(12): 2025–2029.
Macwilliams, P.S. and Friedrichs, K.R. (2003). Laboratory evaluation and interpretation of synovial
fluid. Vet. Clin. North Am. Small Anim. Pract. 33 (1): 153–178.
Marchevsky, A.M. and Read, R.A. (1999). Bacterial septic arthritis in 19 dogs. Aust. Vet. J. 77 (4):
233–237.
Martinez, C.R. and Santangelo, K.S. (2017). Preanalytical considerations for joint fluid evaluation. Vet.
Clin. North Am. Small Anim. Pract. 47 (1): 111–122.
Mielke, B., Comerford, E., English, K., and Meeson, R. (2018). Spontaneous septic arthritis of canine
elbows: twenty‐one cases. Vet. Comp. Orthop. Traumatol. 31 (6): 488–493.
Miller, J.M., Binnicker, M.J., Campbell, S. et al. (2018). A guide to utilization of the microbiology
laboratory for diagnosis of infectious diseases: 2018 update by the infectious diseases society of
America and the American society for microbiology. Clin. Infect. Dis. 67 (6): e1–e94.
Montgomery, R., Long, I., Milton, J., and Dipinto, M. (1989). Comparison of aerobic culturette,
synovial membrane biopsy, and blood culture medium in detection of canine bacterial arthritis. Vet.
Surg. 18 (4): 300–303.
Proot, J.L., De Vicente, F., and Sheahan, D.E. (2015). Analysis of lactate concentrations in canine
synovial fluid. Vet. Comp. Orthop. Traumatol. 28 (5): 301–305.
Scharf, V., Lewis, S., Wellehan, J. et al. (2015). Retrospective evaluation of the efficacy of isolating
bacteria from synovial fluid in dogs with suspected septic arthritis. Aust. Vet. J. 93 (6): 200–203.
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10
Diagnostic Imaging Techniques in Lameness Evaluation

Angela J. Marolf
Department of Environmental and Radiological Health Sciences, College of Veterinary Medicine and Biomedical Sciences,
10.1 Introduction
Diagnostic imaging is usually necessary in the assessment of patients presenting with lameness
and can often provide definitive diagnosis. Radiography and ultrasound have been performed in
dogs for evaluation of musculoskeletal conditions for many years in veterinary medicine, with
newer imaging techniques such as magnetic resonance imaging (MR or MRI), computed tomogra-
phy (CT), and positron emission tomography (PET)/CT being utilized increasingly for diagnosis of
musculoskeletal disease in animal patients. Ideally, the diagnosis is made using the least costly and
most readily available imaging modality. This chapter will provide a brief overview of imaging
modalities used in the diagnosis of musculoskeletal conditions and discuss which are better
selected for identification of certain clinical conditions. Imaging indications and findings for indi-
vidual regions are discussed in greater detail in Section 2, as they apply to the thoracic limb and
pelvic limb specifically. Table 10.1 provides an overview of current imaging modalities.
10.2 Radiography
Long the mainstay of imaging of the musculoskeletal system, radiography (Figure 10.1) continues
to be the frontline imaging choice in many disease processes because it is readily available, obtained
quickly, and relatively inexpensive. Moreover, it is excellent at identifying osseous changes includ-
ing fractures, advanced osteoarthritis, and certain congenital diseases. Many soft tissue changes
can be noted as well on radiographs, including joint effusion/hypertrophy and calcifying tendi-
nopathies (Lafuente et al. 2009). Additional views, such as special oblique (Figures 12.3 and 18.2),
skyline (Figure 15.12), and stress radiographs (Figure 13.8), are particularly useful in determining
location and extent of disease. However, disadvantages of radiography include ionizing radiation
and the possibility of underdiagnosis of certain disease processes. It is important for the clinician
to remember that normal radiographs of a limb or body part do not exclude disease, and additional
advanced imaging may be required for diagnosis.

126 10 Diagnostic Imaging Techniques in Lameness Evaluation
Table 10.1 Imaging modality comparisons.

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Imaging modality Advantages Disadvantages Common uses
Radiography Readily available Underdiagnoses First‐line

Detects osseous disease soft tissue disease diagnosis
and soft tissue Superimposition of
calcification structures
Ultrasonography More available Highly operator Soft tissue injuries
Detects periarticular dependent of the shoulder
soft tissue, muscle, and Underdiagnoses Achilles
meniscal injury in smaller joints and tendinopathy
larger joints medial shoulder Detection of
structures meniscal tears
Evaluation of
specific muscles
(such as iliopsoas)
Computed Excellent osseous detail Less availability Elbow dysplasia
tomography Good soft tissue detail Cost Detection of
Can use intravenous May need general OCD‐lesions
contrast anesthesia Complex fractures
Multi‐plane Multiple regions Angular limb
reconstruction scanned quickly deformities
Magnetic Excellent soft tissue Limited availability Soft tissue injuries
resonance detail Cost of the shoulder
imaging Can use intravenous General anesthesia Evaluation of
contrast Limited to specific specific muscles
Multiple sequences/ region (such as iliopsoas)
planes Detection of
meniscal tears
Nuclear Physiologic/metabolic Very limited Obscure lameness
medicine activity detection availability
Lesion localization and Cost
diagnosis (PET/CT) General anesthesia
(PET/CT)
Long scan times
(PET/CT)
10.3 Ultrasonography
Ultrasonography (Figure 10.2) is used often to evaluate soft tissue changes and can differentiate fluid
and soft tissue thickening, as well as muscle fiber pattern changes; whereas, radiographs cannot.
Ultrasonography is often complementary to radiographs when obvious osseous disease is not present
and muscular injury is suspected. Dynamic evaluation of muscle and joint movement with ultra-
sound is beneficial, and ultrasound imaging has become common in musculoskeletal diagnosis.
Regions commonly evaluated with ultrasound include the shoulder, calcaneal tendon and tarsus,
and stifle (Long and Nyland 1999; Lamb and Duvernois 2005; Caine et al. 2009; Cook 2016).
Advantages to ultrasonography include the ability to perform the study on either awake or sedate
patients and the use of nonionizing sound waves. However, ultrasound is highly operator dependent,
and thorough and accurate evaluation can be limited due to a sonographer’s level of experience.
10.4 Computed Tomograph 127
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(A) (B) (C)
Figure 10.1 Radiographic images – diagnostic examples: (A) lateral view of the stifle. Note the increased
intra‐articular soft tissue opacity within the cranial and caudal aspects of the joint (arrows). This is likely
either effusion or synovial hypertrophy; (B) craniocaudal view of the stifle. Note the subchondral articular
lucency with surrounding sclerosis in the lateral femoral condyle (arrow). This is consistent with an
osteochondrosis lesion; (C) lateral view of the shoulder. Note the smoothly marginated soft tissue
mineralization adjacent to the greater tubercle of the humerus (arrow). This is likely mineralization within
the supraspinatus tendon.
(A) (B)
Figure 10.2 Ultrasound images – diagnostic examples: (A) transverse ultrasound image of the proximal
biceps tendon. Note the heterogeneity of the tendon (small arrow) and increased fluid within the sheath
(large arrow); (B) transverse ultrasound image of the more distal biceps tendon. Note the enlargement and
heterogeneity of the tendon at this level (arrow). Sonographic diagnosis was biceps tenosynovitis and
tendinopathy.
10.4 Computed Tomography
CT (Figure 10.3) has been performed for years to assess the musculoskeletal system in people;
however, the increased availability of CT scanners in veterinary hospitals in recent years has led to
this imaging modality becoming readily accessible for use in dogs as well. Further, with the advent
and greater availability of multi‐slice CT scanners (i.e. a CT with multiple rows of detectors), the
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(A) (D)
(C)
(B)
Figure 10.3 CT images – diagnostic examples: (A) transverse image showing a large fragment associated
with the medial coronoid process of the right elbow (arrow). The adjacent coronoid process is sclerotic and
abnormally shaped; (B) sagittal plane reconstruction of the right elbow. A widening of the humero‐ulnar
joint (small arrow) occurs with mild sclerosis of the anconeal process (large arrow). Humero‐ulnar
incongruity is present; (C) dorsal plane reconstruction of the right elbow. Note the sclerosis of the humeral
trochlea (arrow) with irregular articular margin and small fragments; (D) 3D reconstruction of a dog with
congenital elbow luxation.
speed at which CT studies can be performed has increased, thus allowing for musculoskeletal CT
imaging to be performed with light sedation only. CT provides excellent contrast resolution of soft
tissues and bones, is relatively fast, and can cover multiple regions in one study. It can be combined
with intravenous iodinated contrast to better evaluate the blood flow to tissues (i.e. contrast‐
enhanced CT). The speed of CT, combined with its ability to image regions without superimposi-
tion of overlying structures, offers distinct advantages over other imaging methods. Disadvantages
to CT imaging include ionizing radiation, added expense, need for anesthesia or sedation, and
limited availability in comparison to the ubiquity of ultrasound and radiography.
CT imaging is an excellent diagnostic choice to identify osseous disease or osteochondrosis
dissecans and to evaluate regions with complex osseous anatomy. The shoulder, elbow, and
tarsus joints are some of the most common regions evaluated with CT (Reichle et al. 2000; De
Rycke et al. 2002; Gielen et al. 2005). Bones, muscles, and joints can be evaluated in dorsal
and sagittal imaging planes (Figure 10.4) in unlimited angles for thorough assessment via
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(A) (B) (C)
Figure 10.4 Imaging planes used for lower limb multi‐planar imaging modalities: (A) sagittal plane; (B) transverse plane; and (C) dorsal plane.
ulti‐planar reconstructions (using a commercially available software imaging tool), thus

m
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permitting complete visualization of all anatomic structures.

CT terminology uses the term “attenuation” to describe tissue characteristics in relation to each
other: tissues presenting as bright are described as hyperattenuating, dark tissues are described as
hypoattenuating, and tissues of similar brightness are described as isoattenuating. Fluids are typi-
cally hypoattenuating.
10.5 Magnetic Resonance Imaging
MR (Figure 10.5) is a newer modality in veterinary medicine for evaluation of musculoskeletal

conditions. Soft tissue injuries of the shoulder are often diagnosed with MR imaging (Agnello et al.
2008; Murphy et al. 2008; Schaefer et al. 2010). It provides excellent contrast resolution of the soft
tissues and multiple anatomic planes to visualize the region of interest. Although CT and MR both
offer excellent contrast resolution, MR is considered the gold‐standard imaging modality for evalu-
ation of soft tissue injuries. CT uses X‐rays and attenuation differences in tissues, whereas MR uses
electromagnetic radiation to evaluate the hydrogen nuclei (protons) composition in tissues.
Because different tissues have different amounts of protons, MR imaging can characterize tissues
more sensitively than CT.
However, MR is not without its limitations. Detection of subtle bone changes is more difficult
with MR imaging, and in contrast to CT imaging, MR is usually limited to one region and is often
more time‐consuming due to the multiple sequences in different planes that need to be acquired
for a complete study. Other disadvantages to MR imaging include the need for general anesthe-
sia, added expense, and decreased availability compared to radiography, ultrasonography, and
CT imaging.
(A) (B) (C)
Figure 10.5 MR images of the shoulder showing proton density fat‐saturated images: (A) sagittal plane at
the level of the biceps tendon. Note the hyperintensity of the tendon and surrounding bursa (arrow); (B)
dorsal plane at the level of the biceps tendon within the intertubercular groove of the humerus. Note the
hyperintensity within the tendon and surrounding bursa (small arrow) and the hyperintensity within the
muscle belly distally (large arrow); (C) transverse plane at the level of the biceps tendon within the
intertubercular groove of the humerus. Note the hyperintensity within the biceps tendon and adjacent
bursa (arrow). Diagnosis was biceps tenosynovitis and with possible biceps tendon tear.
10.6 Nuclear Medicin 131
Intravenous contrast media are frequently used with MR and CT imaging to improve contrast reso-
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lution and to evaluate the blood flow (i.e. perfusion and vascularity) of tissues. This can help differ-
entiate different pathologic processes (e.g. neoplastic versus degenerative). The type of intravenous
contrast agents differs between MR and CT. Specifically, MR utilizes gadolinium based while CT
utilizes iodinated contrast media.
Standard imaging sequences obtained in MR include T1, T2, and proton density (PD)‐
weighted sequences, which demonstrate the molecular differences in various tissues and can
detect abnormalities due to differences in tissue appearance in the sequences. MR terminology
uses the term “intensity” to describe tissue characteristics and appearance on various sequences,
whereby tissues that are bright are described as hyperintense; dark tissues as hypointense; and tis-
sues of a similar intensity as isointense. Fluids are typically hypointense on T1‐weighted images,
hyperintense on T2‐weighted images, and of intermediate signal intensity on PD‐weighted images.
An additional technique often used in MR imaging is called “fat saturation.” This technique makes
fat appear hypointense on T1‐, T2‐, and PD‐weighted images and can highlight inflammation and
edema in tissues.
10.6 Nuclear Medicine
In the past, nuclear medicine imaging in small animals was limited to an imaging modality
described as bone scan or bone scintigraphy. This technology uses a gamma camera that captures
gamma radiation emitted by specific radiopharmaceuticals (typically 99mTechnetium methylene
diphosphonate) after intravenous administration, thereby highlighting areas of increased uptake.
It has been found to be helpful in dogs with obscure lameness by several authors (Schwarz et al.
2004; Samoy et al. 2008). Scintigraphy localizes areas of increased radiopharmaceutical uptake due
to inflammation or neoplasia; however, it does not provide a specific diagnosis. Therefore, further
structural imaging of the identified areas is always needed to establish a diagnosis.
Currently, the newest imaging modality for evaluation of the musculoskeletal system is PET
imaging combined with a conventional CT, termed PET/CT (Figure 10.6). PET is a form of nuclear
medicine that uses radiopharmaceuticals that are positron emitters. Positrons are positively
charged particles, also called beta + particles, or β+. These particles travel a short distance (1–2 mm)
before colliding with a negatively charged electron. When the two collide, two annihilation gamma
photons are created and travel 180° from each other. The special detectors in a PET scanner detect
and register these coincident photons – photons that are emitted 180° from each other and arrive
within a few nanoseconds of each other. Fluorine‐18‐fluorodeoxyglucose (FDG), an analog of glu-
cose, is widely used for PET imaging in human medicine and veterinary oncology. FDG is charac-
terized by uptake and retention by hypermetabolic cells, hence it is frequently used for diagnosis
of cancer and metastatic disease; however, it can also be used to evaluate muscle activity. The most
common way to quantify PET tracer accumulation is by standardized uptake values (SUVs), and
the tissue activity concentration is normalized by the fraction of the injected dose/unit weight
(Kinehan and Fletcher 2010).
When this technology was first developed, PET/CT acquired a PET scan and CT scan on separate
machines at different times. However, advances in machine technology now provide the ability to
acquire images using a dual PET/CT scanner as part of one imaging exam. The CT images offer
excellent anatomic depiction of normal and abnormal structures, while PET with FDG identifies
areas of high glucose metabolism. Once obtained, CT and PET images are compared, side by side
and fused, to determine if areas of noticeably high metabolic activity are normal or abnormal on
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(A) (B)
(C)
Figure 10.6 PET/CT images of a dog with subtle right thoracic limb lameness: whole body PET scan fused
PET/CT and CT images of the right and left carpus (left included for comparison): (A) whole body PET scan
showing areas of uptake throughout the body. Salivary gland, brain, gastrointestinal, and urinary tract
uptake is normal. Note the right carpus with increased metabolic activity (arrow) compared to left carpus
(right is on right side in this image [R]); (B) fused PET/CT transverse image at level of right and left carpus.
Note the increased metabolic activity of the right carpus with mild soft tissue thickening (arrow) compared
to left carpus; (C) CT post‐contrast study in soft tissue window at the level of the right and left carpus. Note
the soft tissue thickening of the right carpus (arrow). Right carpal arthrocentesis revealed chronic synovial
inflammation.
CT. PET alone is substantially limited by low spatial resolution and its inability to provide anatomi-
cal detail. Combining PET with structural imaging techniques such as CT (or even MRI) provides
useful physiologic information to detect abnormalities while allowing exact anatomic localization
of pathology.
PET/CT imaging can be used to localize lameness and identify areas of abnormality due to
higher metabolic activity compared to normal (Mann et al. 2016; Grobman et al. 2018). These
changes may guide further diagnostics to determine the cause of the increased metabolic activity
Reference 133
(if the CT imaging is not sufficient to establish a diagnosis). Such diagnostics may include ultra-
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sound (for muscle pathology), fine‐needle aspirate, biopsy, or arthrocentesis to differentiate spe-
cific disease processes causing increased SUV, such as infection, inflammation, or cancer.
All nuclear medicine studies require special imaging equipment and appropriate nuclear medi-
cine facilities. Disadvantages of PET/CT imaging include extremely limited availability, long scan
times, ionizing radiation, need for general anesthesia, and cost. Currently, this imaging modality is
mostly limited to university and tertiary referral hospitals.
R
eferences
Agnello, K.A., Puchalski, S.M., Wisner, E.R. et al. (2008). Effect of positioning, scan plane, and
arthrography on visibility of periarticular canine shoulder soft tissue structures on magnetic
resonance images. Vet Radiol Ultrasound 49 (6): 529–539.
Caine, A., Agthe, P., Posch, B., and Herrtage, M. (2009). Sonography of the soft tissue structures of the
canine tarsus. Vet Radiol Ultrasound 50 (3): 304–308.
Cook, C.R. (2016). Ultrasound imaging of the musculoskeletal system. Vet Clin North Am Small Anim
Pract 46 (3): 355–371.
De Rycke, L.M., Gielen, I.M., Van Bree, H., and Simoens, P.J. (2002). Computed tomography of the
elbow joint in clinically normal dogs. Am J Vet Res 63 (10): 1400–1407.
Gielen, I., Van Ryssen, B., and Van Bree, H. (2005). Computerized tomography compared with
radiography in the diagnosis of lateral trochlear ridge talar osteochondritis dissecans in dogs. Vet
Comp Orthop Traumatol 18 (2): 77–82.
Grobman, M., Cohn, L., Knapp, S. et al. (2018). (18) F‐FDG‐PET/CT as adjunctive diagnostic
modalities in canine fever of unknown origin. Vet Radiol Ultrasound 59 (1): 107–115.
Kinehan, P. and Fletcher, J. (2010). PET/CT standardized uptake values (SUVs) in clinical practice and
assessing response to therapy. Semin Ultrasound CT MR 31 (6): 496–505.
Lafuente, M.P., Fransson, B.A., Lincoln, J.D. et al. (2009). Surgical treatment of mineralized and
nonmineralized supraspinatus tendinopathy in twenty‐four dogs. Vet Surg 38 (3): 380–387.
Lamb, C.R. and Duvernois, A. (2005). Ultrasonographic anatomy of the normal canine calcaneal
tendon. Vet Radiol Ultrasound 46 (4): 326–330.
Long, C.D. and Nyland, T.G. (1999). Ultrasonographic evaluation of the canine shoulder. Vet Radiol
Ultrasound 40 (4): 372–379.
Mann, K., Hart, J., and Duerr, F. (2016). 18F‐FDG positron emission tomography: an innovative
technique for the diagnosis of a canine lameness. Front Vet Sci 3: 45.
Murphy, S.E., Ballegeer, E.A., Forrest, L.J., and Schaefer, S.L. (2008). Magnetic resonance imaging
findings in dogs with confirmed shoulder pathology. Vet Surg 37 (7): 631–638.
Reichle, J.K., Park, R.D., and Bahr, A.M. (2000). Computed tomographic findings of dogs with cubital
joint lameness. Vet Radiol Ultrasound 41 (2): 125–130.
Samoy, Y., Van Ryssen, B., Van Caelenberg, A. et al. (2008). Single‐phase bone scintigraphy in dogs
with obscure lameness. J Small Anim Pract 49 (9): 444–450.
Schaefer, S.L., Baumel, C.A., Gerbig, J.R., and Forrest, L.J. (2010). Direct magnetic resonance
arthrography of the canine shoulder. Vet Radiol Ultrasound 51 (4): 391–396.
Schwarz, T., Johnson, V.S., Voute, L., and Sullivan, M. (2004). Bone scintigraphy in the investigation of
occult lameness in the dog. J Small Anim Pract 45 (5): 232–237.
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11
Diagnostic Approach to Neoplastic Conditions Causing

Lameness
Bernard Séguin
Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Flint Animal Cancer Center,
11.1 Introduction
Neoplasia is a frequent cause of lameness and therefore must be considered as a differential diagnosis
for most patients. Signalment, history, and physical exam may raise suspicion of a neoplastic con-
dition. Neoplasia is a common differential diagnosis in certain breeds and older patients, although
osteosarcoma can affect any breed and is known to affect younger animals as well (Liptak et al.
2004). Certain histories can raise the suspicion of a neoplastic condition, such as one that indicates
a pathologic fracture (e.g. progressive thoracic limb lameness followed by a nontraumatic event
that causes acute non‐weight‐bearing lameness). A general approach to the patient with neoplasia
causing lameness is outlined in Figure 11.1.
11.2 Diagnostic Methods
11.2.1 Physical Examination

Lameness is a common finding with tumors but it may not always be present. Given the paucity of
soft tissues around the lower limb, it is common to visualize a “swelling” or mass effect if tumors
affect these regions. Soft tissue masses should be assessed for their ability to be freely movable, to
determine their origin (skin versus subcutaneous tissue versus deeper soft tissues or bone) and
adherence to the underlying bone. Palpation of the soft tissues or bones affected by cancer gener-
ally is painful, and frequently a mass effect may be observed (Figure 13.13). With osseous neopla-
sia, pain can be elicited when direct pressure is placed on the bone, while arthropathies cause pain
during end range of motion. Tendinopathies can be diagnosed by isolating the muscle and stretch-
ing it (Chapter 5). Physical exam findings should always be confirmed with diagnostic imaging.
11.2.2 Fine-needle Aspirate and Biopsy

In order to diagnose neoplasm, a fine‐needle aspirate (FNA; which leads to cytology) or biopsy
(which leads to histopathology) is required. If a nondiagnostic sample or reactive tissue is obtained

136 11 Diagnostic Approach to Neoplastic Conditions Causing Lameness
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Consider for staging

(based on biologic
behavior of tumor) Neoplasia
Consider to establish
causing
diagnosis
lameness
CBC/chem
Physical exam
Thoracic
radiographs
FNA
Removal of
tumor
Abdominal
radiographs Radiographs of
tumor
Lymph node
aspirate Final diagnosis
Advanced imaging
Abdominal
ultrasound
Biopsy
Determine need
for further
Advanced imaging treatment
Figure 11.1 Schematic representation of the clinical approach to a patient exhibiting lameness caused by
neoplasia. The veterinarian should attempt to establish a diagnosis for the primary tumor and determine
the extent of distant disease (staging). The biologic behavior of the tumor influences the appropriate
diagnostic methods (for example, advanced imaging may not be necessary for all tumor types).
with cytology, this does not rule out the possibility of neoplasm and another attempt at FNA or a
biopsy is necessary. In one study, Ghisleni et al. (2006) reported that the cytology of cutaneous and
subcutaneous masses agreed with the histologic diagnosis in 90% of the diagnostic samples
obtained. Similarly, in a retrospective study that compared the accuracy of using cytology and
histological biopsies to diagnose destructive bone lesions, Sabattini et al. (2017) observed non‐
accurate results in about 20% of the cases for each technique, thus suggesting that cytology is a
valid alternative to histology. When results suggest a false negative (e.g. reactive bone; which has
been reported to occur in up to 17% of biopsies of malignant bone tumors), it is recommended to
repeat the biopsy (Powers et al. 1988; Sabattini et al. 2017). Yet, even this may be nondiagnostic in
some cases, and a final diagnosis can only be obtained once the entire lesion is removed (e.g. via
amputation or limb sparing). Ultrasound guidance can be helpful to increase the likelihood of
acquiring a diagnostic sample with an FNA for bone lesions (Britt et al. 2007). With ultrasound,
breaks in the cortex can be found and used to guide the needle into the intramedullary component
of the tumor. Tumors that have a significant soft tissue component may be successfully aspirated
without ultrasound guidance. If cytology of a bone lesion is obtained, alkaline phosphatase (ALP)
staining can be performed. ALP staining is highly sensitive but not entirely specific for osteosarcoma
11.2 Diagnostic Method 137
(Barger et al. 2005; Ryseff and Bohn 2012). Other bone tumors that can stain positive for ALP
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include chondrosarcoma and multilobular osteochondrosarcoma (MLO), but MLO typically

affects the axial skeleton. Bone biopsies are best performed with a Jamshidi needle (Powers et al.
1988; Sabattini et al. 2017). For bone lesions that are small, using fluoroscopy or performing radio-
graphs throughout the procedure is helpful to ensure the biopsies were indeed taken from the
lesion. It is best to sample the middle of a bone lesion for a biopsy and not the periphery (Powers
et al. 1988; Liptak et al. 2004).
11.2.3 Diagnostic Imaging

Radiographs of the affected region of the limb are indicated when neoplasia is suspected, particu-
larly for tumors that are fixed and poorly movable on palpation. Soft tissue tumors may show bone
invasion on radiographs and as such this technique is still indicated. Primary tumors of bone typi-
cally display lytic and proliferative changes but only one dominant feature may be present.
Particularly for the proximal humerus, it can be difficult to differentiate subtle lytic lesions from
underlying tissues, making orthogonal views mandatory for these cases (Figure 17.1). Tumors of
the synovium typically display lytic changes in the bones on “both sides” (i.e. proximal and distal)
of the joint. It can sometimes be difficult to differentiate between severe osteoarthritis, septic
arthritis, and a neoplasm of the synovium on radiographs (Figure 14.12C). Computed tomography
(CT) can be used to image the area and is more sensitive to show both soft tissue and bone changes.
Magnetic resonance is another useful imaging modality and is superior to CT for imaging soft tis-
sue tumors. It can also be used to image bone tumors, particularly when assessing the extent of the
tumor is important (Davis et al. 2002).
11.2.4 Staging
Once a diagnosis of neoplasia is suspected or confirmed, staging should be performed for any
neoplasia with metastatic potential. A complete blood count and chemistry panel are indicated to
assess overall health of the patient and can be helpful for diagnostic or prognostic purposes in
certain cases (e.g. hyperglobulinemia with multiple myeloma or alkaline phosphatase for osteosar-
coma, respectively). In general, thoracic radiograph (or CT) is recommended for all malignant
neoplasms to evaluate for pulmonary metastases. Abdominal radiographs and ultrasound should
be considered for tumors known to metastasize to intra‐abdominal lymph nodes, spleen, or liver.
Similar to the approach for diagnosing the primary tumor, FNA of these structures is generally the
next step to confirm metastatic disease. If nondiagnostic samples are obtained, biopsy samples
may need to be obtained via exploratory laparotomy/laparoscopy.
Some tumors, such as mast cell tumors and histiocytic sarcomas, are more likely to metastasize
to lymph nodes. For these tumors, any palpable lymph node draining the area from which the
tumor is arising from, even when not enlarged, should be aspirated. But even in the presence of
tumors that uncommonly metastasize to lymph nodes, aspirating the lymph nodes is still recom-
mended. A metastatic lymph node can provide a diagnosis and also have a significant impact on
the prognosis. A good example is osteosarcoma: lymph node metastasis is seen in only about 5% of
cases, but when present the median survival is only about two months (Hillers et al. 2005).
Other staging tests such as bone scintigraphy, or positron emission tomography (PET‐CT), may
be utilized based on the tumor and availability. PET‐CT is a sensitive test to diagnose metastatic
foci in both soft tissue and bone and is therefore an excellent staging modality to evaluate the entire
body with a single test (Selmic et al. 2017). However, availability of this modality is limited.
11.3 Specific Tumors
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Many histologic types of neoplasm cause lameness in dogs. Both skin and subcutaneous tumors
may occur in the thoracic and pelvic limbs. Tumors can also originate from muscles, bones, or the
joint capsule.
11.3.1 Skin and Subcutaneous Neoplasia

Tumors of the skin and subcutaneous tissues can affect any aspect of the limbs. Common tumors
of the skin and subcutaneous tissues are mast cell tumors, soft tissue sarcomas, and lipomas. Both
skin and subcutaneous tumors can cause lameness if they are painful. Furthermore, subcutaneous
tumors can interfere with the tendons, muscles, and joint motion or irritate adjacent nerves and
thereby result in lameness. Infiltrative tumors into a muscle, such as infiltrative lipoma or soft tis-
sue sarcoma, are examples of a tumor that can interfere with muscle function.
11.3.2 Muscle Neoplasia

Tumors of the muscles are not well described in the canine literature, and primary tumors of the
muscles, such as rhabdomyosarcomas, appear to be quite rare. Anecdotally, other tumors arising
within a muscle, such as hemangiosarcoma, histiocytic sarcoma, and soft tissue sarcoma, are more
common than primary muscle tumors. Other differentials for mass effects in muscles include
infection and muscle tears. Tumors of the muscle should be considered as a differential diagnosis,
particularly if swelling and muscle tears are observed without a history of trauma.
11.3.3 Bone Neoplasia

Tumors of the bones and synovium frequently cause severe lameness because of their intimate
association with the tissues involved in motion. Tumors of the bone can be either primary or meta-
static. Primary bone tumors can be osteosarcoma, chondrosarcoma, fibrosarcoma, and hemangio-
sarcoma. By far the most common (98% in one study) tumor of the appendicular skeleton is
osteosarcoma with large and giant breeds being predisposed. Osteosarcoma is most commonly
diagnosed in 7–9 year old dogs, however, even dogs of 1–2 years of age may be affected (Liptak et al.
2004). Osteosarcoma most commonly occurs in the metaphyseal regions of bones, most frequently
in the distal radius and proximal humerus. Diaphyseal lesions have been reported but are uncom-
mon. Chondrosarcoma is the second most common bone tumor.
As a rule, any carcinoma of a bone should be considered metastatic. As such, once a bone carci-
noma is diagnosed, the primary tumor should be identified. In general, a thorough physical exam
(including a rectal exam), radiographs of the chest and abdomen, and abdominal ultrasound are
appropriate first steps.
Other tumors affecting the bones include lymphoma and plasma cell tumor/multiple myeloma.
Multiple myeloma can be associated with hyperglobulinemia. A chemistry panel and protein elec-
trophoresis may be used to detect a monoclonal gammopathy.
11.3.4 Joint Capsule Neoplasia

The most common tumors arising from the joint capsule are histiocytic sarcoma, synovial myxo-
mas, and synovial cell sarcoma (Craig et al. 2002). The most common breeds affected are the
Reference 139
Golden Retriever, Labrador Retriever, and Rottweiler (Schultz et al. 2007; Klahn et al. 2011; Manor
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et al. 2018). Prior joint disease is associated with increased risk of developing periarticular histiocytic
sarcoma in dogs (Manor et al. 2018). Whereas myxomas are identified by their unique histo-
logic appearance, immunohistochemistry with CD 18 or CD204 is required to distinguish histio-
cytic sarcoma from synovial cell sarcoma (Craig et al. 2002). Other types of sarcomas (malignant
fibrous histiocytoma, fibrosarcoma, and undifferentiated sarcoma) have also been rarely
reported from the synovium in dogs (Craig et al. 2002). Although neoplastic cells can at times be
identified with joint fluid analysis, this is not a reliable method to diagnose tumors that involve the
joint capsule in the author’s experience. FNAs and biopsies are preferred to make a definitive
diagnosis.
Villonodular synovitis (also called pigmented villonodular synovitis; PVNS) has been described
in all of the major joints, including the carpus (Hanson 1998). PVNS is considered a benign neo-
plasia (Dempsey et al. 2018); however, the etiology is still not fully understood. The condition
causes proliferation of synovial tissues resulting in lameness and pain (Akerblom and Sjostrom
2006). PVNS has most commonly been described as a monoarticular condition; however, a dog
with bilateral stifle PVNS has been reported (Marti 1997). Diagnostic imaging is generally nonspe-
cific, requiring histopathology to establish the diagnosis. Even though PVNS is extremely rare, it
should be considered as a differential diagnosis when diagnostics are inconsistent with more
commonly observed conditions.
R
eferences
Akerblom, S. and Sjostrom, L. (2006). Villonodular synovitis in the dog: a report of four cases. Vet
Barger, A., Graca, R., Bailey, K. et al. (2005). Use of alkaline phosphatase staining to differentiate
canine osteosarcoma from other vimentin‐positive tumors. Vet Pathol 42 (2): 161–165.
Britt, T., Clifford, C., Barger, A. et al. (2007). Diagnosing appendicular osteosarcoma with ultrasound‐
guided fine‐needle aspiration: 36 cases. J Small Anim Pract 48 (3): 145–150.
Craig, L.E., Julian, M.E., and Ferracone, J.D. (2002). The diagnosis and prognosis of synovial tumors in
dogs: 35 cases. Vet Pathol 39 (1): 66–73.
Davis, G.J., Kapatkin, A.S., Craig, L.E. et al. (2002). Comparison of radiography, computed tomography,
and magnetic resonance imaging for evaluation of appendicular osteosarcoma in dogs. J Am Vet
Med Assoc 220 (8): 1171–1176.
Dempsey, L.M., Maddox, T.W., Meiring, T. et al. (2018). Computed tomography findings of pigmented
villonodular synovitis in a dog. Vet Comp Orthop Traumatol 31 (4): 304–310.
Ghisleni, G., Roccabianca, P., Ceruti, R. et al. (2006). Correlation between fine‐needle aspiration
cytology and histopathology in the evaluation of cutaneous and subcutaneous masses from dogs and
cats. Vet Clin Pathol 35 (1): 24–30.
Hanson, J.A. (1998). Radiographic diagnosis‐canine carpal villonodular synovitis. Vet Radiol
Ultrasound 39 (1): 15–17.
Hillers, K.R., Dernell, W.S., Lafferty, M.H. et al. (2005). Incidence and prognostic importance of lymph
node metastases in dogs with appendicular osteosarcoma: 228 cases (1986–2003). J Am Vet Med
Assoc 226 (8): 1364–1367.
Klahn, S.L., Kitchell, B.E., and Dervisis, N.G. (2011). Evaluation and comparison of outcomes in dogs
with periarticular and nonperiarticular histiocytic sarcoma. J Am Vet Med Assoc 239 (1): 90–96.
Liptak, J.M., Dernell, W.S., Ehrhart, N., and Withrow, S. (2004). Canine appendicular osteosarcoma:
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diagnosis and palliative treatment. Compend Contin Educ Vet 26 (3): 172–182.
Manor, E.K., Craig, L.E., Sun, X., and Cannon, C.M. (2018). Prior joint disease is associated with
increased risk of periarticular histiocytic sarcoma in dogs. Vet Comp Oncol 16 (1): E83–E88.
Marti, J.M. (1997). Bilateral pigmented villonodular synovitis in a dog. J Small Anim Pract 38 (6):
256–260.
Powers, B.E., Larue, S.M., Withrow, S.J. et al. (1988). Jamshidi needle biopsy for diagnosis of bone
lesions in small animals. J Am Vet Med Assoc 193 (2): 205–210.
Ryseff, J.K. and Bohn, A.A. (2012). Detection of alkaline phosphatase in canine cells previously stained
with Wright‐Giemsa and its utility in differentiating osteosarcoma from other mesenchymal tumors.
Vet Clin Pathol 41 (3): 391–395.
Sabattini, S., Renzi, A., Buracco, P. et al. (2017). Comparative assessment of the accuracy of cytological
and histologic biopsies in the diagnosis of canine bone lesions. J Vet Intern Med 31 (3): 864–871.
Schultz, R.M., Puchalski, S.M., Kent, M., and Moore, P.F. (2007). Skeletal lesions of histiocytic sarcoma
in nineteen dogs. Vet Radiol Ultrasound 48 (6): 539–543.
Selmic, L.E., Griffin, L.R., Nolan, M.W. et al. (2017). Use of PET/CT and stereotactic radiation therapy
for the diagnosis and treatment of osteosarcoma metastases. J Am Anim Hosp Assoc 53 (1): 52–58.
141
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Section 2
Regional Diagnosis
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Part III
Distal Limb Lameness

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D I S TA L L I M B R E G I O N
12
Distal Limb Region

Metacarpals, Metatarsals, Digits, Sesamoids, and Associated Structures
Nicolaas E. Lambrechts
12.1 Introduction
Although often overlooked because of the small size and complexity of their component anatomic
structures, minor clinical findings, and paucity of available information regarding disease mani-
festation and methods of clinical examination for this region, injuries and diseases of the distal
limb are a frequent and important source of lameness. This chapter describes many conditions that
may subtly or profoundly affect a dog’s normal gait and ambulatory performance. Figure 12.1 and
Table 12.1 outline common differential diagnoses and diagnostic steps for the distal limb region.
12.2 Normal Anatomy
12.2.1 Thoracic Limb

The five metacarpals, numbered from medial to lateral, have a cylindrically shaped body articulat-
ing proximally with the distal row of carpal bones at their base and distally with the similarly
numbered phalanges at their head (Figure 12.2). Metacarpal I, the smallest, only has a proximal
epiphysis, does not bear weight, and may be supernumerary in some individuals or breeds (e.g.
Saint Bernards). Metacarpals II–V all bear weight, although the longer III and IV are believed to
bear greater loads. They all have a single distal physis and diverge from each other as they course
distally. At each of the metacarpophalangeal joints II–V, there are also articulations with a single
dorsal sesamoid (Figure 12.3), which lies within the common digital extensor tendons and two
(single in metacarpal I) elongated, inwardly curved sesamoids within the ligamentous insertion of
the interosseous muscles. These palmar sesamoids are also numbered from medial to lateral; how-
ever, only the paired sesamoids are numbered (Cake and Read 1995; Figure 12.2).
The metacarpal bones are attached to the distal row of carpal bones by synovial membranes and
numerous straight and oblique ligaments. Distal to the synovial reflections, the individual bones are
held to each other by interosseous metacarpal ligaments. There is very little movement at the carpo-
metacarpal joint. At the transversely oriented metacarpophalangeal joints, movement is mainly flexion

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Table 12.1 Key features for selected diseases affecting the distal limb region.
Disease Common signalment Exam findings Diagnostic test of choice Treatment Clinical pearls Terminology
Fractures/ Any breed or age – racing Pain, swelling, Survey radiographs, External coaptation The choice between
luxations Greyhounds develop stress/ crepitus, and possibly rarely CT for complex or surgical fixation surgical vs.
fatigue fractures instability or fractures nonsurgical treatment
deviations is controversial and
depends on severity/
digits involved
Other trauma Any breed or age Laceration, stabs, and Clinical appearance, When appropriate, Trauma to the distal
foreign body radiographs, and suturing and surgical limb is common and
penetrations and ultrasound to detect exploration frequently missed
splits involvement of
underlying structures or
potential foreign bodies
Osteoarthritis More commonly seen in Initial pain with later Survey radiographs Nonsurgical, rarely May be overuse injury
adult animals. thickening and arthrodesis or
Metacarpophalangeal stiffening of the joint, amputation
joints IV and V more variable lameness,
common than II and III can be associated
with “flat digits”
Sesamoid Mainly racing Greyhounds Focal pain and Survey radiographs Nonsurgical or Can be differentiated Sesamoiditis and
disease and young Rottweilers. swelling. Reduced or CT surgical excision from bipartite sesamoid fracture
Sesamoids II and VII of flexion of adjacent sesamoids via
either thoracic limb most joint(s) imaging and lack of
commonly pain
affected – others can be
involved if traumatic origin
Digital flexor Any breed, more likely Digit(s) flattened Radiographs to detect Appositional suturing Injury can occur “Dropped toe”
muscle and athletic individuals with isolated SDF bony changes; of acutely transected anywhere along the (SDF); “Kicked
tendon injury injury; last phalanx ultrasound to localize muscle and tendons. length of the muscle up toe” or
and claw angled site, extent, and stage of For less severe or “knocked up toe”
dorsally with the disease chronic strains and (DDF)
combined DDF and nonsurgical
SDF injury management
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Disease Common signalment Exam findings Diagnostic test of choice Treatment Clinical pearls Terminology
Corns Sight hounds, especially Well-circumscribed Biopsy and Symptomatic or with 90% affect digital pads Sweet corns:
Greyhounds hyperkeratotic histopathology surgical excision if of digits 3 and 4 of the “wart-like lesion”
lesions with central unresponsive thoracic limbs and or “Porokeratosis
keratin core consider other DD if plantaris discreta”
located in other digits
Dermatologic Multiple etiologies. Visually identifiable Clinical appearance, Depending on cause. Important differential
conditions Predisposed breeds for changes to paw pads, skin scraping, exudate Pharmacologic and for lameness – careful
causing specific conditions, any claws, and nail bed cytology, FNA, bacterial surgical treatment evaluation of the
lameness breed and age for infectious and fungal culture. (amputation if paws/pad necessary
conditions Radiographs to detect extensive bone to establish diagnosis
potential underlying involvement)
bone involvement
Hypertrophic Any breed or age, older Limb thickening and Radiographs of limbs Treat underlying Periosteal reaction Marie’s disease of
osteopathy animals more common pain and thoracic and thoracic and/or and pain in all four the dog,
since most commonly abdominal imaging abdominal cause limbs hypertrophic
associated with thoracic osteoarthropathy/
neoplasia osteopathy
Digit Older animals Swelling or mass Fine-needle aspirate or Digit amputation, Squamous cell
neoplasia effect of the biopsy, and radiographs partial foot carcinoma and
digits – third phalanx (malignant melanoma amputation; rarely malignant melanoma
most commonly frequently does not requires partial or most common rarely
affected cause lytic changes) full-limb amputation can affect multiple
digits
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diagnosis Septic arthritis
Arthrocentesis
Soft tissue
Fracture injury
Ultrasound and/or
NO visible MRI
History of
Traumatic soft abnormality
trauma
Abnormality Sesamoid
History of
tissue injury --
trauma
fracture
X-rays CT
Flexor tendon Visible NORMAL
pathology Osseous displacement abnormality
Soft tissue
Traumatic digit FNA neoplasia
luxation Soft tissue swelling
Pyoderma,
Pain in
NO visible Digit
trauma, etc. distal limb neoplasia
Displaced digits abnormality
region
-- Abnormality
Paronychia, X-rays
trauma, etc. Skin pathology ABNORMAL
Lytic lesion Fracture
Infection,
neoplasia, etc.
Nail pathology
Fracture line Neoplasia,
Osteoarthritis osteomyelitis and
Periarticular swelling hypertrophic
Periosteal reaction osteopathy
Neurologic
disease and pain
Worn toe nails
Degenerative changes Osteoarthritis
Enthesopathy
Chronic collateral
ligament sprain
Figure 12.1 Schematic of common diseases affecting the distal limb region and the steps necessary to establish a diagnosis.
12.2 Normal Anatom 149
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(A) (C) (D)
(E)
(B)
Figure 12.2 Normal anatomy of the paws: pads of the (A) thoracic limb and (B) pelvic limb; (C) fourth digit
of the thoracic limb; (D) forepaw; and (E) hindpaw. (a) Carpal pad; (b) metacarpal pad; (c) digital pads; (d)
metatarsal pad; (e) distal (third) phalanx with claw; (f) middle (second) phalanx; (g) proximal (first) phalanx;
(h) proximal sesamoid bones (paired sesamoids are labeled from medial to lateral; i.e. the sesamoids of
digit II are labeled number 1 + 2); (i) metacarpi (numbered from medial to lateral), (ia) base, (ib) body, (ic)
head; (j1) metacarpophalangeal joint; (j2) proximal interphalangeal joint; (j3) distal interphalangeal joint;
and (k) metatarsi (numbered from medial to lateral).
150 12 Distal Limb Region
with lateral and medial movement restrained by the joint morphology, the bilateral collateral ligaments,
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and the lateral and medial collateral sesamoidean ligaments. Extension is limited by the short sesa-
moidean ligaments and the cruciate ligaments (located between the distal pole of the sesamoid bones
and the proximal palmar surface of the first phalanges). The paired sesamoids are connected to each
other by short palmar ligaments, and the four bones of each joint share a single joint capsule.
The powerful interosseous muscles originate from the palmar side of the bases of metacarpals
II–V. They split into two tendons which each receive a sesamoid bone before inserting on the bases
of the adjacent first phalanx. The muscle bellies run between the bifurcating tendons of the deep
and superficial digital flexors and flex the metacarpophalangeal joints. The flexor carpi radialis
muscle inserts on the proximal palmar surfaces of metacarpals II and III body. The two heads of
the flexor carpi ulnaris muscle both insert on the accessory carpal bone. The two accessory carpal
ligaments anchor the accessory carpal bone to the base of metacarpals IV and V. Together, they
serve to flex the carpus and may also provide antigravity support in dogs. There are numerous
small muscles which lie deep to the deep digital flexor in this area. The extensor carpi radialis
muscles insert on the dorsal surface of the base of metacarpals II and III.
There are three phalanges for each of digits II–V, whereas the underdeveloped digit I has no
second phalanx (Figure 12.3). The first phalanx is a short cylinder with a concave proximal joint
and a distal joint which is sagittally convex, is transversely concave, and extends further on the
palmar than the dorsal surface. This arrangement provides for more flexion than extension and
limited lateral movement. The second phalanx, similarly cylindrical but shorter, forms a flexion
angle of 135° with first phalanx. The four tendons of the superficial digital flexor, which bifurcate
from the primary tendon at the proximal third of the metacarpus and are surrounded by a long
synovial sheath, insert on their proximal bases. They serve to flex both the metacarpophalangeal
(A) (B) (C) (D)
Figure 12.3 Normal radiographs of the forepaw: (A) lateral; (B) dorsopalmar; (C) dorsolateral palmaro-
medial oblique (DLPMO); and (D) dorsomedial palmaro-lateral oblique (DMPLO) view: (a) dorsal sesamoid;
(b) sesamoid 2; and (c) sesamoid 7 (these are the sesamoids most commonly affected by “sesamoid
disease”); metacarpals 1–5 are labeled with roman numerals (I–V).
and proximal interphalangeal joints of digits II–V. The transversely and dorsally oriented base of
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the third phalanx results in it forming an almost 90° dorsal angle with the second phalanx. On
their palmar surfaces, broad, low tubercles receive one of the five branches of the deep digital
flexor tendons. The tendon of this muscle first sends a small medial branch to the first phalanx at
the level of the proximal metacarpus before splitting into its four main branches. The principle
tendon is surrounded by a synovial sheath from the level of the distal radius to proximal metacar-
pus, and the individual branches are similar enveloped. On the dorsal surface just distal to the
joint, the extensor processes of digits II–V receive one of the four tendons of the common digital
extensor muscle. Distal to this, the conical, ventrally curved, and tapered ungula process receives
the claw (nail). The ungula crest surrounds the process dorsally and laterally.
The proximal interphalangeal joints, formed between the first and second phalanx in digits II–V,
are stabilized laterally and medially by stout collateral ligaments. The extensor tendons dorsally
and the flexor tendons on the palmar aspect are attached to the joint capsule. The joint capsule of
the distal interphalangeal joint is thickened to form collateral ligaments. Each of digits II–V has
two dorsal ligaments which extend from the base of the second phalanx to the ungula crest. These
passive extensors keep the claws elevated off the ground and counter the tension of the deep digital
flexors. The digital flexor tendons are held in place by annular ligaments at each phalanx. In the
metacarpophalangeal region, the fascia forms the transverse metacarpal ligament which holds the
digits together and anchors the metacarpal footpad.
Five of the six palmar paw pads occur in this region; whereas the sixth, the carpal pad, is located
adjacent to the accessory carpal bone (Figure 12.2). Palmar pads include the heart-shaped metacar-
pal pad as well as four digital pads which lie under the distal interphalangeal joints of digits II–V.
The digital pads are anchored in place by fibroelastic strands from the digital fascia. Deep to the
dermis and heavily keratinized epidermis, the pad is composed of fat, laced with reticular, colla-
genous, and elastic fibers, along with a scattering of eccrine sweat glands. This arrangement allows
the pads to deform under load yet return to their original shape and size. Pads also provide trac-
tion, load transfer, shock absorption, sensory perception, insulation, plus an additional cooling
mechanism.
12.2.2 Pelvic Limb

Metatarsals II–V are similar to the corresponding metacarpals although they are longer
(Figure 12.4), and their bases are flattened and compressed transversely, resulting in them being
more crowded together and having smaller intermetatarsal spaces compared to the thoracic limb.
Metatarsal I is significantly reduced in size (Figure 12.4) and sometimes fused to the first tarsal
bone (Figure 18.2). Although not always present, the associated phalanx, the dewclaw, is often
vestigial and supernumerary in some breeds. Phalanges II–V are very similar to those of the tho-
racic limb, as are the joints and ligaments.
The superficial digital flexor muscle divides into four branches at the level of the distal row of
tarsal bones. These branches insert on the plantar surface of the proximal base of phalanges II–V.
The lateral and medial heads of the deep digital flexor muscle converge and at the level of the proxi-
mal metatarsus, the common tendon splits into four branches which insert on the plantar flexor
tubercles of the third phalanx of digits II–V. The synovial and ligamentous structures of both these
muscles are similar to the flexor muscles of the thoracic limb. The tendon of cranial tibial extensor
muscle runs obliquely across the tarsus and inserts on the palmer base of metatarsals I and II. The
long digital extensor tendon branches into four at the proximal metatarsus; these synovial-sheathed
tendons run along the dorsal surfaces to phalanges II–V and receive a single sesamoid at the proxi-
mal interphalangeal joint, before inserting on the dorsal surface of the ungula process.
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(A) (B) (C) (D)
Figure 12.4 Normal radiographs of the hindpaw: (A) lateral; (B) dorsoplantar; and (C) dorsolateral
plantaro-medial oblique (DLPMO); and (D) dorsomedial plantaro-lateral oblique (DMPLO) view. (a) Dorsal
sesamoid; (b) metatarsal I; (c) sesamoid 2, and (d) sesamoid 7; metatarsals 2–5 are labeled with roman
numerals (II–V).
12.2.3 Function, Posture, and Carriage

The metacarpal and digital pads should all touch the contact surface. Additionally, the digits
should be slightly splayed, dorsally angled relative to the metacarpals, with digits III and IV ele-
vated above and extending forward relative to digits II and V. The dorsal surface between the distal
interphalangeal joint and the nail bed should be slightly concave. The claws (nails) should curve
downwards, but if appropriately worn or trimmed, the tips should not touch the contact surface
while standing, but rather be suspended slightly above it, ending square as well as caudally bev-
eled. The metacarpophalangeal and metatarsophalangeal joint angles have been measured using
three-dimensional videography (Nielsen et al. 2003); however, they are infrequently measured
objectively in the clinical setting. With increasing velocity, the digits splay slightly more, the pads
expand, and the claws rotate distally into the contact surface. Reported normal range of motion
angles for the carpus and tarsus are described in Chapter 5.
12.3 Arthritis
Osteoarthritis of the lower limb region is poorly described. The condition can involve any joint,
although the metacarpophalangeal joints IV and V have a higher incidence than those of II and III as
well as the metatarsophalangeal joints (Franklin et al. 2009). Individual or multiple joints may be
12.3 Arthriti 153
involved. The condition may be secondary to trauma or associated with strain injuries of the collat-
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eral ligaments and is sometimes seen with flexor tendon injuries or, as observed by the author, in dogs
with excessively long nails and apparent rotary angulation of the digits and their joints. Clinical signs
may be absent or mild. However, dogs with visible swelling are more likely to have clinical lameness
(Franklin et al. 2009) and affected joints may be painful during the early stages of the disease. In
chronic cases, there is thickening of the joint and loss of range of motion. Severe joint thickening may
cause cutaneous impingement of the adjacent digit(s), with ensuing abrasion and pain. Radiographic
imaging may reveal soft tissue proliferation, osteophytosis and enthesopathy, as well as extensive
periosteal reaction, which may give the appearance of a neoplastic process (Franklin 2009). In the
author’s experience, the condition may also be accompanied (and potentially related) to the clinical
syndrome of the hyperextension of multiple digits frequently seen in geriatric dogs (Figure 12.5).
Infective and immune-mediated arthritis are uncommon conditions for this region. The former
may occur from bacterial introduction through local wounding or from adjacent infected tissues,
or spontaneously through hematogenous bacterial extension (see Section 14.12). Typical signs
include acute onset lameness with a warm, swollen, and painful joint (usually single). Immune-
mediated arthritis usually involves multiple joints and may be erosive or nonerosive (Chapter 13).
Erosive forms show bone erosions, subluxation, or luxation of the joints with periarticular bone
proliferation and mineralization of the periarticular soft tissue possible. Joint fluid analysis and
culture is required for diagnosis of both conditions.
(A)
(B) (C) (D)
Figure 12.5 Metacarpophalangeal osteoarthritis: (A, B) this dog presented with hyperextension of all
digits; (C, D) note the severe degenerative changes of the metacarpophalangeal joints of the second and
fourth digits with soft tissue proliferation, osteophytosis, and enthesopathy, as well a periosteal reaction.
12.4 Fractures of the Distal Limb Region

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12.4.1 Metacarpal and Metatarsal Fractures

Fractures of these bones usually occur following a traumatic event. In racing Greyhounds, they are
considered stress/fatigue fractures and most commonly involve metacarpal II of the right limb and
metacarpal V of the left. In these dogs (and possibly other working dogs where the bones are
exposed to cyclical injury and have not had enough time to adaptively remodel), bone injury is
common and manifests as an ill-defined continuum of periostitis, stress fracture, and finally, com-
plete fracture. In racing Greyhounds, a single bone is most commonly fractured (Boemo 1998). In
contrast, traumatic fractures in pets frequently involve multiple bones (Kornmayer et al. 2014).
Clinical signs can range in severity depending on the extent of the force, number of bones
affected, degree of injury, and the size of the animal. There is usually some adjacent swelling and
there may be associated cutaneous injuries. Palpation will reveal pain, swelling, crepitus, and pos-
sibly topographical deformity of the region.
Diagnostic confirmation and fracture details are generally provided through orthogonal radio-
graphs. Lateral views give confusing superimposition of the bones, which may be resolved through
oblique projections and/or gentle elevation or depression of an individual bone to assist with orien-
tation. CT can be useful to elucidate comminuted fractures, especially those that involve the joints.
Numerous surgical and nonsurgical treatments (e.g. external coaptation) have been described to
treat these fractures but there is no evidence-based consensus as to the best treatment. Factors
influencing the choice of treatment include the age and mass of the dog, intended activity of the
dog, which bones are fractured, number of bone fractures, site of the fractures, extent of fragment
displacement, and concurrent local and distant injuries.
12.4.2 Digit Fractures and Luxations

Digit fractures most commonly occur as a result of trauma and frequently involve only a single digit.
The clinical signs and diagnostic approach are similar to those described for metacarpal/metatarsal
fractures. Due to the complexity of this region, careful evaluation of radiographs is necessary for the
diagnosis of minimally displaced fractures (Figure 12.6). There is also no clear consensus on treat-
ment, with both surgical and nonsurgical treatment described. Most frequently these fractures are
managed nonsurgically; however, because of the difficulty in adequately immobilizing the region,
delayed unions and exuberant callus are common. Surgical repair of shaft fractures has been recom-
mended in performance dogs, although there are no studies to support this (Eaton-Wells 1998).
Luxations or subluxations can occur at any level but are reportedly more common at the distal
interphalangeal joints, especially in athletic dogs (DeCamp et al. 2016). These injuries are due to a
strain injury of the associated collateral and/or sesamoid ligaments and usually involve a single
joint. Dogs with this injury are often not lame at the walk but may show lameness during faster
gaits. There is often no, or minimal pain (luxations of the metacarpophalangeal joints are reported
to be more painful than those of the distal joints), swelling, nor crepitation (Blythe et al. 2007).
With complete luxation, the phalanx is displaced laterally or medially (Figure 12.6).
Instability is palpated by gently opening the joints laterally or medially and performing a dorso-
palmar/plantar “drawer” movement. Diagnosis is confirmed with orthogonal radiographs, but stress
radiographs may be necessary to establish the diagnosis. Small avulsion fractures associated with the
collateral ligaments are often seen. Ultrasound may be useful to identify ligamentous injuries or con-
current tendon injury, in larger dogs. Although reduction and nonsurgical treatments are frequently
successful in the author’s experience, surgical treatment is described for athletic dogs (Guilliard 2003).
12.4 Fractures of the Distal Limb Region 155
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(A) (B) (E)
(C) (D) (F)
Figure 12.6 Digit luxation and fractures: the dog depicted in images (A–D) presented with acute
lameness due to a luxation of the proximal interphalangeal joint of the fifth digit of the pelvic limb; (A, B)
the luxation was (C, D) reduced and managed conservatively; (E) mid-diaphyseal fracture of the first
phalanx of digit I, and (F) articular fracture of the second phalanx of digit IV illustrate the difficulty of
diagnosing minimally displaced digit fractures in dogs.
12.4.3 Sesamoid Disease

Sesamoid disease refers to a group of diseases which include traumatic fractures, sesamoid
inflammation (sesamoiditis), degeneration, and fragmentation (Read et al. 1992; Cake and Read
1995; Mathews et al. 2001; Daniel et al. 2008). The pathogenesis is unclear, and it is unknown
whether these conditions are manifestations of a single disease or different diseases. The condi-
tion generally affects the thoracic limbs; however, it may occasionally occur in the pelvic limb as
well. Sesamoids II and VII in Greyhounds and Rottweilers are most commonly affected
(Figures 12.3 and 12.7).
Sesamoiditis is reported in Greyhounds as an inflammation of the sesamoid ligaments sec-
ondary to a strain injury (Blythe et al. 2007). Traumatic sesamoid fractures of sesamoids II and
VII have also been described in racing Greyhounds and other large-breed dogs and are believed
to be caused by excessive tension of the digital flexor tendons across the sesamoid bones (Eaton-
Wells 1998).
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(I)
(A) (C) (E) (G)
(B) (D) (F) (H)
Figure 12.7 Sesamoid disease (white circles are used to outline the affected sesamoid bones in all
images): (A) radiograph and (B) CT of traumatic sesamoid fracture of the fourth proximal sesamoid; note
that establishing a diagnosis on radiographs is difficult, but fracture is clearly revealed on CT. (C–F)
Sesamoid disease of sesamoids 3 and 7; note that radiographs (C, E) permitted to establish the diagnosis in
this case, but (D, F) CT was used to determine the extent of the disease. (G, H) Radiographs of bipartite
sesamoid (sesamoid 7, white arrow) permitted to establish the diagnosis. (I) Typical location for palpation of
thoracic limb sesamoid 7.
Sesamoid fragmentation is a condition mainly occurring in young Rottweilers. It is not associated

with trauma or specific athletic pursuits but, like traumatic fractures, usually also involves sesamoids
II and VII of either of the thoracic limbs (Read et al. 1992; Mathews et al. 2001). Fragmentation has
been reported in other breeds such as Labrador Retrievers and Cattle Dogs (Mathews et al. 2001), and
clinical signs may vary greatly. Traumatic fractures are generally associated with an acute, severe
lameness; whereas chronic conditions may present with mild or no lameness. Pain on deep, direct
palpation and during flexion may be elicited, and local swelling may be palpable. Sesamoids II and
VII are easily palpable adjacent to the metacarpal pad, while sesamoids III–VI may be covered by the
pad (however, as noted above, these are rarely affected). Over time, a thickening of the area may
develop and a reduction of flexion of the adjacent metacarpophalangeal joints may also occur. In
normal animals, this joint should be able to flex to at least 90°.
Diagnosis is generally confirmed with dorsopalmar and oblique radiographs (Figure 12.7) but
CT can also be used and simplifies the diagnosis. Tape traction and/or separation of the digits with
cotton wool may allow better radiographic visualization. Imaging may reveal fragmentation (clus-
ter of ossicles with sharp or rounded margins depending on chronicity) of the affected sesamoids.
Enthesophytosis, soft tissue swelling, or calcification (Cake and Read 1995) and other secondary
arthritic changes may also be observed. Since radiographic evidence of sesamoid disease can be an
incidental finding (Vaughan and France 1986), it is imperative to rule out other causes of thoracic
limb lameness. Further complicating the diagnosis is the fact that bipartite or multipartite sesa-
moids, a congenital abnormality where the sesamoid presents as multiple instead of a single bony
structure, may be present. These are minimally displaced, usually have rounded margins, and are
not accompanied by soft tissue swelling. Scintigraphy or CT can be used to differentiate this
12.5 Conditions of Muscles, Tendon, and Ligament 157
condition from pathological conditions of the sesamoids. Local analgesic blocks may also be used
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to evaluate whether sesamoid pathology contributes to a lameness. There is no consensus on treat-
ment; however, sesamoidectomy (removal of the affected sesamoid) is possible in cases that are
refractory to nonsurgical treatment (Mathews et al. 2001).
12.5 Conditions of Muscles, Tendon, and Ligaments
Numerous major muscles that insert in this region have their origins and muscle bellies well proxi-
mal on the limb. This allows for the muscle mass to be centralized towards the trunk rather than
add to the distal “pendulum” weight and inertia of the limb. This means that many of these mus-
cles cross multiple joints, which makes them more vulnerable to injury compared to those that
only cross a single joint. Any of these muscles may be injured and probably are. The manifestation
of these injuries might be obvious, for example an abnormally elevated digit (i.e. injury of the digi-
tal flexor muscles). Many, however, are insidious, as the impact of their injury may be muted by
muscles with similar function taking over their roles. These injuries may be detectable but require
familiarity with the regional anatomy upon a meticulous clinical examination. Treatment of these
conditions may involve surgical (such as apposition of the injured structures) and nonsurgical
(external coaptation, rest, and pain management) strategies.
12.5.1 Dorsal Digital Ligament Sprain

Dorsal digital ligament sprains occur when the distal phalanx is forcefully and excessively flexed
and has been described in active Greyhounds (Blythe et al. 2007). It may be associated with injury
of the adjacent digital extensor tendon. Animals might be slightly lame and on inspection of the
affected paw, the dorsal (cutaneous) concavity between the proximal interphalangeal joint and
claw is lost. This is caused by swelling of the area, which is accompanied by pain on palpation.
Radiographs to investigate any concurrent fractures, for example avulsion fractures, and ultrasono-
graphic examination are warranted to confirm the ligamentous injury.
12.5.2 Digital Flexor Muscle and Tendon Injuries

12.5.2.1 Superficial Digital Flexor Muscle
The superficial digital flexor muscle may be damaged through overexertion (causing overstretch-
ing or strain injury), or through external trauma, including contusion and laceration. The damage
may occur in both the muscle or in the long tendon and its synovial sheath. The entire paw may
be involved if the muscle is torn and elongates or if the main tendon or multiple branches are
ruptured, for example following a deep laceration to the palmar/plantar aspect of the paw (usu-
ally in the region of the metacarpal or metatarsal footpad). Animals may or may not be lame,
depending on the extent and chronicity of the condition. The clinical appearance is of one or
more digits that appear to lie parallel to the contact surface (Figure 12.8); the proximal inter-
phalangeal joint loses its normally flexed angle, referred to as “dropped toe” in dog racing circles.
If the deep digital flexor tendon is intact, the claw elevates and points forward (but is not cocked
dorsally, see Section 12.5.2.2).
Clinical diagnosis involves palpating for pain and swelling along the entire length of the
affected muscle, since the injury may not be located at the site of obvious abnormality (i.e. the
“dropped toe”). The affected digit(s) may be extended to a greater degree than their unaffected
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(A) (D)
(B) (E)
(C) (F)
Figure 12.8 Clinical appearance with disruption of the superficial and deep digital flexor tendons (SDF/
DDF) in two patients. Patient I (A–C): (A) normal leg for comparison; (B, C) disruption of the SDF only of the
fourth digit; note the loss of the flexed angle of the proximal interphalangeal joint and that the digit
appears to lie parallel to the contact surface (i.e. the claw is elevated and approximately parallel to the
ground). Patient II (D–F): (D) normal leg for comparison; (E, F) disruption of the SDF and DDF of the third
and fourth digit; note that compared to Patient I (B, C) the claw is elevated beyond parallel due to the
complete loss of the flexor mechanism.
opposite number; however, resistance from the deep digital flexor is still palpable (i.e. inability
to elevate the toe dorsally completely). The muscle of the opposite limb should be similarly
palpated for comparison and to detect similar disease. Bear in mind that this muscle crosses
multiple joints, so that stretching of the muscle (i.e. elbow, carpal, and digit extension) may
result in a more pronounced pain response (Chapter 5), particularly if the level of injury is
proximal. Establishing a diagnosis generally involves palpation, and confirmation can be
accomplished by ultrasonographic examination of the muscle and tendons if the tendons are
accessible. This may confirm the diagnosis and can be helpful to describe the extent of the dis-
ease, potentially directing treatment strategies. Radiographs are used to detect associated bony
changes like avulsions, enthesiophytes, or dystrophic mineralization in chronically damaged
tissues. Magnetic resonance imaging, although seldom used for this condition, may provide
more detailed information.
12.6 Conditions of the Digital and Paw Pad 159
12.5.2.2 Deep Digital Flexor Muscle

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Mechanisms of injury are similar to those of the superficial tendon. Both muscles and/or their
tendons may be affected concurrently. The deep digital flexor tendon is more commonly lacer-
ated than the superficial tendon, as it lies superficial to the latter, and so is more vulnerable to
injury. The clinical appearance is of the claw of one or more digits being elevated off the contact
surface, colloquially referred to as “kicked up” or “knocked up” toe. If there is concurrent
superficial flexor muscle injury, the digit becomes flattened as described above, but the claw is
cocked dorsally. Clinical assessment and diagnostic options are similar for those of the superfi-
cial digital muscle.
12.5.2.3 Flexor Tendon Strain: Bowed Tendon

A condition termed “bowed tendon” has been described in racing Greyhounds (Blythe et al. 2007).
This is a strain injury of one or more of the tendons of mainly the superficial and occasionally deep
digital flexors of the thoracic limbs. The condition manifests clinically as a swelling on the palmar
surface of the foot extending from the level of the accessory carpal bone to the level of the metacar-
pal footpad. Palpation of the affected tendon evokes pain and the tendon may feel thickened and
more prominent than the adjacent, unaffected tendons.
12.6 Conditions of the Digital and Paw Pads
12.6.1 Trauma
Laceration of the metacarpal pad has been ascribed to be the most common traumatic injury in
working dogs and pets. In one study, concurrent injuries were uncommon, and the prognosis
remained favorable even for full-thickness injuries, regardless of treatment (Hansen et al. 2015).
Diagnosis can generally be established by careful visual inspection and palpation. Concurrent
damage to underlying structures, such as the flexor tendons, needs to be investigated; this can be
accomplished by blunt probing through the laceration while extending the toes or through use of
ultrasound. Radiographs may be required to detect radiopaque foreign bodies and to investigate
the underlying osseous structures for osteomyelitis.
Aside from laceration, other traumatic injuries to the digital and paw pads include foreign bod-
ies, blistering from hot surfaces, chemical damage (e.g. walking through wet cement or undiluted
surface disinfectants), maceration when pads remain wet for extended periods, abrasions, and
ulcerations. Specifically, ulcerations (Figure 12.9F) often occur when dogs are exposed to hard
surfaces that they are not conditioned to, or through overuse in runs with cement floors such as
found in communities of highly active and driven dogs (e.g. police and military work dogs). In
such cases, the keratinized epidermis is worn away, leaving the sensitive dermis exposed (“hot
spots”) and can cause dogs to show a more pronounced lameness when walking on paved surfaces.
Therefore, establishing a diagnosis may require walking affected animals on soft surfaces or don-
ning paw covers to determine if the lameness disappears.
12.6.2 Corns
Corns are well-circumscribed hyperkeratotic lesions with a central, often conical core of kera-
tin. The validity of the term “corn” has been questioned since in people, corns are generally
non-painful. Other terminology suggested includes “wart-like lesion” or “Porokeratosis planta-
ris discreta” (Balara et al. 2009). The lesions appear as white, flat, and circular thickened areas
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(A) (B) (C)
(D) (E) (F)
Figure 12.9 Pad conditions: (A) corns; (B) paw pad hyperkeratosis; (C) pad overgrowth from abnormal
weight-bearing; (D) pemphigus foliaceus; (E) superficial necrolytic dermatitis; and (F) digital pad ulceration.
on the pads (Figure 12.9A). Sight hounds, especially Greyhounds, are prone to developing these
lesions, perhaps because of the anatomical differences of these dogs compared to other breeds
(i.e. long narrow feet with little distance separating the digital pads). The lesions may be inci-
dental findings or may be painful and cause lameness. They occur most often (90%) on the digi-
tal pads of digits 3 and 4 of the thoracic limbs but can appear on the metacarpal and metatarsal
pads as well (Guilliard et al. 2010). Their etiology is not known but hypothesized to be caused
by scar tissue related to trauma or foreign bodies, or hypertrophy of the eccrine sweat glands
due to pressure (Balara et al. 2009). Controversy exists as to whether they may be a result of a
papilloma virus infection (Balara et al. 2009; Anis et al. 2016).
Clinical signs of corns frequently include lameness when walking on hard surfaces and
excessively long nails due to the animal shifting its weight proximally onto its metacarpal/
metatarsal pads to mitigate discomfort. Radiographs are used to rule out radiopaque for-
eign bodies. The diagnosis is made by visual inspection and pain response during palpation,
12.6 Conditions of the Digital and Paw Pad 161
however, confirmation requires biopsy and histopathology. Treatment is controversial.

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Nonsurgical treatment, digital ostectomy, and surgical excision have been reported; notably,
surgical excision may be curative in some breeds, but recurrence is greater than 50% in
Greyhounds (Guilliard 2003; Balara et al. 2009).
12.6.3 Abnormal Wear and Migration

Although not a primary cause of lameness, some conditions associated with abnormal weight-
bearing on the paw (e.g. angular limb deformities, muscle and ligamentous conditions described
above, and joint conditions that limit limb mobility) may cause eccentric loading or abrasion of the
pads through abnormal motion, such as rotary movements. This may manifest as abnormal pad
wear, ulceration, and/or migration. Pads that do not bear weight may also appear overgrown
(Figure 12.9) or hyperkeratotic. The pads may then become secondary sources of pain and lame-
ness. The attending clinician needs to distinguish between a primary paw problem and a paw
manifestation of a distant condition of that limb.
12.6.4 Dermatologic Conditions Causing Lameness

Many dermatologic conditions can be associated with lameness or altered ambulation if they
affect the distal limb region (Figure 12.10). A few select conditions are presented below; the
reader is encouraged to refer to comprehensive texts for more detailed information (Duclos 2013;
Outerbridge 2013).
(A) (B)
(D) (E) (C)
Figure 12.10 Dermatologic conditions causing lameness: (A) interdigital dermatitis (pododermatitis);
(B) foreign body with draining sinus; (C) acral lick dermatitis; (D) paronychia; and (E) symmetrical lupoid
onychodystrophy/onychitis.
12.6.4.1 Pemphigus Foliaceus

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Pemphigus foliaceus is one of the most commonly reported immune-mediated dermatoses in dogs
and is known to affect multiple sites, but in rare cases the footpad may be the only site affected.
When it occurs on the footpads, it may cause lameness, because of changes to the pad that include
thickening due to swelling and hyperkeratosis with scaling, crusting, hardening, and fissuring
(Mueller et al. 2006). Severe cases may exhibit purulent exudate from beneath hyperkeratotic foot-
pad crusts. Cytology of purulent exudate may demonstrate acantholytic keratinocytes. Diagnosis is
generally confirmed by histopathology.
12.6.4.2 Superficial Necrolytic Dermatitis

Superficial necrolytic dermatitis, also called “necrolytic migratory erythema” and “metabolic epi-
dermal necrosis,” is an uncommon skin disorder associated with a systemic disease. Although
most commonly ascribed to a hepatic disease (hepatocutaneous syndrome), it is also associated
with pancreatic glucagonoma, phenobarbital use, and intestinal conditions. Hypoaminoacidemia
appears to be the common pathophysiological pathway. Shetland Sheepdogs, West Highland White
Terriers, Cocker Spaniels, and Scottish Terriers may be predisposed. Older animals are most com-
monly affected. Lameness and licking of the footpads are often the first signs of the condition.
Typically affecting all the feet, superficial necrolytic dermatitis may also cause the pads to become
hyperkeratotic, crusted, and fissured with secondary bacterial infections. Occasionally the skin of
the muzzle, perineum, elbows, or hocks is also affected. Diagnosis is confirmed with skin biopsy.
Elevated liver chemistry values and ultrasound confirming hepatopathy when accompanied by
pad and skin lesion are highly suggestive of the syndrome (Outerbridge 2013).
12.6.4.3 Paw Pad Hyperkeratosis

Hyperkeratosis of the footpads is familial in Irish Setters, Kerry Blue Terriers, Dogue de Bourdeaux,
and Golden Retrievers, but may also be associated with canine distemper virus (Duclos 2013). The
condition affects all pads and generally presents in 4- to 6-month-old puppies. It is characterized
by a defect of keratinization, causing excessive keratin of the paw pads (Figure 12.9B). The paw
pad keratin presents as hard vegetative, feathered, and fissured projections of horny tissue. Some
affected individuals may be very lame. A tentative diagnosis can be made based on the signalment
and clinical appearance, but confirmation requires histopathology. An idiopathic nasodigital form
which also involves the nasal planum is described in Labrador Retrievers.
12.6.4.4 Zinc-responsive Dermatoses

Zinc-responsive dermatosis is a systemic keratosis that may result in thickening, scaling, and crust-
ing of the pads in approximately one-third of affected dogs (White et al. 2001). Similar changes are
seen on other areas of skin, particularly the facial skin. The condition is described in genetically
predisposed breeds such as Siberian Huskies and Alaskan Malamutes, as well as in rapid growing
large- and giant-breed puppies fed zinc (Zn)-deficient diets. The disease may require biopsies to
confirm the diagnosis (Outerbridge 2013). In genetically predisposed animals, supplementation
with elemental Zn is often curative. In the dietary deficient cases, correcting the diet is curative.
12.7 Conditions of the Digit/Paw Skin
12.7.1 Interdigital Web Injuries

Interdigital web injuries have been most clearly described in racing Greyhounds (Blythe et al.
2007) but can occur in any breed of dog. Injuries include laceration, stabs, foreign body penetra-
tions, and splits between adjacent digits. Such injuries often heal slowly and are vulnerable to
12.8 Conditions of the Claw 163
reinjury because the healed tissue lacks the pliability and durability of the uninjured tissue.
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Unattended lesions that produce excessive granulation tissue leading to large fibrous scars and
exaggerated cicatricial contraction may deform the interdigital skin, making it less distensible and
interfere with individual digit movement. This interdigital deformation may itself result in lame-
ness. Radiographs and ultrasound might be helpful to detect underlying bone involvement and to
locate foreign bodies.
12.7.2 Pododermatitis
Pododermatitis (Figure 12.10a) is a nonspecific term to describe several inflammatory conditions
that affect the skin of the paws (Breathnach et al. 2008; Duclos 2013). There are multiple causes for
the condition: allergic dermatitis, foreign bodies, mechanical or chemical trauma, fungal and para-
sitic infections, in addition to psychogenic or idiopathic sterile pyogranulomas. Bacterial infection
is usually secondary. Tissues that may be affected include the interdigital skin, paw pads, nails, and
nail folds. Clinical signs include pruritus, edema, swelling, erythema, alopecia, paronychia, detach-
ing or detached claws, and serous, hemorrhagic, or purulent discharge. A single, or multiple, digits
or feet may be affected, and the degree of lameness varies.
12.7.3 Acral Lick Dermatitis

Acral lick dermatitis (or acral lick furunculosis/granuloma) is a condition characterized by excessive
licking of the distal limb region of the front limbs, although the pelvic limbs may be affected occa-
sionally (Shumaker 2019). The condition has multiple causes and may be precipitated by allergies,
behavioral, or underlying orthopedic conditions that cause pruritus or pain. Occasionally a tumor,
foreign body (Figure 12.10b), injury, or opportunistic fungal infection may be the inciting cause. The
condition is often associated with a deep staphylococcal and/or mixed bacterial infection, either pri-
marily, or through secondary invasion. The Doberman Pinscher, German Shepherd Dog, Golden and
Labrador Retrievers, Great Dane, Weimaraner, and Irish setters are reported to be predisposed.
Incessant licking produces lesions which appear as firm, raised, erythematous, and erosive plaques
initially. With chronicity, these become more extensive, thickened, hairless, hyperpigmented, and
ulcerated with scattered furuncles which erode and weep exudate. Diagnosis is generally confirmed
by clinical appearance (Figure 12.10c). Radiography is indicated to identify underlying bone reaction
and involvement, as well as to establish an underlying cause for the licking (e.g. joint disease). Tissue
culture is recommended in severe cases for assessment and treatment of deep bacterial, or rarely,
fungal infection. Treatment is aimed at identifying the underlying disease, treating the primary dis-
ease (if possible) as well as the secondary infection (if present), and stopping the licking behavior
(Shumaker 2019).
12.8 Conditions of the Claws
Conditions of the claws are easily overlooked and often subtle, but they can be the primary cause
of lameness (Mueller 1999). Excessively long claws may predispose animals to claw, digital, and
musculotendinous injury as well as pododermatitis, all of which may lead to lameness. In addition,
abnormal nail wear may indicate other conditions causing a lameness. For example, causes of
excessively short nails due to abnormal wear include neurological conditions causing loss of con-
scious proprioception, conditions which cause abnormal foot carriage (e.g. dorsal curvature of the
radius due to premature closure of the distal ulna growth plate), and conditions which cause the
animal to “drag” its feet during the swing phase (e.g. severe bilateral, painful osteoarthritis of the
stifles). Excessively long nails may be due to reduced wear, for example after injury to the digital
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flexor tendons resulting in diminished downward rotation of the digit.
12.8.1 Trauma
Trauma (such as traumatic split, cracked, bruised, and avulsed claws) is a frequent cause of claw
injury and associated lameness. It usually affects a single, or only a small number of claws. To
establish a diagnosis, the claw should be carefully observed for integrity and color abnormalities,
palpated for pain, and pulled away from the nail bed to determine the firmness of its attachment.
12.8.2 Paronychia
Paronychia describes a nonspecific inflammation of the claw fold (Mueller 1999) whereby the nail
bed becomes swollen, red, and painful, with possible purulent discharge (Figure 12.10d). The area
is usually very sensitive to palpation. There are numerous causes for this condition; trauma is con-
sidered the most common primary cause, while bacterial infections are usually secondary. An
allergic or immune-mediated cause is also common. In addition to the examination, skin scrapings
for Demodex, exudate cytology, bacterial and fungal culture, and fine-needle aspirates (FNAs) may
be indicated. Radiographs of the affected digit are useful to identify any underlying bone involve-
ment. Paronychia may lead to deformity and accelerated growth of the claw.
12.8.3 Deformed Claws

Deformed claws usually indicate previous, unappreciated physical injury to, infection, or immune
insult of the nail bed. They may also cause lameness via various mechanisms. For example,
although claws may not be painful themselves, they may impinge on adjacent skin causing abra-
sion and pain. Accelerated growth of the claw may lead to ingrown claws, where the apex curves
back and impinges on the adjacent digital footpad or skin.
12.8.4 Symmetrical Lupoid Onychodystrophy

Symmetrical lupoid onychodystrophy/onychitis, also called symmetrical onychomadesis (Ziener
and Nødtvedt 2014), is a claw-specific disease of mainly young to middle-aged dogs. Gordon Setters
and German Shepherd Dogs appear to be predisposed. The usual presentation is licking of the
paws, lameness, and sloughing of the affected claw(s). Inspection of the claw reveals paronychia
and separation or sloughing of the claw. Claws may be dry, roughened, short, and misshapen as
they regrow (Figure 12.10E). The condition usually progresses until all claws are affected. A puru-
lent discharge may be present due to secondary bacterial infection. Diagnosis is based on signal-
ment, clinical appearance, and the absence of clinical manifestation elsewhere. Diagnosis can be
confirmed histopathologically. Treatment is difficult but involves removal of damaged claw plates,
treatment of secondary infections, as well as pharmacologic therapy to allow for regrowth of nor-
mal claws (Ziener and Nødtvedt 2014).
12.9 Other Conditions Affecting the Distal Limb Region
12.9.1 Neurological Conditions

Neurological conditions causing lameness and proprioceptive deficits (Chapters 16 and 21) may
cause abnormal claw (Figure 4.4) and footpad wear or result in abrasive damage to the dorsal
aspect of the digital skin. Neurological conditions may also manifest in hyper- or paresthesia, with
12.9 Other Conditions Affecting the Distal Limb Regio 165
resultant foot mutilation, poor or nonhealing wounds, and profound atrophy of the soft tissues
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including muscles and tendons, with resultant osteopenia of the underlying bones of the affected
region. It is important that the attending clinician performs a careful neurological examination to
identify such conditions.
12.9.2 Dysostoses
Dysostoses are constitutional bone diseases characterized by abnormal development of individual
bones, or parts of bones. Examples of dysostoses include hemimelia (the congenital absence of a
part or all of one or more bones), dimelia (the duplication of the whole or part of limb), ectrodac-
tyly (congenital split formation or separation between metacarpal bones, also called “split-hand
deformity”), polydactyly (the occurrence of one or more extra digits), and syndactyly (the partial
or complete lack of separation between adjacent digits). Each of these conditions can cause lame-
ness. Diagnosis is made through clinical examination and confirmed with radiographs. Treatment
of these conditions depends on the severity of the disease and the clinical symptoms and may
include surgical correction (Towle-Millard and Breur 2018).
12.9.3 Hypertrophic Osteopathy

Hypertrophic osteopathy, also called Marie’s disease or hypertrophic pulmonary osteoarthropa-
thy, is characterized by the proliferation of periosteal new bone of especially the distal extremi-
ties (Figure 12.11). These distinct osseous changes are generally bilaterally symmetrical and
involve all four limbs. They occur secondary to a separate disease process within the thorax or
(A) (B) (C)
Figure 12.11 Hypertrophic osteopathy: (A, B) radiographs of the thoracic limb show smooth and irregular
palisading periosteal reaction along the cortices of the long bones (white arrows) with associated soft
tissue swelling; (C) chest radiographs reveal an extrapleural thoracic wall mass (black arrow) and
pulmonary nodules. The dog had previously received a thoracic limb amputation for treatment of
appendicular osteosarcoma.
abdomen. The pathophysiology is still unknown; however, it may be due to a neurally or growth
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factor-mediated increase in peripheral blood flow. Hypertrophic osteopathy is typically a

paraneoplastic condition, secondary to pulmonary neoplasia (Withers et al. 2015). However,
various other conditions have been described as causes for hypertrophic osteopathy including
extrapulmonary causes, such as esophageal granuloma formation secondary to Spirocerca lupi,
right–left shunting, esophageal foreign bodies, and various abdominal neoplasia. The bony pro-
liferation is associated with pain during early stages of the disease, such that this together with
the thickening of the tissues, frequently causes lameness or difficulty ambulating. Other clini-
cal signs may include coughing, hyperthermia, weight loss, and depression. These signs often
precede signs associated with the primary disease. In a recent retrospective study, more than
half of the dogs with hypertrophic osteopathy displayed bilateral ocular discharge (Withers
et al. 2015).
Diagnostic investigation should include thoracic and abdominal radiographs in addition to ultra-
sound for identification of the primary cause. Radiographs of affected limbs show periosteal bone
formation in a circumferential and columnar (“palisade-like”) appearance. Initially, new bone for-
mation will be absent or minimal. Treatment requires management of the primary condition. The
osseous lesions resolve spontaneous if successful treatment of the primary disease can be
accomplished.
12.9.4 Metabolic Bone Diseases

Metabolic bone diseases are rare conditions which affect calcium, phosphorus, and vitamin D
metabolism. These can occur as a result of inappropriate nutrition, including deficiencies in cal-
cium and/or phosphorous, hypo- or hypervitaminosis A and D, and hypovitaminosis E. They may
also involve abnormal metabolism or production of these mineral and vitamins, such as primary
and secondary (renal) hyperparathyroidism, chronic renal failure, and intestinal malabsorption
conditions. These diseases tend to result in generalized bone conditions that may result in lame-
ness, such as osteopenia, osteomalacia, pathological (spontaneous) fractures, fragile (“brittle”)
bones, deformed limbs, and excessive new bone production.
12.9.5 Distal Limb Region Neoplasia

Digit neoplasia is the most common tumor encountered in the distal limb region. Digital squa-
mous cell carcinomas frequently cause bone lysis, whereas melanoma does not. Further details
about digit tumors and other neoplastic conditions affecting the region are described in Chapter 11.
References
Anis, E.A., Frank, L.A., Francisco, R., and Kania, S.A. (2016). Identification of canine papillomavirus
by PCR in Greyhound dogs. Peer J 4: e2744.
Balara, J.M., Mccarthy, R.J., Kiupel, M. et al. (2009). Clinical, histologic, and immunohistochemical
characterization of wart-like lesions on the paw pads of dogs: 24 cases (2000–2007). J Am Vet Med
Assoc 234 (12): 1555–1558.
Boemo, C.M. (1998). Injuries of the metacarpus and metatarsus. In: Canine Sports Medicine and
Surgery (eds. M.S. Bloomberg, J.F. Dee and R.A. Taylor), 150–165. Philadelphia: Saunders.
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Blythe, L.L., Gannon, J.R., Craig, A.M. and Fegan, D.F., 2007. “Break-in” or “schooling”. In: Care of the
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Racing and Retired Greyhound, 1, 231–278. Abilene, KS: American Greyhound Council.
Breathnach, R.M., Fanning, S., Mulcahy, G. et al. (2008). Canine pododermatitis and idiopathic
disease. Vet J 176 (2): 146–157.
Cake, M. and Read, R. (1995). Canine and human sesamoid disease. A review of conditions affecting
the palmar metacarpal/metatarsal sesamoid bones. Vet Comp Orthop Traumatol 8 (2): 70–75.
Daniel, A., Read, R.A., and Cake, M.A. (2008). Vascular foramina of the metacarpophalangeal
sesamoid bones of Greyhounds and their relationship to sesamoid disease. Am J Vet Res 69 (6):
716–721.
DeCamp, C.E., Johnston, S.A., Déjardin, L.M., and Schaefer, S.L. (2016). Fractures and other
orthopedic conditions of the carpus, metacarpus, and phalanges. In: Brinker, Piermattei, and Flo’s
Handbook of Small Animal Orthopedics and Fracture Repair, 5e (eds. C.E. DeCamp, S.A. Johnston,
L.M. Déjardin and S.L. Schaefer), 389–433. St. Louis: Elsevier.
Duclos, D. (2013). Canine pododermatitis. Vet Clin North Am Small Anim Pract 43 (1): 57–87.
Eaton-Wells, R. (1998). Injuries of the digits and pads. In: Canine Sports Medicine and Surgery (eds.
M.S. Bloomberg, J.F. Dee and R.A. Taylor), 165–173. Philadelphia: Saunders.
Franklin, S.P., Park, R.D., and Egger, E.L. (2009). Metacarpophalangeal and metatarsophalangeal
osteoarthritis in 49 dogs. J Am Anim Hosp Assoc 45 (3): 112–117.
Guilliard, M.J. (2003). Proximal interphalangeal joint instability in the dog. J Small Anim Pract 44 (9):
399–403.
Guilliard, M.J., Segboer, I., and Shearer, D.H. (2010). Corns in dogs; signalment, possible aetiology and
response to surgical treatment. J Small Anim Pract 51 (3): 162–168.
Hansen, L.A., Hazenfield, K.M., Olea-Popelka, F., and Smeak, D.D. (2015). Distribution, complications,
and outcome of footpad injuries in pet and military working dogs. J Am Anim Hosp Assoc 51 (4):
222–230.
Kornmayer, M., Failing, K., and Matis, U. (2014). Long-term prognosis of metacarpal and metatarsal
fractures in dogs. A retrospective analysis of medical histories in 100 re-evaluated patients. Vet
Mathews, K.G., Koblik, P.D., Whitehair, J.G. et al. (2001). Fragmented palmar metacarpophalangeal
sesamoids in dogs: a long-term evaluation. Vet Comp Orthop Traumatol 14 (1): 7–14.
Mueller, R.S. (1999). Diagnosis and management of canine claw diseases. Vet Clin North Am Small
Anim Pract 29 (6): 1357–1371.
Mueller, R.S., Krebs, I., Power, H.T., and Fieseler, K.V. (2006). Pemphigus foliaceus in 91 dogs. J Am
Anim Hosp Assoc 42 (3): 189–196.
Nielsen, C., Stover, S.M., Schulz, K.S. et al. (2003). Two-dimensional link-segment model of the
thoracic limb of dogs at a walk. Am J Vet Res 64 (5): 609–617.
Outerbridge, C.A. (2013). Cutaneous manifestations of internal diseases. Vet Clin North Am Small
Anim Pract 43 (1): 135–152.
Read, R.A., Black, A.P., Armstrong, S.J. et al. (1992). Incidence and clinical significance of sesamoid
disease in Rottweilers. Vet Rec 130 (24): 533–535.
Shumaker, A.K. (2019). Diagnosis and treatment of canine acral lick dermatitis. Vet Clin North Am
Small Anim Pract 49 (1): 105–123.
Towle Millard, H.A. and Breur, G.J. (2018). Miscellaneous orthopedic conditions. In: Veterinary
Surgery: Small Animal, 2e (eds. S.A. Johnston and K.M. Tobias), 1299–1315. St. Louis: Elsevier.
Vaughan, L.C. and France, C. (1986). Abnormalities of the volar and plantar sesamoid bones in
Rottweilers. J Small Anim Pract 27 (9): 551–558.
White, S.D., Bourdeau, P., Rosychuk, R.A. et al. (2001). Zinc-responsive dermatosis in dogs: 41 cases
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Withers, S.S., Johnson, E.G., Culp, W.T.N. et al. (2015). Paraneoplastic hypertrophic osteopathy in 30
dogs. Vet Comp Oncol 13 (3): 157–165.
Ziener, M.L. and Nødtvedt, A. (2014). A treatment study of canine symmetrical onychomadesis
(symmetrical lupoid onychodystrophy) comparing fish oil and cyclosporine supplementation in
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Part IV
Thoracic Limb Lameness

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171
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13
Carpal Region
CA R PA L R E G I O N
Denis J. Marcellin-Little1 and Dirsko J.F. von Pfeil2,3
1
Department of Veterinary Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, CA, USA
2
Small Animal Surgery Locum PLLC, Dallas, TX, USA
3
13.1 Introduction and Common Differential Diagnoses
The carpus connects the antebrachium to the manus. Overall in dogs, carpal region pathology is
less common than elbow or shoulder pathology. The carpus is prone to instability, particularly
excessive extension secondary to damage to the palmar ligaments. The carpus is also a common
site of inflammation (e.g. immune-mediated polyarthritis [IMPA]). Carpal osteoarthritis is com-
mon and may occur as primary osteoarthritis (i.e. without an underlying disease) or secondary
osteoarthritis (e.g. secondary to carpal hyperextension or other primary conditions). The identifi-
cation of carpal problems most commonly relies on palpation, radiographs, and computed tomog-
raphy (CT); MRI and ultrasound are helpful if soft tissue pathology is suspected. Figure 13.1 and
Table 13.1 outline common differential diagnoses and diagnostic steps for this region.
13.2 Normal Anatomy and Osteoarthritis
The carpus is a complex joint that allows motion at three levels: antebrachiocarpal, middle carpal,
and carpometacarpal (Figure 13.2). The carpus includes 14 bones: the distal aspect of the radius and
ulna, proximal carpal row (intermedioradial carpal bone, ulnar carpal bone, and accessory carpal
bone), distal carpal row (first, second, third, and fourth carpal bones), and the proximal aspect of the
five metacarpal bones. The intermedioradial carpal bone (frequently referred to as radial carpal bone)
is the largest of the carpal bones. The carpus functions mostly in flexion and extension, with approxi-
mately 170° of sagittal plane motion. The carpus is the only limb joint that functions past a straight
line (i.e. 180°). All other joints extend to approximately 165° and stop short of a straight line. By
comparison, the carpus extends 15–20° past a straight line to almost 200° (Jaegger et al. 2002).
Extension is limited by the palmar fibrocartilage, by the radiocarpal and ulnocarpal ligaments, and,
to a lesser extent, by the medial and the lateral collateral ligaments (Slocum and Devine 1982;
Milgram et al. 2012). Approximately 70% of carpal motion occurs at the antebrachiocarpal joint level,
25% at the middle carpal joint level, and 5% at the carpometacarpal joint level (Yalden 1970).

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Table 13.1 Key features for selected diseases affecting the carpal region.
Diagnostic test of
Disease Common signalment choice Exam findings Treatment Clinical pearls Terminology
Hyperextension All breeds Stress radiographs Increased carpal Mild injuries are protected Conservative
injury extension with a brace or splint. management most
Arthrodesis for severe often fails
injuries
Carpal bone Racing and sporting Computed Swelling and loss Bone screws placed with Use intraoperative
fractures dogs tomography of carpal flexion precision fluoroscopy to enhance
precision of screw
placement
Distal R/U Toy-breed dogs Radiographs Swelling, pain, and Surgical Fixation Frequently happen
fractures obvious instability without substantial
trauma
Antebrachial Chondrodystrophic Palpation, Varus or valgus, External fixation or bone Deformities should be Valgus = lateral
deformities dogs and physeal radiography, and length deficit, and plate treated promptly, deviation
injuries computed elbow joint before the onset of joint Varus = medial
tomography subluxation subluxation deviation
Lack or loss of Large-breed growing Gait observation Lack of extension Conservative, coaptation, Optimize growth in Flexural deformity
carpal extension dogs and goniometry and exercise growing dogs by and carpal laxity
decreasing food intake syndrome
Immune-mediated Large-breed Radiographs and Effusion, pain, and Immunosuppressive drugs Severe carpal effusion
polyarthritis (nonerosive) and arthrocentesis hyperextension and pancarpal arthrodesis suggests polyarthritis
small-breed (erosive) Instability suggests that
polyarthritis is erosive
Hypertrophic Large-breed puppies Clinical signs and Metaphyseal pain Supportive care Most patients will
osteodystrophy radiographs and swelling and recover
(HOD) hyperthermia Antebrachial
deformities can occur as
a consequence of HOD
0004507096.INDD 172 12/10/2019 1:28:02 PM

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Septic arthritis
Carpal luxation Visible

History of
abnormality
trauma
Immune-
Consider to establish mediated
diagnosis polyarthritis
Carpal joint
Fracture dislocation
Arthrocentesis Non-calcifying
X-rays X-rays tendinopathy
Incomplete abnormal normal
ossification of Fracture/fissure line
radial carpal
bone Ultrasound/MRI Carpal
hyperextension
Articular degenerative
changes
Osteoarthritis
Stress radiographs Collateral
Pain in ligament injury
Osseous Angular limb carpal
deformities/ deformity region
premature Incomplete
physeal closure CT ossification of
radial carpal
Lytic lesion bone
Osseous
History of
neoplasia Visual observation/ Minimally
trauma
Soft tissue examination displaced
Regional tendinopathies: fracture
calcification
• Flexor carpi ulnaris
Calcifying • Abductor pollicis longus
tendinopathy
Juvenile
FNA
dog
“Double physis” Flexor deformity
Hypertrophic
osteodystrophy
Soft tissue
neoplasia
Figure 13.1 Schematic of common diseases affecting the carpal region and the steps necessary to establish a diagnosis.
174 13 Carpal Region
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(A) (C) (E)

(B) (D) (F)
Figure 13.2 Normal anatomy of the carpal joint depicted by radiographs of (A, B) an adult dog and of
(C–F) an immature dog: (a) radius; (b) ulna; (c) intermedioradial carpal bone; (d) ulnar carpal bone; (e) first
carpal bone; (f) second carpal bone; (g) third carpal bone; (h) fourth carpal bone; (i) accessory carpal bone;
(j) first metacarpal bone; (k) second metacarpal bone; (l) third metacarpal bone; (m) fourth metacarpal
bone; (n) fifth metacarpal bone; (o) sesamoid bone of abductor pollicis longus muscle; (p) antebrachiocarpal
joint; (q) middle carpal joint; (r) carpometacarpal joint; (s) distal radial physis; and (t) distal ulnar physis.
The carpus has a slight lateral (valgus) orientation of 5° (Goodrich et al. 2014) and allows approx-
imately 20° of motion in the frontal plane (Jaegger et al. 2002). A small amount of pronation and
supination occurs within the carpus but has not been differentiated from the pronation and
supination that occurs within the antebrachium.
Osteoarthritis of the carpus can result from a variety of causes such as the subluxation present
in dogs with chondrodystrophy (Theyse et al. 2005), joint instability (e.g. hyperextension injury
and collateral ligament injury), intra-articular fracture, IMPA, or the presence of deep wounds
including shearing injuries. Treatment of carpal osteoarthritis ranges from nonsurgical manage-
ment to carpal arthrodesis.
13.3 Fractures of the Carpal Regio 175
13.2.1 Immune-Mediated Polyarthritis

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The carpus is a common site of IMPA including erosive (i.e. radiographic evidence of bone lysis) and
nonerosive (i.e. lack of erosive radiographic changes) forms of the disease. In contrast to other dif-
ferential diagnoses (e.g. septic arthritis, neoplasia, and degenerative joint disease), immune-medi-
ated diseases generally affect multiple joints, most frequently the distal joints (i.e. carpi and tarsi).
Treatment consists of immunosuppressive drug therapy or carpal arthrodesis, if pain is severe.
Non-erosive polyarthritis can occur in all breeds but tends to affect middle-aged large-breed dogs
(Johnson and Mackin 2012). It can be idiopathic (Type I), which is the most common form, or
secondary to amyloidosis (Shar-Peis), to receiving sulfa drugs (Doberman Pinschers), or to the
presence of neoplasia (Type IV), enterohepatic disease (Type III), or other chronic diseases,
particularly infectious diseases (Type II). The clinical signs of polyarthritis vary but may include
reluctance to walk, stiffness, vocalizing, exercise intolerance, and systemic signs such as inap-
petence and pyrexia. In one study, 40% of dogs with fever of unknown origin were diagnosed
with polyarthritis (Lunn 2001). Lameness may be mild to severe and shift from one leg to another
but frequently affects both thoracic limbs. Loss of carpal joint flexion secondary to carpal effu-
sion, and pain response may be present; however, in one study, only 40% of dogs showed joint
pain (Jacques et al. 2002). Besides joint effusion, the diagnosis of nonerosive polyarthritis relies
on the lack of radiographic changes (Figure 13.3) and arthrocentesis showing suppurative
inflammation without evidence of infection (Chapter 9). The most commonly affected joints are
the tarsi, carpi, and the stifle. Aspiration of these joints is generally recommended (Johnson and
Mackin 2012) since some dogs with polyarthritis do not have palpable carpal effusion or show
signs of pain, so it is important to collect joint fluid when polyarthritis is suspected, even if effu-
sion is not detected. It is also important to collect joint fluid to evaluate the response to therapy
regardless of the presence or absence of effusion.
Erosive polyarthritis, also termed rheumatoid arthritis, tends to occur in smaller dogs and is rare.
In one study, all dogs with erosive polyarthritis had erosive lesions of the carpal joint
(Shaughnessy et al. 2016). The diagnosis of erosive polyarthritis relies on radiographs (to diag-
nose erosive lesions) in combination with joint fluid analysis. Carpal joint instability and hyper-
extension may occur secondarily. A juvenile form of polyarthritis has been reported in Akitas
(Dougherty et al. 1991).
13.3 Fractures of the Carpal Region
Fractures of the carpal region (Figure 13.4) include fractures of the distal aspect of the radius and
ulna, particularly Salter-Harris (SH) fractures of the distal radial and ulnar physes, as well as frac-
tures of the carpal bones. Physeal fractures of the distal radial and ulnar physes appear to be the
most common physeal fractures in dogs (Marretta and Schrader 1983). These fractures are generally
classified using the SH classification system (Figure 13.5). In the radius, fractures across the distal
radial physis without (SH Type I) or with a metaphyseal bone fragment (SH Type II) and asymmetric
compressive lesions leading to premature physeal closure (described as SH Type VI) are most com-
mon. Physeal distal radial fractures that involve the articular surface without (SH Type III) or with
a metaphyseal bone fragment (SH Type IV) rarely occur. In the ulna, the distal physis is cone-shaped
and excessive bending leads to a compressive injury on one side of the cone and secondary prema-
ture closure (SH Type V). Since these distal ulna fractures frequently lead to angular limb deformity
due to premature growth plate closure, their identification prior to the development of deformities
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(A) (C) (E)

(F)
(B) (D)
(G)
Figure 13.3 Immune-mediated polyarthritis: (A, B) dog with nonerosive polyarthritis; (C–F) dog with
erosive polyarthritis: (A) lateral view of the carpus with (white arrow) soft tissue opacity; (B) no lytic
osseous changes are seen; (C, D) note the (white arrow) soft tissue opacity and lytic osseous changes; (E, F)
visible, severe carpal joint effusion; (G) joint effusion is best palpated dorsally by identifying the extent of
the distal radius during flexion, identifying the joint space.
is crucial. In dogs with unilateral problems, comparing the length and geometry of the ulna and
radius from both thoracic limbs greatly facilitates the assessment. Surgical treatment options that
may prevent the development or limit the severity of deformities (e.g. distal ulnar ostectomy) are
available, although they are only effective if performed while growth potential remains.
Carpal bone fractures are rare overall and most commonly occur in sporting dogs. Among these,
accessory carpal bone fractures are among the most common fractures seen in racing Greyhounds.
Accessory carpal bone fractures have been classified into Type I–V based on the avulsed or crushed
portion of the bone (Johnson 1987; Johnson et al. 1989). To detect damage to the accessory carpal
bone, digital pressure is applied to the bone while slowly extending the carpus. Radial carpal bone
fractures have been seldom reported (Li et al. 2000; Tomlin et al. 2001). Incomplete ossification of the
13.3 Fractures of the Carpal Regio 177
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(E)
(A) (C) (F)
(B) (D) (G)
Figure 13.4 Radial fractures: (A, B) distal radius ulna fracture; (C, D) SH Type I fracture of the distal radius,
note the widening of the physis (black arrow) and soft tissue swelling (white arrow), (E) is the contralateral
normal limb for comparison; (F, G) SH Type II fracture of the distal radius: the white arrow indicates the
metaphyseal portion.
radial carpal bone has been suggested as an underlying etiology (Gnudi et al. 2003; Perry et al. 2010).
An ulnar carpal bone fracture has been reported in a Labrador Retriever (Vedrine 2013). A slab frac-
ture of the fourth carpal bone has been reported in a racing Greyhound (Rutherford and Ness 2012).
13.3.1 Signalment and History

Traumatic fractures may be observed in any breed or age of dog. Distal radius/ulna fractures are
frequently observed in Toy-breed dogs without a history of trauma. Commonly, these fractures or
observed after falling or minor jumping (e.g. off the couch). This is related to the proportionally
reduced cross-sectional diameter of the distal radius in these dogs (Brianza et al. 2006) compared
to large-breed dogs, who more frequently sustain carpal hyperextension injuries instead.
(A) (B) Figure 13.5 Salter-Harris (SH) fracture classification: the

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SH classification is intended for fractures in juveniles that

are involving variable components of the (a) metaphysis,
(b) epiphysis, and (c) physis. (A) SH Type I fractures describe
a fracture directly though the physis without a fracture
component of the metaphysis or epiphysis. (B) A Type II
fracture, which is the most common physeal fracture type
in dogs, involves the physis and a portion of the
metaphysis. (C) Type III fractures involve a portion of the
physis and epiphysis and, therefore, are articular fractures.
(D) Type IV fractures involve all three components and,
therefore, are also a type of articular fracture. (E) Type V
fractures are symmetric, and (F) Type VI are asymmetric

(C) (D) compressive fractures of the physis, both of which cannot
initially be identified radiographically since no
displacement is present.
(E) (F)

Carpal fractures can lead to varying degrees of lameness from a mild, weight-bearing lameness to
a severe, toe-touching or non-weight-bearing lameness based on the potential loss of carpal sta-
bility. Slab fractures, chip fractures, and non-displaced carpal bone fractures often lead to mild
lameness that may be more severe after a period of rest (dogs “warm out of the lameness”) or after
a period of heavy exercise. Fractures with ligamentous disruptions and loss of carpal stability are
incompatible with weight-bearing and lead to a toe-touching stance and severe lameness. On
palpation, carpal fractures are associated with mild and focal swelling to severe and diffuse swell-
ing, based on carpal disruption. Swelling is generally most severe on the dorsal aspect of the joint.
Carpal flexion is decreased and range of motion generally elicits a pain response. To flex and
extend the carpus, the leg is held with one hand proximal to the carpus, and the other hand is
placed distal to it. Motion of the elbow and shoulder joints should be avoided when performing
the evaluation of the carpus to reduce a possible response from a painful source in these areas. A
normal carpus can be flexed to a point where the metacarpal pad contacts the caudal surface of
the antebrachium.
13.4 Carpal Hyperextension and Other Carpal Ligamentous Injurie 179
13.3.3 Diagnostics
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Suspected carpal fractures are investigated using orthogonal radiographs. Soft tissue swelling over
the carpus may be visible on radiographs. SH Type I fractures may be difficult to identify radio-
graphically if they are minimally displaced (Figure 13.4). Early after injury, SH Type V and VI
fractures are generally not visible radiographically, although soft tissue swelling may be present. If
the history and physical exam suggests that these fractures are present, serial radiographs (e.g.
every two weeks) should be performed since a few weeks later premature closure of the physis will
be visible. Ideally radiographs of both limbs are performed allowing to monitor for a length deficit
compared to the contralateral bone. The goal is to monitor for the development of secondary angu-
lar limb deformities and institute treatment early during the progression of the disease.
If the problem is chronic, focal periosteal reaction over the fracture site may be visible and the
joint may be osteoarthritic. For minimally displaced fractures, if the orientation of the radiographic
beam approximates the orientation of the fracture plane, a fracture line may be visible on radio-
graphs. CT greatly enhances the sensitivity and precision of the diagnosis of these fractures.
Incomplete ossification of the radial carpal bone may also not be visible on radiographs, and there-
fore a CT may be needed to diagnose the condition.
13.4 Carpal Hyperextension and Other Carpal

Ligamentous Injuries
Carpal hyperextension is the term used to describe an increase of carpal extension. Excessive car-
pal extension can be developmental or acquired. Acquired carpal hyperextension is a frequent
carpal joint problem that most often results from trauma (Bristow et al. 2015). The antebrachiocar-
pal joint is mainly stabilized by the radiocarpal and ulnarcarpal ligaments, the palmar carpal fibro-
cartilage stabilizes the distal carpal joints (Slocum and Devine 1982; Milgram et al. 2012), and the
accessory metacarpal ligament as well as the accessory carpoulnar ligaments stabilizes the acces-
sory carpal bone (Figure 13.6). With traumatic impact, the main structures supporting the normal
angulation of the carpus become damaged, leading to the typical presentation of a palmigrade
stance. Traumatic carpal hyperextension is generally treated with arthrodesis, since external coap-
tation does not seem to allow for healing of the ligaments. Depending on the level of injury, a
partial carpal (i.e. fusion of the distal carpal joints, leaving the antebrachiocarpal joint intact) or
pancarpal (i.e. fusion of all carpal joints) arthrodesis may be performed (Bristow et al. 2015).
Other, less common causes of carpal hyperextension include immune-mediated joint disease
and hyperadrenocorticism (Cushing’s syndrome; Parker et al. 1981; Lotsikas and Radasch 2006;
Shaughnessy et al. 2016). Immune-mediated mono- or polyarthritis may be associated with carpal
hyperextension and thus should be kept in mind during the diagnostic workup. Increased corticos-
teroid levels negatively impact tenocyte proliferation, inhibit collagen synthesis, decrease tenocyte
migration, and induce tendon cell apoptosis (Galdiero et al. 2014). In affected dogs, joint instability
and tendon rupture may also occur elsewhere.
Immobilization in a splint can also result in ligament laxity of the immobilized limb; in one
report, carpal hyperextension was observed in dogs after only 10 days of immobilization
(Altunatmaz and Guzel 2006).
Developmental carpal hyperextension is unusual but has been reported in growing Doberman
Pinchers and Shar-Peis and various other breeds including German Shepherd Dogs (GSD) (Shires
et al. 1985; Altunatmaz and Guzel 2006; Cetinkaya et al. 2007). The problem is often bilateral, and
in severe cases the tarsi can also be affected.
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(A) (C) (E)
(B)
(D) (F)
(G) (I)
(J)
(H)
Figure 13.6 Illustration of carpal hyperextension: (A, B) normal appearance for the (a) medial collateral ligament, (b) lateral collateral ligament, (c) accessory
metacarpal ligaments, (d) palmar radiocarpal ligament, (e) palmar ulnocarpal ligament, (f) intercarpal ligaments, (g) palmar fibrocartilage; (C, D) injury at the
level of the antebrachiocarpal joint (red arrow), the accessory carpal and ulnar carpal bones are in a normal position indicating disruption of the radiocarpal and
ulnocarpal ligaments only; (E, F) injury at the level of the middle carpal joint (red arrow) with proximal displacement of the accessory carpal bone and ulnar
carpal bone suggested by an increased joint space between the ulnar carpal bone and fourth carpal bone indicating disruption of several intercarpal ligaments.
In this dog, no disruption of the ligament between the accessory carpal and ulnar carpal bone is seen, indicating that the ligament connecting the two is intact;
(G, H) injury at the level of the middle carpal joint (red arrow) with proximal displacement of the accessory carpal bone and ulnar carpal bone suggested by an
increased joint space between the accessory carpal and ulnar carpal bone as well as between the ulnar carpal bone and fourth carpal bone indicating disruption
of several intercarpal ligaments, the ligament connecting the accessory carpal and ulnar carpal bone, and the accessory metacarpal ligaments; and (I, J) injury at
the level of the distal carpal (carpometacarpal) joint (white arrows) indicating disruption of the palmar fibrocartilage.
Other causes, including collateral ligament damage, fractures, and luxations of the carpal bones,
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as well as injuries to muscles and tendons traveling over the carpus, may also lead to chronic pain,
decreased carpal function, and carpal hyperextension. Subluxation or luxation of carpal bones
other than hyperextension injuries is rare. Luxations of the carpal joint are also rare but generally
associated with severe trauma.

Traumatic carpal hyperextension most often occurs in large-breed active dogs. However, small-
breed dogs can also be affected. Carpal hyperextension is most commonly associated with a fall,
jump, or motor vehicle accident (Denny and Barr 1991). Carpal injuries related to trauma can also
be seen in competitive agility dogs (Levy et al. 2009; Cullen et al. 2013). The angle of the A-frame
(a tall “contact” obstacle that agility dogs must overcome) has been hypothesized to be related to
carpal hyperextension injury in these dogs. However, a prospective study evaluating the landing
carpal extension angles refuted this hypothesis (Appelgrein et al. 2018). In that study, the antebra-
chiocarpal landing angle was approximately 240° for any given A-frame angle and it was concluded
that this angle likely represents the maximum physiological carpal extension angle when contact-
ing the A-frame.
Another cause for carpal injury could be from repetitive trauma as seen in Herding dogs (Jerram
et al. 2009). A similar etiology could be considered for long-distance sled dogs. Indeed, carpal
injury and an increased risk to be dropped from a team during marathon sled dog racing was found
to be associated with increased training miles (von Pfeil et al. 2015).
Carpal hyperextension and collateral ligament injuries have no specific predisposition for age,
weight, or breed. However, older working Collies have been suggested to potentially be predis-
posed to progressive degenerative hyperextension as a result of chronic, repetitive carpal injury
(Jerram et al. 2009).
Regardless of the specific underlying traumatic cause, acutely affected dogs are in pain and
exhibit varying degrees of lameness of the affected leg. Carpal swelling can be present, particularly
if the injury is acute. Once the condition is more chronic, there is typically less discomfort. The
main abnormality noted by owners is hyperextension and lameness of the affected thoracic limb.
Depending on the severity of the injury, the degree of hyperextension can be mild or severe. In
severe situations, patients may develop a palmigrade stance with the accessory carpal bone in con-
tact with the ground (Video 13.1).
Video 13.1:
Video of patients with carpal hyperextension (traumatic and due to immune-mediated polyarthritis).

Lameness can vary in severity, depending on the amount and location of damage and chronicity.
The contralateral side is used to compare the carpal angle and the presence of swelling. Upon
palpation of the carpus, soft tissue swelling and discomfort can be noted in addition to carpal
hyperextension (Figure 13.7). The examiner should also evaluate the presence of crepitus and
resistance and assess for collateral ligament instability (Figure 13.8), requiring knowledge of
normal motion. Palpation of the dorsal surface of the carpus will help to detect minor swelling or
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(A) (B) (C)

(D) (E)
(F)
Figure 13.7 Radiograph images depicting ligaments affected by carpal hyperextension corresponding to
illustrations in Figure 13.6: (A) normal appearance; (B) injury at the level of the proximal carpal joint (white
arrows): the accessory carpal and ulnar carpal bones are in a normal position indicating disruption of the
radiocarpal and ulnocarpal ligaments only; (C) injury at the level of the middle carpal joint with proximal
displacement of the accessory carpal bone and ulnar carpal bone suggested by an increased joint space
between the ulnar carpal bone and fourth carpal bone (white arrows) indicating disruption of several
intercarpal ligaments. In this dog, no disruption of the ligament between the accessory carpal and ulnar
carpal bone is seen, indicating that the ligament connecting the two is intact; (D) injury at the level of the
middle carpal joint with proximal displacement of the accessory carpal bone and ulnar carpal bone
suggested by an increased joint space between the accessory carpal and ulnar carpal bone as well as
between the ulnar carpal bone and fourth carpal bone (white arrows) indicating disruption of several
intercarpal ligaments and the accessory metacarpal ligaments; (E) injury at the level of the distal carpal
(carpometacarpal) joint (white arrows) indicating disruption of the palmar fibrocartilage; and (F) typical
appearance of carpal hyperextension when applying dorsal stress to the distal limb.
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(A) (B) (E)
(C) (D) (F)
Figure 13.8 Traumatic medial collateral ligament injury in a 4-year-old GSD: (A–C) radiographs, (D)
illustration of the injury, and (E, F) physical examination to detect collateral ligament injury by applying
medial/later stress to these ligaments. (A) Radiographs of the affected limb showing soft tissue swelling on
the medial aspect but no evidence of instability. (B) Stress radiograph of the affected limb showing an
increased antebrachiocarpal joint space (white arrow) indicating disruption of the medial collateral
ligament. (C) Stress radiograph of the unaffected, normal limb highlighting a normal antebrachiocarpal
joint width. Note: while this is a similar stress view of the opposite limb, due to slightly different
positioning, the sesamoid bone (arrow) within the abductor pollicis longus is more obvious due to lack of
superimposition with other carpal bones. Similarly, the different positioning gives the appearance of a
wider middle carpal joint (black arrow). (D) Illustration of image (B) depicting the torn collateral ligament
and widened joint space. (E) Application of valgus stress and (F) varus stress to the carpus, testing the
integrity of the medial ligament and lateral collateral ligament, respectively.
discomfort of tendons or joint areas. Goniometry and flexibility measurements of the carpal flexors
should be measured to quantify the degree of hyperextension and establish a baseline (Chapter 5).
For healthy Labrador Retrievers, the mean (±SD) normal range of motion in dogs is reported to be
32° (±2°) in flexion and 196° (±2°) in extension (Jaegger et al. 2002).
13.4.3 Diagnostics
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Radiographs should be acquired in every patient as the first diagnostic step. When the problem is uni-
lateral, orthogonal views of the unaffected, contralateral side are obtained for comparison purposes.
Standing or stress views mimicking weight-bearing are imperative to identify the location of injury
within the carpal joint (Figure 13.7). Stress views can be safely acquired using adhesive tape or ties
to extend the carpus. Otherwise a wooden spoon can be used to provide counterpressure. This ensures
a safe distance of the examiner’s hands from the radiation beam, while simultaneously being able to
provide the necessary amount of pressure needed to achieve appropriate stress view imaging. In addi-
tion to regional soft tissue swelling, based on the level of subluxation and associated supportive
structures, injuries occur at three levels (Slocum and Devine 1982). Subluxation of the antebrachiocar-
pal level results from damage to the short oblique radial carpal, palmar radiocarpal, and palmar
ulnarcarpal ligaments. Injuries to the intercarpal level result from rupture of the metacarpal accessory
ligaments and the short intercarpal ligament between the accessory and ulnar carpal bones.
Carpometacarpal joint injuries include rupture of the ligaments of the middle carpal- the carpometa-
carpal joints and the palmar fibrocartilage. In addition to flexed and hyperextended views, views
with mediolateral stress (Figure 13.8) are also acquired to evaluate the medial and lateral collateral liga-
ments. Finally, oblique views acquired at 45° angles can help identify carpal bone fractures.
CT can be considered if there is concern for additional fractures of the carpal bones that may not
be visible on radiographs or if stress views do not reveal a subluxation of any joint. MRI may reveal
very subtle lesions and allow for evaluation of all periarticular soft tissue structures of clinical
interest. Advanced imaging can aid in treatment decision and increase the success for each specific
treatment, which depending on the damaged structures involved, may include partial or pancarpal
arthrodesis. Ultrasound has also been used, albeit its value for the diagnosis of these injuries has
not yet been established.
Arthrocentesis should be performed if infectious or inflammatory etiologies are possible. While
infrequently reported in the literature, IMPA should be considered as a possible cause for carpal
lameness (Lotsikas and Radasch 2006). With chronicity, affected dogs can progress to palmigrade
stance, mimicking a traumatic hyperextension injury. Based on the authors’ experience, Shelties
and Welsh Corgies may be at increased risk of IMPA affecting the carpus, although other breeds
are also affected. Arthroscopy of the carpus has also been suggested as a potential additional
imaging technique, to aid in the diagnosis of hyperextension, infection, and IMPA (Warnock and
Beale 2004).
13.4.4 Other Carpal Ligamentous Injuries

No ligament crosses the entire carpus. Rather, ligaments cross one or two carpal rows. The main
carpal ligaments are the medial collateral ligament, the short radial lateral collateral ligament and
the short oblique lateral collateral ligament. Medial collateral ligaments sprains can result from
severe trauma or, more seldomly, from athletic activities. Lateral collateral injuries have been
reported in racing Greyhounds and other dogs (Roe and Dee 1986; Guilliard and Mayo 2000).
Dorsal carpal ligament sprains have also been reported in a series comprising two racing
Greyhounds, one working Pointer, one working Border Collie, and one working Labrador Retriever
(Guilliard 1997). Injuries to collateral and dorsal ligaments result in focal swelling in the short
term and in focal fibrosis over time. Collateral injuries are detected by placing varus or valgus
stress on the carpus with the joint extended and are confirmed by use of stress radiography
(Figure 13.8) or diagnostic ultrasonography.
13.5 Deformities of the Carpal Regio 185
13.5 Deformities of the Carpal Region

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Deformities of the distal aspect of the antebrachium are the most common limb deformities, with
a reported prevalence of 0.74% of all orthopedic problems (Marcellin-Little et al. 1998). These
deformities result from genetic problems, most commonly chondrodystrophy and chondrodyspla-
sia (Parker et al. 2009; Brown et al. 2017). They can also result from developmental skeletal disor-
ders or inflammatory bone diseases including hypertrophic osteodystrophy (HOD) or multiple
epiphyseal dysplasia or premature growth plate closure.
Carpus valgus, a term used to describe lateral angulation originating in the distal portion of the
antebrachium, is the most common antebrachial deformity. The lateral deviation of the manus is
generally associated with excessive external rotation of the radius, and a loss of carpal flexion.
Carpus valgus can also be associated with subluxation of the elbow joint, particularly distal
humero-ulnar subluxation, and with a varus angulation of the proximal portion of the radius,
resulting in biapical antebrachial deformity (Kwan et al. 2014).
Carpus varus, the medial deviation of the carpus, is much less common than carpus valgus and is
most often the result of an injury to the distal radial physis.

Deformities of the carpal region are common in chondrodystrophic and chondrodysplastic
dog breeds (Parker et al. 2009; Brown et al. 2017). Genetically driven deformities are bilat-
eral. However, one thoracic limb can be more severely affected than the contralateral tho-
racic limb (Kwan et al. 2014). Trauma to a radial or ulnar physis can lead to premature
closure and result in antebrachial deformity. In one study, 7% of physeal injuries led to a
limb deformity (Marretta and Schrader 1983). Antebrachial deformities secondary to trauma
are generally unilateral.

Antebrachial deformities are diagnosed by observation and palpation and are confirmed by use of
radiographs. The deviation of the manus will vary when measured while standing, while sedated,
and on radiographs (Kwan et al. 2014). The examination of a patient with antebrachial deformity
includes the evaluation of varus or valgus; the presence of effusion, crepitus, and pain response to
joint motion in the carpus and elbow; and the range of motion of the carpus and elbow measured
using a goniometer (Chapter 5).
13.5.3 Diagnostics
Palpation and goniometry under sedation may be the most accurate way to evaluate valgus
or varus deformities; standing measurements appear to overestimate it and radiographs
appear to underestimate it. Radiographs should include the entire limb distal to the elbow.
It is easiest to evaluate deformities if an attempt is made to provide a true lateral and cranio-
caudal view of the elbow, without attempting to correct the position of the distal limb
(Figure 13.9). Complex deformities can be assessed using CT (Kwan et al. 2014), which
allows the objective assessment of radial rotation, length deficit, and subluxation of the
elbow and carpus.
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(A) (B) (C)

(D)
Figure 13.9 Typical radiographic appearance of an (A, B) angular limb deformity secondary to premature
closure of the distal ulnar physis showing radius procurvatum, valgus deformity, and external rotation of
the distal limb, elbow incongruity, and a shortened ulna. (C) Clinical appearance of (C) carpus varus
secondary to premature radial physis closure, and (D) carpus valgus secondary to premature distal ulnar
physis closure.
13.6 Tendinous and Muscular Lesions of the Carpal Region
Tendon and muscular injuries in the carpal region are sparsely described in the veterinary litera-
ture but, in the authors’ experience, are a more common cause of lameness than previously
thought. These injuries are unlikely to lead to severe disability, and lameness is generally moderate
to mild. Most severe carpal tendon and muscular injuries result from trauma such as shearing
injuries or penetrating wounds (e.g. bite wounds and gunshot wounds). The flexor tendons may be
injured at any level, including caudal to the carpal joint and should therefore be palpated for swell-
ing and pain (Chapter 12).
Flexor carpi ulnaris (FCU) tendinopathy or partial avulsions of the insertion site of the FCU on the
accessory carpal bone occur in dogs, most often in large, athletic dogs. It has been reported in
Greyhounds and a Weimaraner dog (Kuan et al. 2007). The FCU consists of two muscle bellies: the
ulnar head originates from the proximal medial ulna, and the humeral head originates from the
medial epicondyle of the humerus. Both insert as a combined tendon on the accessory carpal bone.
FCU injuries result in a weight-bearing lameness. Upon palpation, a firm swelling is palpable
proximal to the accessory carpal bone. Pain may be exacerbated if the muscle is stretched (e.g.
carpal hyperextension). The diagnosis is confirmed using musculoskeletal ultrasound by seeing a
disruption of collagen fibers and the presence of intratendinous fluid. Radiographs may show
13.7 Other Diseases Affecting the Carpal Regio 187
swelling or calcification if a chronic injury is present (Figure 13.10). Neoplasia has to be considered

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as a differential diagnosis and appropriate diagnostics (e.g. ultrasound, fine-needle aspirate (FNA),
and biopsy) should be utilized on an individual basis.
Inflammation of the abductor pollicis (digiti I) longus, described as stenosing tenosynovitis, has
also been reported as a cause of lameness (Hittmair et al. 2012). This muscle originates from the
lateral surface of the radius and ulna as well as the interosseous membrane and curves medially to
insert on the base of the first metacarpus. The muscle abducts and extends the first digit and as
such adduction and flexion of the digit will stretch the muscle. This may result in a pain response
in affected animals. Animals may present with a visual swelling (Figure 13.11) of the medial aspect
of the carpus, and radiographs may show enthesopathy and bony proliferation in the area of the
radial sulcus (that the muscle passes through). These changes result in stenosis of the tendon and
may be associated with clinical symptoms, although they may also be nonclinical. Surgical
(resection or release of the tendon) and nonsurgical treatments have been described.
13.7 Other Diseases Affecting the Carpal Region
13.7.1 Lack or Loss of Carpal Extension

Carpal laxity syndrome is a term used to describe loss of carpal extension or flexion. Lack of carpal
extension, also termed “carpal flexural deformity” has been reported in growing large-breed dogs
(Vaughan 1992; Altunatmaz and Guzel 2006; Cetinkaya et al. 2007). Although the cause of this
lack of carpal extension is not known, malnutrition, lack of exercise, or a discrepancy between
rapid bone growth and slower muscle growth leading to tightness of the antebrachial flexor mus-
cles may possibly play a role. Affected dogs stand with the carpus flexed, potentially relieving the
tension on their digital flexor tendons. Treatment with appropriate nutrition and exercise generally
resolves the condition.
(A) (B) (C)
Figure 13.10 Radiographs of a dog affected with flexor carpi ulnaris (FCU) tendinopathy: (A) early stages
showing soft tissue swelling only (white arrow); (B) chronic stages showing calcification of the tendon of
insertion; and (C) location for palpation of FCU tendon insertion at the accessory carpal bone.
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(A) (B) (C)

Figure 13.11 Images depict (A, B) radiographic and (C) clinical presentation of a dog with abductor
pollicis longus tendinopathy; (A) osseous proliferation in the area of the radial sulcus visible on the
lateral and (B) craniocaudal radiograph. Also note (C) typical soft tissue swelling associated with this
tendinopathy.
Lack of carpal extension has also been described in dogs with neurologic injury (Holland 2005).
It can occur in dogs with palsy of the distal (antebrachial) branch of the radial nerve. The loss of
radial innervation leads to a lack of ability to extend the carpus and, with continued active flexion
from antebrachial flexor muscles, a progressive loss of carpal extension can occur. This type of loss
of carpal extension is seen in dogs with brachial plexus avulsion (Chapter 16) and in dogs with
iatrogenic transection of the radial nerve.
Lack of carpal flexion while standing and walking is also seen in dogs with severe antebrachial
deformities, a situation described as carpal buckling. A transient loss of carpal extension is
routinely present after limb lengthening (Kwan et al. 2014).
Since full carpal extension is required while standing and walking, loss of carpal extension has a
major clinical impact in dogs. A loss of approximately 30° of extension can make limb use impos-
sible. Lack or loss of carpal extension is diagnosed by observing or videotaping dogs while standing
and walking and using palpation and goniometry. Imaging is performed to identify or rule out
underlying structural disease (in juvenile animals).
13.7.2 Lack or Loss of Carpal Flexion

Since complete carpal flexion is not required for locomotion and to perform activities of daily
living, a loss of carpal flexion has minimal function impact in dogs. Lack of carpal flexion is
frequently present in dogs with carpal osteoarthritis and as a consequence of fractures affecting the
carpal region. Lack of carpal flexion is also present in the majority dogs with antebrachial deformi-
ties secondary to impaired physeal growth. In a case series, 6 of 7 dogs with antebrachial deformi-
ties were lacking carpal flexion with an average loss of flexion of 50° (Marcellin-Little et al. 1998).
The authors have also observed lack of carpal flexion in geriatric, large-breed dogs without identi-
fiable underlying disease.
13.7 Other Diseases Affecting the Carpal Regio 189
13.7.3 Hypertrophic Osteodystrophy

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HOD is an inflammatory disease affecting the metaphyseal region of long bones in growing dogs,
particularly dogs of large and giant breeds. The disease is often limited to or is most severe in the
distal portion of the antebrachium (if it extends beyond the distal region). Usually developing at
3–4 months of age, HOD is often associated with hyperthermia, anorexia, diarrhea, severe pain in
the metaphyseal regions of long bones, and a loss of willingness to ambulate. The clinical signs
often subside after a week or so. However, severely affected dogs may require hospitalization and
supportive care. Episodes can recur every few weeks until the end of growth. The cause of HOD is
not known. Factors implicated have included vitamin C deficiency and the presence of viral RNA
in metaphyseal osteoblasts. In severe instances, HOD can lead to the formation of periosteal new
bone and to antebrachial and crural deformities. Soft tissue mineralization has been reported in
severely affected dogs. HOD is diagnosed by use of radiography (Figure 13.12). The distal radial
(A) (C) (E)
(B) (D)
Figure 13.12 Hypertrophic osteodystrophy (HOD): (A, B) classic appearance of a lucent “double physis” line
(white arrow) paralleling the distal radial and ulnar physes; (C, D) variations of a double physis; (C) a broader
lucent line is visible particularly in the distal radius; (D) early changes with HOD, showing a faintly visible lucency
adjacent to the physis; and (E) chronic appearance of HOD, note that the double physeal lines are still visible.
and ulna growth plate may be irregular or appear to be doubled (i.e. “double physis” sign as a result
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of impaired ossification of the metaphyseal region) and periosteal bone formation may be visible
depending on the disease stages (Demko and Mclaughlin 2005).
13.7.4 Shearing Injuries

Shearing injuries routinely affect the carpal region (Benson and Boudrieau 2002) and often include
a loss of tendon and collateral ligaments. The orthopedic examination of carpal region with
(A) (C) (E) (G)
(I)
(B) (D) (F) (H)
Figure 13.13 Other miscellaneous conditions of the carpal region. Images (A–D) depict distal radius
osteosarcoma: (A) swelling associated with distal radius osteosarcoma; (B) craniocaudal radiograph of a dog
showing predominantly osteolytic changes consistent with osteosarcoma; (C, D) radiographs of a dog
showing typical osteolytic-osteoproliferative changes consistent with osteosarcoma. Images (E, F) depict
radiographs of a dog with retained cartilaginous core of the ulna. Images (G–I) depict incomplete
ossification of the radial carpal bone: (G) the lateral radiograph shows a very faint line (white arrow), note
that the (black arrow) frequently identified line at the joint surface is normal and results from
superimposition of the ulnar carpal bone over the radial carpal bone; (H) the craniocaudal view shows a
lucent line that is suggestive of incomplete ossification; and (I) the craniocaudal view confirms the
diagnosis (white arrow indicates the fissure line across the radial carpal bone).
Reference 191
s hearing injuries includes the assessment of mediolateral and craniocaudal carpal instability. In
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most instances, the loss of carpal stability is medial and dorsal, and the joint will be stable once
tissues heal as a result of periarticular fibrosis. Diagnosis is easily accomplished based on visualiza-
tion but imaging may be required to detect the degree of soft tissue involvement (e.g. stress views
to detect collateral ligament instability, etc.).
13.7.5 Carpal Region Neoplasia

By far, the most common neoplasia of the carpal region is osteosarcoma of the distal radius
(Figure 13.13). Further information is provided in Chapters 11 and 17.
13.7.6 Miscellaneous Other Conditions
Idiopathic ischemic necrosis of the accessory carpal bone has been reported in one dog (Harris and
Langley-Hobbs 2013).
Incomplete ossification of the radial carpal bone has been reported in several dog breeds, including
Pointers, Setters, and Boxers (Gnudi et al. 2003; Perry et al. 2010). The intermedioradial carpal
bone represents a fusion of the primitive radial, central, and intermediate carpal bones, and
failure of this fusion can result in incomplete ossification. Radiographs may not show the lesion,
but CT will clearly identify the separation (Figure 13.13).
Subluxation or luxation of carpal bones other than hyperextension injuries is rare. Two reports
described luxations of numbered carpal bones (Guilliard and Mayo 2001; Comerford et al. 2006).
One report described a dorsomedially luxated radial carpal bone (Palierne et al. 2008).
Radiographs or CT are utilized to establish these diagnoses.
Retained cartilaginous cores of the ulna are cones of non-ossified cartilage that project into the dis-
tal metaphysis (Figure 13.13). Unless they are associated with premature closure of the distal
ulnar growth plate, no treatment is needed for this condition.
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injuries occurring in dogs participating in canine agility. Vet Comp Orthop Traumatol 22 (4): 321–324.
Li, A., Bennett, D., Gibbs, C. et al. (2000). Radial carpal bone fractures in 15 dogs. J Small Anim Pract
41 (2): 74–79.
Lotsikas, P.J. and Radasch, R.M. (2006). A clinical evaluation of pancarpal arthrodesis in nine dogs
using circular external skeletal fixation. Vet Surg 35 (5): 480–485.
Lunn, K.F. (2001). Fever of unknown origin: a systematic approach to diagnosis. Compendium 23 (11):
976–992.
Marcellin-Little, D.J., Ferretti, A., Roe, S.C., and Deyoung, D.J. (1998). Hinged Ilizarov external fixation
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Marretta, S.M. and Schrader, S.C. (1983). Physeal injuries in the dog: a review of 135 cases. J Am Vet
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Milgram, J., Milshtein, T., and Meiner, Y. (2012). The role of the antebrachiocarpal ligaments in the
prevention of hyperextension of the antebrachiocarpal joint. Vet Surg 41 (2): 191–199.
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Parker, H.G., Vonholdt, B.M., Quignon, P. et al. (2009). An expressed fgf4 retrogene is associated with
breed-defining chondrodysplasia in domestic dogs. Science 325 (5943): 995–998.
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growth deformities with a lengthening procedure using a circular external skeletal fixation system
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14
Elbow Region
Felix Michael Duerr
Pathology in the elbow region is probably the most frequent source of chronic thoracic limb lame-
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ness in dogs. The elbow joint is a complex joint that is affected by many diseases. In general, elbow
arthritis is more common and manifests in more severe clinical symptoms when compared to
shoulder and carpal arthritis. In addition to the joint itself, soft tissue injuries of the region also
cause lameness. Therefore, definitively identifying the source of lameness within the elbow region
based on palpation can be very difficult and additional diagnostic tests are often necessary for
establishing a diagnosis. The most commonly employed tests include CT and arthroscopy for the
diagnosis of joint pathology. Figure 14.1 and Table 14.1 outline common differential diagnoses and
diagnostic steps for the elbow region.
14.2 Normal Anatomy and Arthritis
The elbow (or cubital) joint is a hinge joint (with the main motion being limited to the sagittal
plane, i.e. flexion and extension). The joint is formed by the radius, ulna, and humerus and divided
into the following joints (Figures 14.2):
●● Humeroradial joint, which is responsible for ~52% (Mason et al. 2005) of the weight-bearing
forces of the elbow joint.
●● Proximal radioulnar joint, which is responsible for ~48% (Mason et al. 2005) of the weight-bearing
forces of the elbow joint and allows for supination and pronation.
●● Humeroulnar joint, which is the responsible joint for restricting motion of the elbow to sagittal
plane motion.
The medial (i.e. trochlea) and lateral (i.e. capitulum) humeral condyles articulate with the ulna and
radial head, respectively (Figure 14.2). The trochlea is of greater size than the capitulum and sloped
more distally, which becomes relevant for the pathophysiology of condylar fractures and elbow luxa-
tions (i.e. lateral condylar fractures and luxations are more common). In some dogs, the sesamoid of

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Table 14.1 Key features for selected diseases affecting the elbow region.
Common
Disease signalment Diagnostic test of choice Exam findings Treatment Clinical pearls Terminology
Fractures Any (condylar Radiographs (orthogonal Pain, crepitus, Depends on location Articular fractures generally Y-T fracture = inter- or
fractures most views non-weight-bearing but frequently surgical require surgical fixation, bicondylar fracture
common in needed – particularly to lameness fixation recommended hence condylar fractures are
small-breeds, detect minimally generally treated surgically
approximately displaced condylar
4 months old) fractures; Figure 14.4)
Incomplete Spaniel breeds CT (Radiographs may Pain on elbow Surgical fixation Frequently DD: Progressive
ossification of the show radiolucent line hyperextension or recommended (to avoid bilateral – evaluate (and humeral intracondylar
humeral condyle across condyles or smooth may be fracture) treat) both sides ASAP fissure (HIF) – same
(IOHC) proliferation along lateral asymptomatic treatment
supracondylar crest)
Incongruity Same as MCD/ CT or arthroscopy Same as MCD/UAP Same as MCD/UAP Incongruity is contributing Premature physeal
UAP feature to Elbow dysplasia closure may result in
severe incongruity and
angular limb deformity
Medial Large-/giant- Radiographs if secondary Pain upon ROM Surgical treatment in Adult dogs may present with Previously known as
Compartment breeds, with changes are present – CT and Campbell’s combination with traumatic fractures of the FCP – Fragmented
Disease (MCD) Labrador during early stages or for test, joint effusion, lifelong medical coronoid Coronoid Process;
Retrievers and “traumatic fractures of periarticular management or medical process – establishing a other terminology
Bernese the coronoid process” swelling or no clear management diagnosis in these patients includes (medial)
Mountain Dogs abnormalities requires CT/arthroscopy coronoid disease
are predisposed since radiographs are
normal
Osteochondrosis Same as MCD CT or arthroscopy Same as MCD Same as MCD Generally not an isolated “Kissing lesions” occur
Dissecans (OCD) disease in the elbow but in the same
rather with MCD location – these are due
to coronoid pathology
and not a true OCD
lesion
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Ununited German Radiographs (after Pain on elbow Surgical removal, Ideally diagnose and treat
anconeal process Shepherd Dogs, 4–5 months of age) manipulation reattachment ± ulna prior to six months (greater
(UAP) Bernese sufficient – ideally CT to (particularly osteotomy or medical chance of fusion of the
Mountain Dogs, evaluate for MCD and hyperextension) management UAP)
and Mastiffs incongruity
Traumatic elbow Any Radiographs Non-weight-bearing Closed or open Dogs will hold limb in an The Campbell’s test is
luxation lameness and severe reduction (if closed abducted and externally used to detect collateral
pain reduction fails or is rotated position ligament integrity (but
contraindicated) also to detect pain in
dogs with MCD)
Congenital elbow Juvenile Radiographs (CT if Lameness and pain Surgical or nonsurgical Generally have obvious
luxation small-breed (Type surgery is performed) variable management abnormal bony
I) and large-breed conformation of elbow joint
(Type II) dogs
Panosteitis Frequently seen Radiographs (but may Pain on long bone Rest and pain Disease should be self- Other terms include
in German require CT during early palpation and management limiting, if clinical eosinophilic
Shepherd Dogs stages) show shifting leg symptoms continue in the panosteitis, juvenile
between 5 and intramedullary lameness same leg, further imaging osteomyelitis, and
18 months of age radiodensities should be considered enostosis or medullary
fibrosis
Septic arthritis Postsurgical dogs Joint fluid analysis, Moderate-to-severe Antibiotics and Dogs with preexisting joint
and dogs with culture, and physical pain on ROM, consider joint lavage disease (such as arthritis)
preexisting exam findings periarticular are predisposed. A lack of
arthritis swelling, and pitting fever or negative culture
limb edema results do not rule out septic
arthritis
Flexor Same as MCD Radiographs may show Variable degree of Address concomitant Important to differentiate Other terms include
enthesopathy (FE) calcification; however, lameness and pain pathologies if present, primary FE (i.e. no ununited medial
ultrasound is required to upon palpation and nonsurgical concomitant elbow epicondyle and medial
diagnose noncalcified FE stretching of flexor management most pathology) and concomitant humeral condylar
muscles common for primary FE (i.e. together with, most osteochondritis
form commonly, MCD) dissecans
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Fracture IMPA/septic
arthritis
History of
Visible
trauma
Traumatic elbow abnormality

luxation
Soft tissue
Traumatic soft Fracture line Consider to establish injury
tissue injury
diagnosis
History of
Soft tissue Luxated elbow
trauma
neoplasia X-rays X-rays Brachial plexus
Arthrocentesis injury
abnormal normal
Chronic soft Soft tissue swelling

tissue injury
Soft tissue
Soft tissue Ultrasound neoplasia
UAP calcification
Coronoid Lucent line through

disease anconeal process IOHC
Pain in MRI
elbow
OCD Secondary OA region
Coronoid
disease
IMPA/septic Lucent line through FNA
arthritis condyle
IOHC Lytic lesions OCD

Common tendinopathies: CT
Osseous Luxated and
• Flexor enthesopathy
neoplasia deformed elbow Juvenile
dog
Panosteitis
Congenital elbow Intramedullary
luxation
Juvenile
radiodensities
dog
Osseous
Panosteitis
neoplasia
Figure 14.1 Schematic of common diseases affecting the elbow region and the steps necessary to establish a diagnosis.
14.2 Normal Anatomy and Arthriti 199
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(A) (C) (E) (G)
(B) (D) (F)
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Figure 14.2 Normal anatomy of the elbow joint (Note: for all craniocaudal images, lateral is on the left):
(A–E) radiographs of canine patients without elbow pathology; (A, B) note that the proximal radial physis is
clearly visible in a 9-month-old dog; (C, D) note the appearance of the proximal radial physis in an adult
dog; (E) note the sesamoid of the supinator muscle (white arrow), a normal structure that is visible in some
dogs and should not be confused with a pathologic condition; and (F, G) normal anatomy of the bones
contributing to the elbow joint: (a) humerus; (b) ulna; (c) radius; (d) lateral humeral condyle (=capitulum);
(e) medial humeral condyle (=trochlea); (f) medial supracondylar crest; (g) olecranon fossa; (h) medial
epicondyle; (i) proximal radial physis; (j) tuber olecranon; (k) trochlear notch; (l) coronoid process of the
ulna; and (m) anconeal process.
the supinator muscle is present and can be identified radiographically (and should not be confused
with a pathologic condition). The coronoid process of the ulna consists of a lateral and medial portion;
pathology of the latter frequently results in lameness. It is in contact with the radius via the radial
incisure (i.e. the notch of the ulna within which the radius can supinate and pronate). The olecranon
fossa, located above the humeral condyles, accommodates the anconeal process during elbow exten-
sion. During development, a large apophysis (i.e. separate ossification center at site of tendon attach-
ment) is visible at the tuber olecranon which should not be confused with a pathologic condition (e.g.
fracture or ununited anconeal process [UAP]). The triceps muscle attaches at the tuber olecranon and
is the major extender of the elbow joint. The biceps brachii muscle inserts on the radius and ulna and
together with the brachialis muscle is one of the major flexors of the elbow joint. Normal range of
motion (ROM) of the elbow joint is approximately 30–160° (Chapter 5). The digital flexor and exten-
sor muscles originate from the area of the medial and lateral epicondyle, respectively. The median and
ulnar nerves are located on the medial aspect of the elbow, with the ulnar nerve being superficial so
that it can be palpated caudally. The radial nerve is located on the lateral aspect of the elbow.
Osteoarthritis (OA) of the elbow joint is generally thought to be the consequence of a primary
problem such as elbow dysplasia (i.e. “secondary” osteoarthritis). One of the most common reasons
200 14 Elbow Region
for secondary osteoarthritis of the elbow joint is medial compartment disease (MCD). Reports of
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immune-mediated and infectious arthritis of the elbow joint exist (Chapter 13; Stull et al. 2008).
Therefore, arthrocentesis and synovial fluid evaluation should be considered in cases where estab-
lishing a diagnosis is difficult.
14.3 Fractures of the Elbow Region
The most commonly observed fracture of the elbow region is a Salter-Harris Type IV of the lateral
humeral condyle (Figure 14.3). These fractures are articular (Chapter 13 for review of Salter-Harris
classification), and as such immediate surgical treatment is recommended. Typically, treatment for
these fractures involves reducing them anatomically (i.e. perfect alignment of the joint surface is
(A) (C) (E)

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(B) (D) (F)
Figure 14.3 Examples of condylar fractures in three patients: Patient I (A, B) moderately displaced lateral
condylar fracture. Note that the fracture lines are easily identified (black arrows) on the craniocaudal view,
but difficult to identify on the lateral view; Patient II (C, D) minimally displaced lateral condylar fracture.
While the fracture lines (black arrows) are visible on the craniocaudal view, the fracture is very difficult to
identify on the lateral view. In such cases, comparing to the (E) normal, unaffected limb can be helpful;
Patient III (F) Y-T fracture in an adult patient affecting both condyles (black arrow identifies the medial
condylar fracture that is not present in the other two patients).
14.4 Incomplete Ossification of the Humeral Condyl 201
the goal) and stabilizing them with internal fixation utilizing a transcondylar lag screw in
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combination with pins or a plate (Perry et al. 2015). Medial humeral condylar fractures are observed
less commonly but the diagnostic and treatment approaches are similar. If condylar fractures are
observed in older animals, consideration should be given to incomplete ossification of the humeral
condyle (IOHC) as an underlying disease. Less commonly observed fractures of the elbow region
include Salter-Harris Type I fractures of the distal humerus and proximal radius, intercondylar
(also described as T-Y fracture) and supracondylar fractures, as well as proximal ulna fractures
with luxation of the radial head (i.e. Monteggia fracture).

As for any fracture, trauma is the main cause which can happen to dogs of any age/signalment.
However, fractures of the elbow region are frequently seen in immature dogs. In these patients,
lateral humeral condylar fractures are most common because of the smaller-sized lateral (vs.
medial) supracondylar crest (Figure 14.2). These fractures occur frequently in smaller breeds (with
the French Bulldog being predisposed) and often occur with minor trauma. The peak age has been
reported to be four months (Perry et al. 2015).
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14.3.2 Physical Exam
Because of the acute nature of the injury, physical exam findings usually show severe pain upon
elbow ROM. However, pain may present as less severe in stoic animals or when fractures are
minimally displaced.
14.3.3 Diagnostics
Diagnosis of these fractures is readily accomplished with orthogonal radiographs, although the
diagnosis can be missed if only a lateral view is taken (Figure 14.3).
14.4 Incomplete Ossification of the Humeral Condyle
IOHC is defined as failure of ossification of the lateral and medial aspects of the humeral condyle.
This ossification should be completed during the first three months of growth, while the distal
humeral physis (which is located proximally to the ossification centers) continues to grow until
five to eight months. A lack of fusion of the medial and lateral condyles results in a fibrous band
connecting the two parts of the condyle which creates a weak area predisposing for development
of condylar fractures.
Recently, Farrell and others (2011) have reported that dogs may also suffer from a condition
termed “progressive humeral intracondylar fissure (HIF).” The condition is very similar to IOHC;
however, animals develop the separation of the condyles after normal ossification has occurred,
thus indicating a fatigue fracture due to cyclic loading rather than a failure of fusion during devel-
opment (Farrell et al. 2011). Because of the uncertainty about the difference in etiology, some
authors use the term HIF to encompass both conditions, IOHC and stress fractures of the humeral
condyle (Moores and Moores 2017).
Treatment of condylar fractures due to IOCH/HIF requires open reduction and surgical fixation
like that used for traumatic condylar fractures. Ideally IOHC/HIF is identified prior to the patient
202 14 Elbow Region
developing a condylar fracture, in which case treatment is much simpler and associated with less
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cost and a better prognosis (Moores and Moores 2017). Treatment consists of surgical fixation
across the condyles to prevent fracture development (Hattersley et al. 2011).

Spaniel breeds are predisposed to IOHC (Moores et al. 2012), however, many other breeds (including
Yorkshire Terriers, Labrador Retrievers, German Shepherd Dogs, Rottweilers, and Mastiff) may also
be affected by this condition. Dogs typically present for lameness due to IOHC later in life with a peak
age at presentation of three to four years. However, recent awareness of the condition (particularly in
the United Kingdom) has allowed for earlier diagnosis prior to the patient showing clinical signs.
Early clinical signs of lameness may result from micromovement of the condyles (without fracture),
but if the condition remains undiagnosed, animals may present later with more acute lameness once
condylar fractures occur (Figure 14.4; Witte et al. 2010). Therefore, the degree of lameness and acuity
can be highly variable amongst the different patients presenting with this condition. Certain features
of the patient history, taken together with the patient signalment, should alert the clinician to con-
sider IOHC as an underlying cause when patients are presented with acute condylar fractures:
Owners may have observed a lameness prior to the non-weight-bearing lameness associated
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●●
with the fracture (prodromal lameness).

●● Condylar fractures because of IOHC may occur after minimal trauma (similarly to condylar
fractures in immature animals).
In such cases, diagnostics of the non-affected limb should be considered to evaluate whether pro-
phylactic treatment should be considered (in addition to treating the affected limb).

In patients with IOHC, pain is most pronounced with hyperextension of the elbow and in some
cases upon palpation of the lateral epicondylar region. However, it is important to note that physi-
cal exam findings may be deceiving as in some cases, dogs with IOHC may possess normal ROM
with no effusion, crepitus, or periarticular thickening (Butterworth and Innes 2001). Therefore,
diagnostics should be recommended in any middle-aged Spaniel breed (or other predisposed
breeds) with undiagnosed lameness even in face of a normal elbow examination.
14.4.3 Diagnostics
Diagnosing IOHC can be challenging and may require advanced imaging. Radiographs may show
a radiolucent line extending through the condyles or a smooth proliferation along the lateral supra-
condylar crest indicating stress remodeling (Figure 14.4) of this area due to instability of the con-
dyles (Marcellin-Little et al. 1994). If such findings are not observed, IOHC or HIF may not be
ruled out and advanced imaging should be considered as the next step. It is most common to use
CT, although MRI has also been reported (Piola et al. 2012). Since IOHC is bilateral in ~25% of the
dogs, both limbs should be evaluated. This is easily accomplished using CT, thus making it the
ideal imaging modality. Bilateral radiographs may be considered instead if CT is unavailable,
recognizing that some lesions may be missed since the radiographic beam must be parallel to the
fissure line to accomplish a diagnosis. Therefore, oblique radiographs (including a 15° craniome-
dial caudolateral view) should be performed if radiographs are used as the sole diagnostic tool
(Hattersley et al. 2011).
14.5 Elbow Dysplasia/Incongruit 203
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(A) (C) (F)
(D)
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(B) (E) (G)
Figure 14.4 IOHC examples: Patient I (A, B) was diagnosed on radiographs with IOHC based on observation of
a radiolucent line across the condylar area (black arrow); Patient II (C–E) was definitively diagnosed via CT as
illustrated in (D) (black arrow) which was recommended after noting (C) smooth periosteal proliferation of the
lateral supracondylar crest that is indicative of IOHC (white arrow); patients I and II underwent prophylactic
transcondylar lag screw fixation without complications; Patient III (F, G): upon initial presentation, (F) the
diagnosis of IOHC/HIF (black arrow) was missed and the condition progressed (G) to a Y-T fracture, illustrating
the importance of careful evaluation of radiographs/the importance of pursuing advanced imaging.
14.5 Elbow Dysplasia/Incongruity
Elbow dysplasia (ED), also termed “developmental elbow disease,” was defined as UAP, frag-
mented coronoid process (FCP), osteochondrosis dissecans (OCD), and incongruity by the
International Elbow Working Group over 25 years ago (Michelsen 2013). However, the terminol-
ogy has since changed particularly for FCP, and incongruity is now considered a contributing fea-
ture to the other three components of ED rather than an independent disease (Michelsen 2013).
The following two types of incongruities (Figure 14.5) have been most commonly proposed to play
a role in the pathophysiology of ED:
●● Radioulnar incongruity – this incongruity describes a mismatch between the radius and ulna
resulting in a step at the radioulnar joint. If the radius is shorter than the ulna, excessive pressure
is placed on the coronoid process resulting in excessive loading and subsequent pathologic
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(A) (B) (C) (D) (E)
(F) (G) (H) (I)
Figure 14.5 Elbow dysplasia CT: (A) transverse plane reconstruction; large fragment of the medial coronoid process and mild radioulnar incisure incongruity in
a dog with medial compartment disease (MCD); (B) transverse plane reconstruction; normal appearance of the coronoid process; (C) sagittal plane
reconstruction; congruent elbow; (D) 3D reconstruction; appearance of a fragment of the medial coronoid process; (E) typical bow-legged stance with external
rotation of the limb in a clinical patient with chronic MCD; (F) dorsal plane reconstruction; normal appearance of the medial aspect of the humeral condyle; (G)
dorsal plane reconstruction; the defect (white arrow) and subchondral sclerosis are consistent with OCD; (H) sagittal plane reconstruction; humeroulnar (notch)
incongruity (black arrow); and (I) sagittal plane reconstruction; radioulnar incongruity (black arrow) resulting in UAP.
14.6 Medial Compartment Diseas 205
changes. In contrast, if the radius is longer than the ulna, excessive pressure is placed on the
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anconeal process which may result in lack of fusion of the process. These incongruities are gen-
erally subtle and consequently CT or arthroscopy is necessary to make the diagnosis of incon-
gruity. Specific knowledge of the type of incongruity aids the treatment decision and therefore is
highly valuable. These two types of incongruity may also be secondary to premature growth
plate closures (i.e. short ulna = premature closure of the distal ulna physis; short radius = pre-
mature closure of either the proximal or distal radius physis). In cases where the degree of incon-
gruity is severe, radiography is useful to detect which incongruity scenario applies.
●● Humeroulnar incongruity – this incongruity describes either a mismatch between the ulna
notch and the humeral trochlea or displacement of the humerus from the ulnar notch because
of a long radius. CT or arthroscopy is preferred to make the diagnosis of humeroulnar incongru-
ity, although in severe cases radiographs can be diagnostic.
Many other mechanisms for the pathophysiology of ED have been described, such as radioulnar incisure
incongruity (i.e. a misshapen radial incisure that results in increased pressure on the coronoid;
Figure 14.5), as well as excessive pressure on the coronoid because of traction forces caused by the biceps
muscle (that attaches medially at the proximal ulna; Michelsen 2013). However, the influence that the
different types of incongruities have on the development of ED is still being investigated. Further, it is
important to understand that not every dog with ED will have detectable evidence of incongruity, even
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when advanced imaging is used. This can be explained by the inability of commonly used diagnostic
modalities to identify dynamic (i.e. movement during motion) incongruity. Alternatively, transient
incongruity (i.e. incongruity during development) may have resolved by the time imaging is performed.
ED results in debilitating elbow arthritis and since many animals are affected bilaterally, it poses
one of the greatest treatment challenges in small animal orthopedics – amputation may not be a
feasible option and function after successful elbow arthrodesis is questionable due to substantial
mechanical lameness (Coppieters et al. 2015). Therefore, treatment decisions should carefully
weigh the potential risks against short- and long-term benefit of any intervention. Because most
animals with ED will develop a considerable amount of arthritis during their life span, lifelong
medical management should be part of the treatment plan for any dog with ED.
14.6 Medial Compartment Disease
The terminology “fragmented medial coronoid process (FCP)” is used to describe fragmentation of
the medial aspect of the coronoid process of the ulna (Figure 14.5A). This terminology is less com-
monly used nowadays since the pathologic changes encompass far more than pathology of the
coronoid process. Such changes include disseminated cartilage and subchondral bone pathology
of the entire joint, particularly the medial compartment resulting in variable degrees of lameness
(Video 14.1). Therefore, some authors have used the term “(medial) coronoid disease.” However,
because some dogs may experience erosion of the medial compartment without fissuring or frag-
mentation of the coronoid process (Coppieters et al. 2015), “medial compartment disease” (MCD)
is the currently preferred term to describe this condition (Michelsen 2013).
Video 14.1
Clinical lameness and conformation with elbow arthritis/dysplasia.

206 14 Elbow Region
Treatment of MCD frequently includes arthroscopic debridement, although surgical treatment

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has been questioned by some since arthritis progression is expected even with surgical intervention
(Burton et al. 2011; Barthélémy et al. 2014; Dempsey et al. 2019). Others have concluded that
arthroscopy is superior to medical management and treatment via arthrotomy (Evans et al. 2008). The
lack of definitive information regarding the ideal treatment is likely related to a lack of objective
outcome measures and the wide variability seen with the disease complex of MCD (Fitzpatrick and
Yeadon 2009). If traditional medical management is exhausted, novel treatment options such as
joint injections, elbow resurfacing, load-shifting procedures, or total elbow replacement may therefore
be considered despite a lack of sufficient long-term data to support their use (Coppieters et al. 2015).

MCD is considered a developmental disease and diagnosed most commonly in juvenile patients.
Nonetheless, some patients may not present until later in life when symptoms arise due to second-
ary elbow osteoarthritis. Large-/giant-breeds are predisposed, with Labrador Retrievers and
Bernese Mountain Dogs most frequently affected. However, the disease has also been reported in
smaller dogs (such as Dachshund and French Bulldog).
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Diagnosis of MCD is usually based on the following features: reduced ROM, discomfort on hyper-
flexion and -extension, joint effusion, and periarticular swelling (in chronic cases with secondary
degenerative changes). Patients with MCD attempt to redirect the forces to the lateral compart-
ment (to off-load the medial compartment), resulting in a typical bow-legged stance with external
rotation of the limb (Figure 14.5E). Although it is not always palpable, joint effusion can be identi-
fied caudal to the humeral epicondyles (Figure 14.6). Diagnosis of MCD based on a pain response
is difficult since some patients appear to show little to no response to palpation. To increase the
odds of eliciting a pain response, the elbow should be evaluated during flexion, during hyperextension,
and while performing a manipulation known as the “Campbell’s test.” This test was originally
developed for detection of collateral ligament disruption (Farrell et al. 2007), but it can be particu-
larly useful when screening for ED in young animals since other features of chronic elbow OA (e.g.
periarticular swelling, reduced ROM, etc.) may not be present. For this test, the limb is pronated
and supinated while keeping the carpus and elbow flexed at approximately 90° while applying
gentle pressure at the area of the medial aspect of the coronoid process. This area is located approx-
imately 1 cm distal to the medial epicondyle (which is easily palpated when the elbow is extended)
in large-breed dogs. Hyperextension of the joint is performed by pushing cranially at the level of
the elbow joint while keeping the shoulder in a consistent position (i.e. the ROM of the shoulder
should not change when the elbow is extended). Pain on flexion can be tested while the animal is
standing by simply flexing the elbow joint and evaluating for symptoms of pain and whether the
dog “moves” away and hops towards the contralateral side (Videos 14.2 and 3.1).
Video 14.2
Clinical exams of elbow examination for detection of elbow pathology and how to differentiate elbow
from shoulder pain.
14.6 Medial Compartment Diseas 207
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(A) (C) (E)
(B) (D) (F)
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Figure 14.6 Examination to detect elbow dysplasia: (A) flexion of the elbow; (B) isolated hyperextension
of the elbow without hyperextension of the shoulder; (C, E) palpation of joint effusion caudal to the
humeral epicondyles; (D, F) the “Campbell’s test” is performed by pronating and supinating the limb while
keeping the carpus and elbow flexed at approximately 90° and applying gentle pressure to the area of the
medial aspect of the coronoid process.
14.6.3 Diagnostics
Unfortunately, establishing a diagnosis in the juvenile patient frequently requires advanced imag-
ing since radiographs may only show subtle changes. Such changes may include sclerosis of the
ulnar trochlear notch, an indistinct coronoid process, incongruity, and mild degenerative changes
(Figure 14.7). Once osteoarthritis is established, the diagnosis is easily accomplished with radiog-
raphy. Although a CT is generally recommended in juvenile patients to accomplish a diagnosis, it
is important to consider that even this modality is not 100% accurate with a reported specificity of
85–93% (Groth et al. 2009; Villamonte-Chevalier et al. 2015). Hence, the diagnosis of MCD may
require arthroscopy in addition to CT, particularly for cases that are suffering from cartilage
changes only (Coppieters et al. 2015). Additional diagnostic steps may include intra-articular injec-
tion of mepivacaine (Chapter 8). This diagnostic tool is helpful if a positive effect is observed (i.e.
to confirm the diagnosis of ED) but has been shown to have an approximately 10% chance of false-
negative results (Van Vynckt et al. 2012).
208 14 Elbow Region
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(A) (C) (E) (G)
(B) (D) (F) (H)

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Figure 14.7 Examples of MCD: (A, B) juvenile patient with no degenerative changes, the only subtle
abnormality is the lack of a clear distinction of the coronoid process on the lateral view (white arrow); (C, D)
11-month-old dog with mild sclerosis (C; lateral view, white arrow) and irregularity in the area of the
medial coronoid process (D; craniocaudal view and white arrow); (E, F) adult dog with degenerative changes
secondary to MCD; (G, H) 7-year-old dog with normal-appearing radiographs that was diagnosed with
traumatic fracture of the medial coronoid process based on CT.
14.7 Traumatic Fracture of the Medial Coronoid Process
Fragmentation of the coronoid process has also been described in adult patients without degenera-
tive changes (Meyer-Lindenberg et al. 2002; Tan et al. 2016). Termed “traumatic fracture of the
medial coronoid process,” this presentation is also referred to as “adult-onset FCP” or “jump-down
syndrome” (Tan et al. 2016). This disease has been proposed to be associated with traumatic
descents or concussive activities such as agility or fly ball. It is unknown to date whether these
patients suffer from nonclinical, developmental ED prior to the traumatic event or whether the
disease is exclusively traumatic in origin. Regardless of the etiology, it is important to note that
adult dogs can suffer from coronoid disease even if radiographs are normal (Figure 14.7).
Establishing a diagnosis follows the same diagnostic pathway as for juvenile dogs with MCD (i.e.
CT and/or arthroscopy). Treatment with arthroscopic fragment removal carries a good prognosis
based on the limited information available (Tan et al. 2016).
14.9 Ununited Anconeal Proces 209
14.8 Osteochondrosis Dissecans

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Osteochondrosis/osteochondritis dissecans (OCD) of the elbow joint affects the medial humeral
condyle (trochlea). In contrast to OCD lesions of other joints, elbow OCD is frequently diagnosed
together with MCD. Similar to OCD lesions in other joints, OCD of the elbow is the consequence
of an endochondral ossification failure resulting in excessive thickness of the cartilage that may
detach (and develop a flap). Cartilage pathology affecting the trochlea may also develop secondary
to a mismatch between the humerus and ulna, as well as from erosion from the opposing coronoid
pathology. Such lesions are termed “kissing lesions” and can be difficult to distinguish from true
OCD lesions in some cases (Cook and Cook 2009). Although OCD of the elbow can sometimes be
identified with radiography, most often CT (Figure 14.5) or arthroscopy is used to establish a final
diagnosis. The use of these technologies also allows to identify concurrent incongruity and
coronoid pathology. Because the prognosis for elbow OCD is questionable, treatment is somewhat
controversial, with most authors recommending surgical debridement of the lesion (and address-
ing concurrent elbow pathology if indicated).
14.9 Ununited Anconeal Process
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Failure of fusion of the ossification center of the anconeal process is defined as UAP. The patho-
physiology of UAP is unclear, but premature distal ulnar physis closure frequently results in UAP
indicating that radioulnar incongruity may play a substantial role. Ossification of the anconeal
process should be completed by 20 weeks during normal development, although fusion frequently
occurs earlier. UAP has been reported to occur together with MCD in 16% of the cases (Meyer-
Lindenberg et al. 2006). A wide variety of treatment options are available including ulnar osteot-
omy procedures, lag screw fixation, or removal of the anconeal process.

Any large-/giant-breed dog is susceptible to UAP, especially German Shepherd Dogs, Bernese
Mountain Dogs, and Mastiffs. Nevertheless, even small dog breeds, including French Bulldogs and
Dachshunds, have been diagnosed with UAP. Animals with unilateral disease usually present
before they reach maturity. Bilateral disease, which is present in 20–25% of the cases, may make
the lameness harder to identify for owners and hence these animals may present later in life due to
advanced degenerative disease (Cross and Chambers 1997).

Dogs with UAP generally have more obvious physical exam findings compared to dogs presenting
with MCD. Significant joint effusion is generally palpable, and pain is most evident with hyperex-
tension of the joint.
14.9.3 Diagnostics
In contrast to the other forms of ED, UAP is easily diagnosed with radiographs. If a lack of anco-
neal fusion is observed after 20 weeks of age, the diagnosis is confirmed (Figure 14.8). The flexed
lateral radiographic view (Figure 14.8A) eliminates superimposition of the anconeal process and
210 14 Elbow Region
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(A) (B)
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Figure 14.8 UAP: (A) 7-month-old dog with UAP (white arrow); the black arrow indicates the normal
appearance of the apophysis of the tuber olecranon; (B) 12-month-old dog with UAP (white arrow) – note
the different appearance compared to the patient shown in image (A).
the humerus, thereby simplifying observation of the radiolucent line separating the anconeal pro-
cess. However, since the treatment recommendations differ if concurrent incongruity and MCD
are diagnosed, a CT is generally recommended if available.
14.10 Elbow Luxation
Elbow luxation is categorized into traumatic and congenital etiologies. It is important to differentiate
the two etiologies since treatment and prognosis differ greatly. Treatment for traumatic elbow luxa-
tions (TELs) generally consists of immediate closed reduction (if no articular fractures or chronic
degenerative changes are present). Open (surgical) reduction is performed if closed reduction fails.
On the other hand, congenital elbow luxations (CELs) cannot be treated with closed reduction since
the osseous and soft tissue anatomy is altered. Treatment options for CEL include surgical and non-
surgical management depending on clinical factors and type of luxation (Figure 14.9). CEL can be
categorized into three forms: Type I is defined as caudolateral luxation of the radial head without
disruption of the humeroulnar joint (i.e. the ulna is in a normal position); Type II is defined as a
lateral rotation and subluxation of the ulna; Type III is associated with severe skeletal deformities and
defined as luxation of radius and ulna. Outlined below are the diagnostic criteria and features of both
TEL and CEL etiologies to assist the reader in differentiating between them.

TEL is most commonly a result from vehicular accidents or falls and, therefore, can happen in
dogs of any signalment. Congenital luxations are generally seen in juvenile animals, although
mild forms may not present clinically until later in life. Type I luxation more typically manifests
14.10 Elbow Luxatio 211
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(A) (C) (E) (G) (I)
(B) (D) (F) (H) (J)
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Figure 14.9 Elbow luxation: (A, B) Type I congenital elbow luxation (caudolateral luxation of the radial head); (C,
D) Type II congenital elbow luxation (lateral rotation and subluxation of the ulna); (E, F) traumatic, lateral
elbow luxation (note the collateral ligament avulsion fragments, white arrow); (G, H) traumatic, lateral subluxation
of the elbow; and (I, J) clinical picture and 3D-CT reconstruction of the patient shown in images (A, B).
in large-breed dogs but is also described in Yorkshire Terriers. Type II luxations occur more often
in small-breed dogs (Rahal et al. 2000). Of the three variants of CEL, Type III luxation occurs less
frequently and is poorly described, but it is known to occur in small-breed dogs with a case study
in Cavalier King Charles Spaniel reported (McDonell 2004).

TELs are generally associated with severe pain and non-weight-bearing lameness. Most TELs are
lateral (i.e. the radius and ulna are lateral to the humerus) because of the larger-sized and distally
sloped trochlea (medial humeral condyle; Figure 14.2) making the radial head easily palpable and
the lateral epicondyle less distinct. Patients with lateral TEL present with their limb in an abducted
and externally rotated position. Congenital luxations may cause various degrees of lameness and
degrees of pain. Depending on the severity and chronicity, limited ROM and crepitus may be pre-
sent. Palpation of the elbow (for both types) allows palpation of the abnormal/displaced anatomic
structures. In extension, the anconeal process is located within the olecranon fossa, making the
elbow inherently stable. When the elbow is flexed, Campbell’s test can be used to evaluate the
integrity of the medial and lateral collateral ligament. This is done by flexing the elbow and carpus
to 90° and evaluating the maximum angles of pronation (testing medial collateral ligament integ-
rity) and supination (testing lateral collateral ligament). Normal values for Campbell’s test have
212 14 Elbow Region
been described to change pronation from approximately 30–60° after transection of the medial
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collateral ligament and supination from approximately 45–70° after transection of the lateral col-
lateral ligament. However, a large inter-animal variation was also reported (Farrell et al. 2007).
Therefore, comparison to the contralateral limb is recommended. NOTE: this test is also used to
evaluate for a pain response in dogs with ED as discussed in Section 14.6.2.
14.10.3 Diagnostics
Elbow luxations (congenital and traumatic) are generally suspected based on history (for
traumatic luxations) and palpation; the diagnosis is easily confirmed via radiography. For
TEL, craniocaudal projections clearly show displacement of the radius/ulna while lateral pro-
jections may be less obvious. The observer should also evaluate the radiographs for evidence
of chronic changes (such as osteoarthritis) or avulsion fragments of the collateral ligament
(Figure 14.9F) or other fractures since these findings may pose a contraindication for closed
reduction and require surgical intervention. For CEL, radiographic changes vary based on the
type of luxation and severity. If surgical treatment is planned, further imaging (CT) may be
indicated to assess the integrity of the coronoid process and degree of elbow incongruity, and
to aid in surgical planning.
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14.11 Panosteitis
Panosteitis is a developmental disease that affects the adipose components of the bone marrow of
long bones. The disease has also been reported in the literature as eosinophilic panosteitis, juvenile
osteomyelitis, as well as enostosis (i.e. medullary fibrosis). Histologically, the disease cycles through
a phase where adipose bone marrow is replaced with osseous tissue followed by regeneration of
the bone marrow to its original constitution. The disease was once thought to be of bacterial or
viral origin; however, currently the etiology is controversial, and newer theories have included an
association with high-protein diets and osseous compartment syndrome (Schawalder et al. 2002).
Moreover, the high incidence in German Shepherd Dogs suggests a genetic component. The dis-
ease is self-limiting and generally not associated with systemic signs. Treatment consists of rest
and pain management.

Dogs affected with panosteitis most commonly present symptomatically between 5 and
18 months of age, although the disease has been reported in patients up to 5 years of age.
Lameness can be of varying degrees of severity and may affect one or multiple limbs simultane-
ously or sequentially since the disease frequently affects multiple bones (Bohning et al. 1970).
The latter explains one of the hallmark signs of panosteitis, a lameness that shifts from one leg
to another. Since the disease is self-limiting, owners may also report that the symptoms resolved
without treatment. Recurrence may occur, yet in most cases subsequent episodes are less severe.
Panosteitis is seen most frequently in German Shepherds (with a male predisposition), although
many other large/giant breeds and even small-breed dogs are reported to be affected. As such,
the disease should be considered a differential for any juvenile dog presented with shifting leg
lameness (Towle-Millard and Breur 2018).
14.11 Panosteiti 213

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Panosteitis can affect all long bones, most commonly the bones of the elbow region (radius, ulna,
and humerus) followed by bones of the stifle region (Towle-Millard and Breur 2018). These long
bones should be carefully evaluated for pain upon deep palpation. When performing long bone
palpation, it is important to be aware of the local anatomy, since compression of the nerves may
result in a false-positive pain response. The disease starts in the location of the nutrient foramina;
however, the entire diaphysis and areas of the metaphysis can be affected. Physical exam should
also evaluate for any concomitant disease (such as ED).
14.11.3 Diagnostics
Radiographs are used most frequently to confirm the clinical suspicion of panosteitis. Radiographic
changes vary depending on the stages of the disease and are most visible in the location of the nutrient
foramina. During the early stages, a decreased radiodensity of the medullary cavity has been reported
(Towle-Millard and Breur 2018). However, the hallmark feature of panosteitis is an intramedullary
increase in radiodensity (Figure 14.10) since the early stages are frequently missed. Specific lesions
include opacities of the medullary canal (these can be well demarcated or diffuse, i.e. “medullary
blurring”), loss of normal trabecular pattern (i.e. “trabecular coarsening”), and changes to the endos-
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teum (the layer that lines the medullary cavity, i.e. “endosteal roughening;” Stead et al. 1983).
(A)
(B)
(C) (D) (E) (F) (G)
Figure 14.10 Panosteitis: (A, F, G) normal radiographs for comparison; (B–E) radiographs consistent with
panosteitis illustrating the variable radiographic appearance of this disease: (B) increased intramedullary
opacity and loss of trabecular pattern (black arrow); (C) well-demarcated intramedullary opacity (white
arrow); and (D, E) endosteal roughening and diffuse intramedullary opacities (white arrows).
214 14 Elbow Region
Early stages of the disease may not be detectable with radiography. If panosteitis is suspected, yet
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no radiographic changes are evident, advanced imaging such as CT or nuclear scintigraphy may be
utilized. Alternatively, repeat radiographs in two to four weeks in combination with an improve-
ment in clinical symptoms may verify the diagnosis.
14.12 Septic Arthritis
Septic (or infectious) arthritis results from one of three general mechanisms: direct introduction
(i.e. via surgery or trauma), hematogenous seeding, or local spread of infectious organisms into the
synovium/joint space. Regardless of the mechanism, the most common cause of infection is bacte-
rial. However, fungal, protozoal, mycoplasmal, mycobacterial, and rickettsial infections have all
been reported and should therefore be considered as differential diagnoses particularly if treat-
ment with antibiotics is unsuccessful. Since lameness associated with septic arthritis requires a
change of the treatment plan, it is an important differential diagnosis to consider.
Septic arthritis resulting from direct introduction via surgery is probably the most common form
of septic arthritis in dogs, yet the incidence is fairly low (approximately 1–5%). The stifle, elbow,
and carpus have been reported to be most commonly affected.
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Hematogenous septic arthritis is likely the second most common form of septic arthritis in
dogs. Two different types have been described: a juvenile form in dogs <1 year of age (Fitch
et al. 2003) and an adult form, recently also termed “spontaneous septic arthritis,” that is
described in middle-aged dogs with preexisting joint disease (e.g. osteoarthritis; Benzioni
et al. 2008; Mielke et al. 2018). Regardless of the type, in small animals with hematogenous
septic arthritis, most often a single joint is affected. The juvenile form appears to be rare, but
large-/giant-breed dogs appear predisposed and the elbow is most frequently affected (Fitch
et al. 2003). Spontaneous septic arthritis of both the elbow and hip joint has been described
(Benzioni et al. 2008; Mielke et al. 2018). It is unknown why preexisting joint disease predis-
poses to hematogenous spread to the joint, although, increased synovial vascularity/blood
flow due to chronic osteoarthritis may ease hematogenous introduction of bacteria into the
joint (Clements et al. 2005).
Joint infection causes local inflammation followed by release of catabolic enzymes and loss of
glycosaminoglycan resulting in further deterioration of the joint. As such, early intervention
including at least joint aspiration, culture, and antibiotic therapy should be instituted as soon as
possible. Other treatment options such as joint irrigation, arthroscopic debridement/lavage, and
local antibiotics may also be considered.

Most dogs with septic arthritis have a history of surgical intervention, trauma, or previous osteo-
arthritis in the affected joint. Particularly in the latter case, it can be difficult for owners to dif-
ferentiate infection from the variable severity of clinical signs associated with osteoarthritis. Dogs
presenting for septic arthritis after surgery can be of any age and breed. Infection after surgery is
observed frequently during the early postoperative phase but may also be seen months–years after
surgery with low-grade infections. Dogs with septic arthritis secondary to chronic osteoarthritis
are frequently middle-aged to older medium large-breed dogs (Clements et al. 2005; Milgram
et al. 2018). If acute worsening of a dog with previously diagnosed osteoarthritis is observed,
spontaneous septic arthritis should be considered an important differential diagnosis.
14.13 Flexor Enthesopath 215

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Lameness associated with septic arthritis is generally severe and associated with substantial pain
upon joint manipulation. Periarticular joint swelling (in severe cases pitting edema) and local heat
is common and can be severe at times (Video 14.3). Other symptoms associated with postsurgical
septic arthritis may include discharge (varying from serous purulent) from the incision site, licking
of the surgical site, or exposure of the implant. Some animals present with pyrexia and/or local lym-
phadenopathy; however, a lack of either or both does not rule out septic arthritis as a diagnosis.
Video 14.3
Clinical presentation of septic elbow arthritis mimicking a neurologic problem.
14.12.3 Diagnostics
A diagnosis of septic arthritis is made based on a combination of clinical symptoms, physical exam
findings, cytology, and joint fluid culture. However, cytologic findings in septic arthritis vary
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(Chapter 9) and rarely show the pathognomonic finding of intracellular bacteria. Similarly, a nega-
tive culture has been reported in up to 50% of dogs with septic arthritis (Clements et al. 2005).
Therefore, because some cases with suspected septic arthritis may not be diagnosed definitively,
response to antibiotic therapy may be used to solidify a tentative diagnosis.
Radiographs may be used to diagnose chronic changes associated with ongoing septic arthritis.
Such changes may include secondary degenerative or erosive changes and signs of osteomyelitis
(Figure 14.12C). For some joints (such as stifle), substantial joint effusion can be seen radiographi-
cally and be a helpful indicator of intra-articular disease.
14.13 Flexor Enthesopathy
Flexor enthesopathy (FE) is defined as pathologic changes of the flexor muscles originating at the
medial epicondyle of the humerus (De Bakker et al. 2012). The disease has previously been reported
under the names ununited medial epicondyle and medial humeral condylar osteochondritis dis-
secans. This disease can be a single disease entity (primary FE) or may occur together with other
elbow pathologies such as MCD (concomitant or secondary FE). Treatment of the primary form
focuses on treating the affected muscles while the concomitant form is frequently treated by
addressing the concomitant pathologies (De Bakker et al. 2013).

FE has been described in several large medium-sized breeds. The incidence has been reported to
be 15% in nonclinical Labrador Retrievers (Paster et al. 2009) and 40% in dogs presented for lame-
ness thought to be due to elbow pathology (De Bakker et al. 2012).

Palpation of the origin of the flexor muscles may reveal thickening and occasionally the calcified
bodies can be palpable. Pain upon stretching of the flexor muscles (carpal extension while flexing
216 14 Elbow Region
the elbow; Chapter 5) may be elicited, while hyperextension of the elbow joint is non-painful with
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the primary form. Medial compartment palpation may indicate MCD (i.e. indicating the secondary
form of FE; Section 14.6).
14.13.3 Diagnostics
A diagnosis of FE can be made if radiographs show calcification in the area of the medial epicon-
dyle (Figure 14.11). However, radiographs do not always allow to differentiate primary from
concomitant FE. For this purpose, CT is generally recommended in dogs with radiographic evi-
dence of FE to evaluate for MCD. Arthroscopy can be used to evaluate the origin of the flexor
muscles, nonetheless in one study it was unable to allow differentiation of the two forms (De
Bakker et al. 2013). If no radiographic calcification is present, ultrasound is a useful tool to identify
(A) (C) (E)

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(F)
(B) (D)
(G)
Figure 14.11 Flexor enthesopathy (FE): (A, B) primary FE (white arrow); (C, D) concomitant FE with MCD
resulting in severe osteoarthritis; (E, F) primary FE, note the difficulty in identifying the calcification if it is
superimposed over other osseous structures (F, white arrow); (G) primary FE calcification (black arrow) in 3D
reconstruction of a CT.
14.14 Other Diseases Affecting the Elbow Regio 217
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(A) (B) (C)
(D)
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Figure 14.12 Other diseases affecting the elbow region: (A, B) radioulnar ischemic necrosis (RUIN), note
the focal, ill-defined cortical lucency and adjacent endosteal bone formation (white arrows); (C) severe
osseous remodeling and soft tissue swelling in a dog with chronic, septic arthritis. The visible changes
could also be consistent with a synovial neoplasm; (D) calcinosis circumscripta.
smaller areas of calcification or structural abnormalities of the flexor muscles. Other reported
imaging modalities for the differentiation of FE include MRI, HisPECT, and scintigraphy.
14.14 Other Diseases Affecting the Elbow Region
14.14.1 Calcinosis Circumscripta

Calcinosis circumscripta (also termed tumoral calcinosis; Figure 14.12D) is defined as ectopic dep-
osition of calcium salts resulting in formation of mineralization in the soft tissues (Tafti et al.
2005). The condition has been described in young large-breed dogs with the German Shepherd
218 14 Elbow Region
Dog apparently predisposed. Lesions may occur anywhere in the body, with the pelvic limb and
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tongue most commonly affected (Tafti et al. 2005). Recently a case report described calcification of
the triceps muscle in a Rottweiler (Tambella et al. 2013).
Mineralization occurs because of deposition of serum calcium areas of tissue damage due to
trauma (including surgical intervention), necrosis, inflammation, or neoplasia. The patient should
be evaluated for elevated calcium levels and screened for neoplasia. Surgical excision has been
reported.
In people, a similar well-recognized condition, heterotopic ossification (defined as the formation
of ectopic lamellar bone in soft tissues), is categorized as traumatic, neurogenic, and genetic
(Balboni et al. 2006).
14.14.2 Radioulnar Ischemic Necrosis

Radioulnar ischemic necrosis (RUIN) (Figures 14.12A, B) describes an osteolytic lesion at the level
of the interosseous ligament (Lisbeth et al. 2018). The disease has been described in a Jack Russell
Terrier and Golden Retriever (Deffontaines et al. 2016), although the authors have seen this find-
ing in several other breeds. Although the etiology is unknown, tearing of the ligament with sec-
ondary desmitis/enthesiopathy and potential ischemia is suspected. This condition is an important
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differential diagnosis since presence of the osteolytic lesion may rise suspicion of fungal or neo-
plastic disease. The location at the radioulnar ligament is key for differentiation of these from
RUIN. In both reported cases, the patients presented with a thoracic limb lameness that resolved
after treatment (nonsurgical or ulna ostectomy).
14.14.3 Triceps Tendon Disruption

Rupture or avulsion of the triceps tendon has been described in approximately 20 cases in the
veterinary literature (Earley et al. 2018), with most of these dogs presenting with a history of
trauma. In addition, prior surgery or steroid administration has also been reported. The most
frequently reported treatment consists of surgical repair followed by immobilization of the elbow
with a trans-articular fixator or splint. Important differential diagnoses include a fracture of the
olecranon or soft tissue neoplasia weakening the muscle predisposing it to rupture. Therefore,
diagnostics should include at least radiographs and ideally ultrasound to evaluate the muscle for
structural abnormalities inconsistent with a traumatic rupture. Advanced imaging such as MRI
has also been reported.
14.14.4 Elbow Region Neoplasia

Neoplasia of the elbow region is observed infrequently. Nonetheless, tumors of the synovium and
triceps muscle should be considered as differential diagnoses. Both are difficult to diagnose with
radiography and therefore additional imaging and/or diagnostics should be considered if neoplasia
is suspected. Further details about neoplastic conditions affecting the region are provided in
Chapters 11 and 17.

Other rare causes of lameness associated with pathology in the elbow region include a subchon-
dral bone cyst of the ulnar trochlear notch (Makielski et al. 2015); bilateral bone cysts affecting the
Reference 219
humeral condyles (Choate and Arnold 2011); and ossifying myositis of the extensor carpi radialis
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origin (Morton et al. 2015). Brachial plexus avulsion (Chapter 16) may be confused with disease of
the elbow region. The author has diagnosed insertional biceps tendinopathy, although this has not
been reported in peer-reviewed literature.
References
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features, and the role of radiotherapy for prophylaxis. Int J Radiat Oncol Biol Phys 65 (5): 1289–1299.
Barthélémy, N.P., Griffon, D.J., Ragetly, G.R. et al. (2014). Short- and long-term outcomes after
arthroscopic treatment of young large breed dogs with medial compartment disease of the elbow.
Vet Surg 43 (8): 935–943.
Benzioni, H., Shahar, R., Yudelevitch, S., and Milgram, J. (2008). Bacterial infective arthritis of the
coxofemoral joint in dogs with hip dysplasia. Vet Comp Orthop Traumatol 21 (3): 262–266.
Bohning, R.H. Jr., Suter, P.F., Hohn, R.B., and Marshall, J. (1970). Clinical and radiologic survey of
canine panosteitis. J Am Vet Med Assoc 156 (7): 870–883.
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Burton, N.J., Owen, M.R., Kirk, L.S. et al. (2011). Conservative versus arthroscopic management for
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Clements, D.N., Owen, M.R., Mosley, J.R. et al. (2005). Retrospective study of bacterial infective
arthritis in 31 dogs. J Small Anim Pract 46 (4): 171–176.
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(2): 144–153.
Coppieters, E., Gielen, I., Verhoeven, G. et al. (2015). Erosion of the medial compartment of the canine
elbow: occurrence, diagnosis and currently available treatment options. Vet Comp Orthop Traumatol
28 (1): 9–18.
Cross, A.R. and Chambers, J.N. (1997). Ununited anconeal process of the canine elbow. Compend
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De Bakker, E., Samoy, Y., Coppieters, E. et al. (2013). Arthroscopic features of primary and
concomitant flexor enthesopathy in the canine elbow. Vet Comp Orthop Traumatol 26 (5): 340–347.
De Bakker, E., Saunders, J., Gielen, I. et al. (2012). Radiographic findings of the medial humeral
epicondyle in 200 canine elbow joints. Vet Comp Orthop Traumatol 25 (5): 359–365.
Deffontaines, J.-B., Lussier, B., Bolliger, C. et al. (2016). Chronic desmitis and enthesiophytosis of the
radio-ulnar interosseous ligament in a dog. Can Vet J 57 (5): 487.
Dempsey, L.M., Maddox, T.W., Comerford, E.J. et al. (2019). A comparison of owner-assessed long-
term outcome of arthroscopic intervention versus conservative management of dogs with medial
coronoid process disease. Vet Comp Orthop Traumatol 32 (1): 1–9.
Earley, N.F., Ellse, G., Wallace, A.M. et al. (2018). Complications and outcomes associated with 13
cases of triceps tendon disruption in dogs and cats (2003–2014). Vet Rec 182 (4): 108.
Evans, R.B., Gordon-Evans, W.J., and Conzemius, M.G. (2008). Comparison of three methods for the
management of fragmented medial coronoid process in the dog. A systematic review and meta-
analysis. Vet Comp Orthop Traumatol 21 (2): 106–109.
220 14 Elbow Region
Farrell, M., Draffan, D., Gemmill, T. et al. (2007). In vitro validation of a technique for assessment of
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canine and feline elbow joint collateral ligament integrity and description of a new method for
collateral ligament prosthetic replacement. Vet Surg 36 (6): 548–556.
Farrell, M., Trevail, T., Marshall, W. et al. (2011). Computed tomographic documentation of the natural
progression of humeral intracondylar fissure in a cocker Spaniel. Vet Surg 40 (8): 966–971.
Fitch, R.B., Hogan, T.C., and Kudnig, S.T. (2003). Hematogenous septic arthritis in the dog: results of
five patients treated nonsurgically with antibiotics. J Am Anim Hosp Assoc 39 (6): 563–566.
Fitzpatrick, N. and Yeadon, R. (2009). Working algorithm for treatment decision making for
developmental disease of the medial compartment of the elbow in dogs. Vet Surg 38 (2): 285–300.
Groth, A.M., Benigni, L., Moores, A.P., and Lamb, C.R. (2009). Spectrum of computed tomographic
findings in 58 canine elbows with fragmentation of the medial coronoid process. J Small Anim Pract
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Hattersley, R., Mckee, M., O’Neill, T. et al. (2011). Postoperative complications after surgical
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Lisbeth, S., Andrea, K., Nikola, K. et al. (2018). Imaging diagnosis: radiography and computed
tomography of radioulnar ischemic necrosis in Jack Russell. Vet. Radiol. Ultrasound 59 (1): E7–E11.
Makielski, K., Muir, P., and Bleedorn, J. (2015). Focal defect resembling a subchondral bone cyst of the
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Marcellin-Little, D.J., DeYoung, D.J., Ferris, K.K., and Berry, C.M. (1994). Incomplete ossification of
the humeral condyle in Spaniels. Vet Surg 23 (6): 475–487.
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McDonell, H.L. (2004). Unilateral congenital elbow luxation in a Cavalier King Charles Spaniel. Can
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Michelsen, J. (2013). Canine elbow dysplasia: aetiopathogenesis and current treatment
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15
Shoulder Region
Kristina M. Kiefer1 and Dirsko J.F. von Pfeil2,3
1
Veterinary Surgery and Sports Medicine Assistance, Research and Tutelage, St. Paul, MN, USA
2
Small Animal Surgery Locum, PLLC, Dallas, TX, USA
3
Shoulder disease is becoming a more frequently recognized cause of thoracic limb lameness.
Shoulder pathology can be difficult to localize and distinguishing between elbow and shoulder
pain is a challenge that can frustrate even the most seasoned orthopedists. Osteochondrosis is one
example of a common shoulder disease that is easily identified diagnostically, as radiographs are
frequently sufficient to establish a diagnosis. However, many sources of shoulder pain arise from
soft tissue injuries and show no radiographic pathology. As such, other types of diagnostic imaging
are frequently a component in evaluation of shoulder lameness. If the clinician is struggling to
identify a painful reaction in a dog with a thoracic limb lameness, a neurologic examination
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evaluating cervical pain, brachial plexus palpation, and neuromuscular reflexes should also be
evaluated, as root signatures of the thoracic limb are not an uncommon finding.
Figure 15.1 and Table 15.1 outline common differential diagnoses and diagnostic steps for this
region.
15.2 Normal Anatomy and Osteoarthritis
The joint surfaces of the canine shoulder comprise the concave glenoid cavity of the scapula and
the convex surface of the humeral head (Figure 15.2). Shoulder stability depends on a complex
interaction between numerous structures, which can be divided into passive (i.e. static compo-
nents that are unable to contract) and active (i.e. dynamic components that can actively contract)
stabilizers. Passive shoulder stability is provided through appropriate synovial fluid volume, the
concave and convex joint surfaces of the glenoid and humeral head, and the medial and lateral
glenohumeral ligaments (MGL and LGL, respectively; Figures 15.3 and 15.4). These ligaments are
intra-articular structures and act as collateral ligaments of the shoulder joint. Another passive
stabilizer is the joint capsule, which travels from the scapular glenoid to the humeral head. Active
shoulder-stabilizing structures include some of the so-called “(rotator) cuff muscles,” such as the

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Table 15.1 Key features for selected diseases affecting the shoulder region.
Disease Common signalment Diagnostic test of choice Exam findings Treatment Clinical pearls Terminology
Fractures Any breed or age Radiographs Pain, crepitus, and Depends on location Articular fractures require
(orthogonal views)/CT non- or minimally surgical fixation; scapular
weight-bearing fractures depend on
lameness location
Medial shoulder Adult hunting and Arthroscopy/MRI Abduction pain, Nonsurgical and Frequently not identified Medial shoulder
instability agility dogs ±muscle atrophy, and surgical for severe without advanced imaging syndrome/disease
±increased abduction cases or arthroscopy
angles
Shoulder luxation History of traumatic Radiographs ROM pain, soft tissue Closed reduction or Luxation of shoulder
incident (orthogonal views) swelling, and surgical reconstruction without a traumatic
increased distance incident should be
between acromion and evaluated for glenoid
humeral head dysplasia
Biceps brachii Large-breed, active Ultrasound/MRI Pain with shoulder Depends on severity: Pain with this disease is Classified as
tendinopathy dogs flexion and elbow medical management highly variable – biceps is calcifying and
extension, and ±pain versus surgical release intra-articular (e.g. joint non-calcifying
on direct palpation of blocks/injection can be
tendon pursued)
Supraspinatus Large-breed, active Ultrasound/MRI Pain with shoulder Medical management Calcification can be Classified as
tendinopathy dogs flexion (without elbow versus surgical release incidental – need to calcifying and
extension) correlate with clinical non-calcifying
symptoms
Infraspinatus Hunting breeds Classical gait and Swelling and pain at Medical management Can be a biphasic disease Infraspinatus
disease palpation – ultrasound infraspinatus, or surgical release at process, acute (often contracture; fibrotic
to confirm diagnosis incapable of internal acute phase and missed), followed by myopathy of
rotation with tendon release with contracture infraspinatus
contracture contracture
Osteochondrosis/ Young large- or Radiographs Pain on shoulder ROM Arthroscopic Radiographs are typically
osteochondrosis giant-breed dogs (orthogonal views) and and ±weight-bearing debridement diagnostic, while
dissecans arthroscopy lameness arthroscopy confirms and
allows therapy
0004507098.INDD 224 12/10/2019 1:34:17 PM

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Caudal glenoid Any dog but Radiographs Weight-bearing Nonsurgical This can be an incidental Accessory caudal
fragments Rottweilers may be (orthogonal views) lameness, pain on management or finding and may be a sign glenoid ossification
overrepresented for ROM of joint surgical removal of osteoarthritis rather center; incomplete
accessory caudal than developmental ossification of caudal
glenoid ossification glenoid
center
Glenoid dysplasia Young dogs, mini Radiographs Non- or weight- Nonsurgical or
and toy Poodles (orthogonal views) bearing lameness, excision arthroplasty
overrepresented humeral head medial or shoulder arthrodesis
to scapula
Adhesive capsulitis Unknown Ultrasound or MRI Chronic lameness, Unknown Rare Frozen shoulder
ROM pain, and limited
shoulder mobility
Neoplasia Older dogs Radiographs Pain and non- or Depends on location Proximal humerus is
(orthogonal views), weight-bearing and neoplasia predilection site
±MRI or CT scan lameness
0004507098.INDD 225 12/10/2019 1:34:17 PM

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Fracture Septic
Visible arthritis
History of
abnormality
trauma
diagnosis
Shoulder Fracture line Non-calcifying
luxation tendinopathy
Arthrocentesis
X-rays X-rays
Shoulder joint abnormal normal
Incomplete dislocation Adhesive
ossification capsulitis
Ultrasound/MRI
Caudal glenoid Medial

fragment shoulder
Osteoarthritis
instability
Arthroscopy
Pain in
Flattening of caudal shoulder
Juvenile
humeral head region OCD
dog
OCD
CT
Lytic lesion
History of
Minimally
trauma
Osseous displaced
neoplasia fracture
Muscle biopsy/
surgery
Soft tissue Common tendinopathies:
calcification • Biceps brachii
Calcifying • Supraspinatus Infraspinatus
tendinopathy contracture
FNA
Abnormally shaped
glenoid
Glenoid Soft tissue
dysplasia neoplasia
Figure 15.1 Schematic of common diseases affecting the shoulder region and the steps necessary to establish a diagnosis.
15.2 Normal Anatomy and Osteoarthriti 227
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(A) (C) (E)
(B) (D)
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Figure 15.2 Radiographic anatomy of the (normal) shoulder joint: (A) lateral and (B) craniocaudal
radiographic view of a normal adult shoulder; (C) lateral and (D) craniocaudal radiographic view of an
immature dog, wherein the white arrows indicate normal appearance of the proximal humerus physis;
(E) separation of the humerus in a cadaver, to illustrate normal shape of the proximal physis of the
humerus (white arrow).
infraspinatus, supraspinatus, subscapularis, and teres minor muscles. The teres major, biceps
brachii, caput longum of the triceps, the coracobrachialis, and the deltoideus muscles have also
been suggested to provide minor active support.
The tendon of the biceps brachii, subscapularis muscle, and the MGL are located intra-articu-
larly and therefore can be evaluated arthroscopically. The supraspinatus is located extra-articu-
larly. The main stabilizers of the medial shoulder are the MGL and subscapularis, while the
tendons of the supraspinatus, infraspinatus, and teres minor muscles and the LGL provide the
majority of the lateral stability.
Osteoarthritis of the shoulder joint is generally thought to be associated with common shoulder
pathologies (e.g. osteochondrosis, medial shoulder instability [MSI], and tendinopathies) indicat-
ing a secondary (i.e. due to underlying disease) etiology. Interestingly, a study found that over 50%
of dogs necropsied for unrelated reasons showed cartilage erosion of the caudal humeral head, of
(A) (B)
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(C)
Figure 15.3 Normal anatomy of the medial shoulder for (A) osseous structures; (B) muscles; and (C) the
collateral ligament of the medial shoulder: (a) scapula; (b) humerus; (c) humeral head; (d) greater tubercle;
(e) supraglenoid tubercle; (f) glenoid; (g) medial glenohumeral ligament; (h) subscapularis; (i)
supraspinatus; and (j) biceps brachii.
(C)
(A) (B)
Figure 15.4 Normal anatomy of the lateral shoulder for (A) osseous structures; (B) muscles; and (C) the
collateral ligament of the lateral shoulder: (a) scapula; (b) humerus; (c) humeral head; (d) greater tubercle;
(e) supraglenoid tubercle; (f) glenoid; (g) lateral glenohumeral ligament; (h) infraspinatus; (i) supraspinatus;
(j) teres major; (k) teres minor; (l) acromial part and (m) scapular part of the deltoideus; and (n) latissimus dorsi.
15.3 Fractures of the Shoulder Regio 229
which only 0.1% were due to osteochondrosis (Craig and Reed 2013). These findings suggest that
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primary osteoarthritis (i.e. without a known cause) may be common in canine shoulder joints.
Probably because of its less confined anatomy, osteoarthritis of the shoulder joint appears to be
tolerated better than arthritis of other joints (e.g. elbow).
15.3 Fractures of the Shoulder Region
Fractures of the shoulder joint are generally associated with a history of trauma, unless they are
pathologic (Chapter 17). Most humeral fractures involve the diaphysis or distal aspect of the
humerus; fractures of the proximal, mature humerus are a rarity if no underlying pathology such
as bone neoplasia is present (Rochat 2018). Proximal Salter-Harris (SH) fractures should be consid-
ered as a differential in juvenile patients and can be mistaken for shoulder luxation (Figures 15.5
(A) (C) (E)
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(B) (D) (F)
Figure 15.5 Fractures of the shoulder region: (A) mid-diaphyseal, long-oblique humeral fracture; (B)
supraglenoid tubercle avulsion fracture (white arrow); (C, D) proximal humeral Salter-Harris Type I fracture
(white arrow); and (E, F) minimally displaced mid-body scapular fracture.
230 15 Shoulder Region
and 15.9). Fractures close to the shoulder joint more commonly consist of scapular fractures.
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Avulsion fractures of the supraglenoid tubercle (the origin of the biceps brachii) become more
obvious when performing a fully flexed view of the shoulder with the elbow extended, causing
greater displacement of the fracture due to the pull of the biceps tendon. Physical exam findings
usually reveal moderate to non-weight-bearing lameness, soft tissue swelling that may range from
minimal to severe, and significant pain on shoulder range of motion (ROM) and/or direct palpa-
tion of bony structures.
As a general note, it is important to realize that the shoulder can be a challenging joint to
isolate during manipulation and ROM, making it difficult to distinguish it from the elbow as
the source of pain. This caveat particularly applies for less painful conditions (e.g. osteochon-
drosis and mild arthritis), though it may also pertain when minimally displaced fractures are
present. When the shoulder is passively extended, the elbow also extends passively (Figure 15.6)
and while it is most convenient to flex the shoulder joint by grasping the antebrachium, this
approach simultaneously flexes the elbow. However, with conscious recognition of anatomy, it
is possible to eliminate flexion of the elbow by intentionally grasping the humerus when flexing
the shoulder joint.
Most fractures can be diagnosed with radiographs but scapular fractures can sometimes be
difficult to identify (Figure 15.5). Given the frequent traumatic nature of presentation, they may
first be identified on thoracic radiographs obtained during initial assessment and stabilization of a
traumatic patient. If the fracture is complex, a CT scan is valuable to clearly assess the extent of the
fracture as well as formulate therapeutic planning. Articular fractures and proximal humeral
fractures (including SH fractures) generally should be surgically stabilized. Minimally displaced
scapular body fractures are frequently amenable to external coaptation for management. Severely
comminuted fractures involving the articular surfaces may require arthrodesis.
(A) (B) (C) (C)

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Figure 15.6 Physical examination of the shoulder: flexion of the joint to assess for a pain response
attributable specifically to the shoulder requires intentional isolation of the joints. This is best
achieved by (A) grasping the humerus and drawing it caudodorsally toward the body of the scapula,
rather than (B) grasping the antebrachium. Note that it is impossible to isolate the elbow from the
shoulder during extension, so that (C) passive extension of the shoulder joint results in passive
extension of the elbow.
15.4 Medial Shoulder Instabilit 231
15.4 Medial Shoulder Instability

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MSI describes a condition of reduced stability of the shoulder, caused by pathology of the medial
structures of this joint. MSI is the most common type of canine shoulder instability and a frequent
cause of shoulder-related lameness (Cogar et al. 2008). Lateral and multidirectional shoulder insta-
bility has been reported to occur in about 25% of shoulder instability cases (Franklin et al. 2013).
MSI is believed to result from repetitive trauma. Depending on the amount and magnitude of
involved forces, the structures supporting the shoulder can become strained, frayed, disrupted, or
broken down completely. This results in various degrees of instability, including subluxation or
complete luxation (covered in 15.5) of the scapulohumeral joint. As MSI does not always result in
detectable instability, the term “medial shoulder syndrome or disease” has been suggested in the
non-peer-reviewed literature. While the official nomenclature may change in the future, for the
scope of this chapter, MSI will be used throughout.
The anatomy of the shoulder and its stabilizers needs to be understood to diagnose MSI. The two
most important structures affected with MSI include the subscapularis tendon (SST) and MGL.
Based on the degree of disruption of these structures, a grading system (Table 15.2) has been
proposed (O’Donnell et al. 2017).
The suggested causes for MSI include slipping, falling, and other unusual high-impact stress, as
well as chronic repetitive activity, overuse, or repetitive micro-trauma. Collectively, these all lead to
abduction of the shoulder joint with the shoulder stabilizers tested to their limits. The main stress
seems to be concentrated on the medial joint capsule, the MGL, and the SST. While it has been sug-
gested that the MGL provides the majority of medial shoulder stability (Sidaway et al. 2004), an
experimental study in purpose bred laboratory Beagles reported no instability after isolated transec-
tion of the cranial band of the MGL (Fujita et al. 2013). Six weeks after transection, villous hyper-
plasia and vascularization of the medial compartment were found. These findings suggest that an
inflammatory response caused by partial disruption of the ligament may eventually result in MSI.
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This observation is consistent with descriptions of patients who were clinically normal, but surpris-
ingly had severe damage to the MGL and SST during arthroscopic examination (Rochat 2018). The
SST can also be damaged or inflamed, which can affect medial shoulder stability. In one study,
significant MSI was detected in cadavers after transection of the SST (Pettitt et al. 2007). Muscle
atrophy, damage to other shoulder cuff muscles and congenital abnormalities such as loss of con-
cavity of the glenoid or a misshapen proximal humerus, can also contribute to instability. The latter
is a common cause for shoulder instability in small-breed dogs (Vaughan and Jones 1969).
Treatment of MSI can be nonsurgical or surgical with the choice of treatment depending on the
degree of injury and on which structures are damaged. Nonsurgical treatment generally includes
Table 15.2 Medial shoulder instability (MSI) grading scheme.
Grade Description Definition
1 Mild MSI Laxity without gross tearing of the medial glenohumeral ligament (MGL)
or subscapularis tendon (SST)
2 Moderate MSI Partial tear of MGL, SST, or both
3 Severe MSI Complete tear of MGL, SST, or both
4 Luxation Complete tear of MGL, SST, and complete displacement of humeral head
Source: Adapted from O’Donnell et al. (2017).

rehabilitation, Velpeau slings, or the use of a shoulder stabilization system (“shoulder hobbles”) that
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prevent abduction (Henderson et al. 2015). Severe instability such as subluxation and complete luxa-
tion typically require surgery. Surgical options reported comprise thermal capsulorrhaphy, intra-
articular reconstruction, and arthroscopically assisted or open placement of prosthetic ligaments.

MSI is most commonly seen in middle-aged working dogs with hunting, field trial, or competitive
agility dogs seemingly predisposed. Agility dogs must overcome jumps and A-frames, pass weave
poles, and perform quick turns, which is believed to result in damage to the medial shoulder stabi-
lizers. The reported mean age of affected dogs is four to five years (Cook et al. 2005b; O’Donnell
et al. 2017).
History and clinical signs with MSI consist of varying degrees of lameness and depend on the
severity and time since injury. Clinical signs may be very mild and only noted during performance.
Owners may observe a shortened stride and reduced level of performance, avoiding certain activi-
ties such as quick turns. However, particularly with high-grade MSI, dogs may also show more
severe symptoms such as non-weight-bearing lameness. Typically, lameness is worse after exercise
or heavy work. Further, despite rest and administration of nonsteroidal anti-inflammatories, these
signs often do not improve and return quickly once activity levels are increased.

Pain and muscle spasm upon regional palpation, atrophy of the shoulder muscles, and restricted
ROM (particularly in extension) are frequently noted upon examination of patients with MSI.
Discomfort upon abduction and increased abduction angles (as identified during the abduction
test; Figure 15.7) are also common but may not always be present.
The abduction test quantifies the degree of abduction of the shoulder. This assessment should be
SHOULDER REGION
performed with the patient awake as well as sedated. Although sedation provides the most accu-
rate measurement, evaluating the patient while awake allows the clinician to assess the degree of
discomfort. The latter can be performed with the dog standing or in lateral recumbency. To prop-
erly perform the abduction test, the elbow and shoulder are extended so that the humerus and
spine of the scapula are axially aligned. The center of the goniometer is located over the shoulder
joint. One limb of the goniometer is aligned with the spine of the scapula and the other extends
over the lateral aspect of the antebrachium, placed parallel to the humerus. One hand holds the
antebrachium at the level of the elbow and abducts the shoulder while the other hand holds the
shoulder joint/spine of the scapula. This allows the clinician to ascertain that the shoulder and
elbow joints are both extended; allowing for flexion of either joint will result in an abnormally high
value (Figure 15.7). Abduction is performed until resistance by the soft tissues is detected. The
measured goniometer value (considering straight would be 0) at that point is reported. To avoid
variations based on improper technique, it is important to always perform the abduction test fol-
lowing the same protocol. The frequently referenced normal values are based on a previous study
that evaluated 33 medium to large-breed dogs with clinical MSI and 26 control dogs. The authors
reported mean abduction angles of ~54° in the MSI group and ~33° in the control group (Cook
et al. 2005a). While these values are still used as a general reference, recent work suggests that
there are likely breed variations as well as significant variability between observers (Devitt et al.
2007; George et al. 2017). For example, a recent study in sled dogs (n = 130 shoulders) reported a
median shoulder abduction angle of ~45° in clinically normal dogs (George et al. 2017). This dis-
15.4 Medial Shoulder Instabilit 233
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(A) (B)
(C)
Figure 15.7 Shoulder abduction test: (A) subjective evaluation of the degree of shoulder abduction during
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stance which also allows to evaluate for a pain response; (B) goniometric evaluation in lateral
recumbency – for the measurements to be accurate, the elbow and shoulder must be fully extended; the
center of the goniometer is placed over the shoulder joint, the two limbs of the goniometer are aligned
with the spine of the scapula and the humerus; (C) note, if the elbow is not fully extended as illustrated in
the image, an (false) increased goniometric measurement may result.
crepancy may be due to breed variability and function, or inclusion of dogs that were affected by
nonclinical MSI, or discrepancy of measurement techniques. An increased abduction angle makes
a diagnosis of MSI more likely (Devitt et al. 2007); however, a “normal” shoulder abduction angle
does not rule out MSI. Like cranial cruciate ligament disease, partial tearing of the MGL and SST
may not result in detectable instability. Although in the authors’ experience, these patients
frequently show a more pronounced pain response during abduction.
Because of the subjective nature and variability associated with the shoulder abduction test, it
should only be used as a guide in making a diagnosis of MSI and considered in combination with
other diagnostics. In unilaterally affected dogs, abduction angles should be evaluated by compar-
ing the affected and non-affected side. A diagnosis of MSI is more likely if a patient has signifi-
cantly higher abduction on the side the patient is lame compared to the non-lame side.
Despite these possible limitations of goniometric assessment of abduction angles to help diag-
nose MSI, it remains the mainstay of diagnosis since definitive tests are more costly and involved.
The authors therefore recommend applying this test to any dog presenting with thoracic limb
lameness, keeping its limitations in mind.
15.4.3 Diagnostics
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As mentioned above, the shoulder abduction test may result in a tentative diagnosis of MSI, but
advanced imaging is necessary to confirm this diagnosis. The diagnostic modalities of choice
include ultrasound, magnetic resonance imaging (MRI), and arthroscopy, or a combination of
these. Radiographs and CT can be used to rule out other diseases.
Currently, orthogonal survey radiographs of the shoulder are mainly recommended to rule out
diseases that are easily detected radiographically (such as primary bone tumors). Dogs with MSI
frequently show no radiographic abnormalities and therefore radiographs are not very sensitive to
help diagnose MSI (or other soft tissue pathology of the shoulder). Notably, one study in particular
found up to 45% of shoulder radiographs to be normal despite severe intra-articular or periarticular
disease, such as synovitis, MGL disease, SST inflammation, or tears (Bardet 1998). The most com-
monly seen radiographic abnormality in dogs with MSI is mild osteoarthritis (Figure 15.8). On the
other hand, radiographs have recently been suggested as a more objective means of measuring
shoulder abduction angles. One cadaveric study described a technique aiming to provide a stand-
ardized radiographic measurement for shoulder abduction angles, using a specific positioning and
a restraint device (Livet et al. 2018). Clinical evaluation of this technique has not been described
yet but it may become a clinically valuable tool to help diagnose MSI in the future. Because of the
low sensitivity of radiographs to detect MSI, advanced imaging such as musculoskeletal ultra-
sound and/or MRI should be considered to establish a diagnosis.
Magnetic resonance imaging is a sensitive imaging modality for canine shoulder conditions that
allows for evaluation of the entire joint and surrounding structures. Unfortunately, MRI typically
requires full anesthesia, is time-consuming, and is costly. Recent developments in MRI technology
will likely facilitate the development of shorter protocols that can be performed under sedation but
currently, MRI is not a routine diagnostic for detection of MSI at the authors’ institutions. However,
particularly in diagnostically challenging cases or if involvement of the spinal cord, regional
nerves, and the brachial plexus is suspected, MRI is strongly recommended.
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Ultrasound is frequently used to assess the soft tissue structures of the shoulder, particularly the
lateral muscles and tendons which are easily accessible. The medial compartment of the shoulder
(A) (B) (C) (D)
(E)
Figure 15.8 Diagnostic imaging techniques of a dog diagnosed with medial shoulder instability (MSI):
(A) lateral radiograph showing minimal osteoarthritic changes; (B) MRI (sequence: Dorsal Proton Density)
illustrating typical thickening along the medial aspect of the shoulder joint (white arrow), at the
attachment of the medial glenohumeral ligament (MGHL) and subscapularis; (C) a normal shoulder MRI of
a different patient for comparison; (D) ultrasound images showing thickening and ill-defined MGHL and
subscapularis (white arrow); and (E) arthroscopic image showing tearing of the MGHL (black arrow).
15.5 Traumatic Shoulder Luxatio 235
is more difficult to assess, particularly in overweight dogs. In one study, poor correlation between
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ultrasonographic and arthroscopic evaluation of the SST was described (Cogar et al. 2008). To facil-
itate evaluation of the MGL and SST, sedation and a hockey-stick probe are recommended (Cook
2016). Benefits of ultrasound include the relatively low cost, ability to perform the examination
without general anesthesia, and possibility of performing a dynamic assessment. However, inter-
pretation of the images can be challenging and requires advanced training. If both, MRI and ultra-
sound are performed, MRI should ideally be done prior to ultrasound to avoid creation of
artifacts.
Shoulder arthroscopy has been recommended as the gold standard for diagnosing MSI (Devitt
et al. 2007). Arthroscopy allows excellent assessment of the intra-articular shoulder structures,
including the intra-articular components of the MGL and the SST. These structures can also be
placed under stress by abduction of the shoulder during arthroscopy or palpated with a probe.
Arthroscopy can also help identify concurrent shoulder pathologies, for example changes to the
biceps tendon that may occur secondary to the inflammation associated with MSI. Such changes
(secondary biceps tendinopathy) must be differentiated from primary biceps tendon disease as this
may influence the treatment. Standard arthroscopy allows to establish a diagnosis and proceed
with potential treatment at the same time, if indicated. The disadvantage of arthroscopy is that the
evaluation is limited to the intra-articular structures.
Since treatment for MSI is frequently nonsurgical, needle arthroscopy may also be used if the
focus is on the diagnostic aspect. This technique was initially reported as a diagnostic tool in horses
and uses a smaller arthroscope that can be used under sedation (Frisbie et al. 2014). Needle arthros-
copy has recently been assessed for diagnostic exploration in dogs (Fournet et al. 2018) and is
becoming more commonly used in small animal practice. The author uses needle arthroscopy if
advanced imaging has not revealed a diagnosis and if it is not clear that standard arthroscopy is
indicated. The current technical difficulty associated with needle arthroscopy is obtaining high-
resolution images similar to those acquired when using standard arthroscopy.
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While CT (and CT arthrography) is a convenient and more readily available imaging modality, it
is of limited use for the diagnosis of MSI (Eivers et al. 2018). However, CT is useful in ruling out
other diseases (such as shoulder osteochondrosis dissecans [OCD] and elbow dysplasia). A recent
report suggested that adding epinephrine to the contrast medium may improve image sharpness
by delaying diffusion of the contrast (De Simone et al. 2013). Similarly, while joint fluid analysis
can be helpful for other joints, dogs with significant pathology may show no cytological abnormali-
ties in their joint fluid (Akerblom and Sjostrom 2007).
15.5 Traumatic Shoulder Luxation
Shoulder luxation (Figure 15.9) is an uncommon condition that is typically a consequence of trau-

matic injury in dogs. This condition is different than the above-described low-grade, chronic insta-
bility of the shoulder joint (MSI). Luxation direction (based on the location of the humerus) is
most commonly medial, although lateral, cranial, and caudal have all been reported. Congenital
deformities (Section 15.10.2) may also result in luxation, which tend to be medially displaced.
These must be differentiated from traumatic luxations since the treatment is different (i.e. closed
reduction is not indicated). Acute, traumatic luxations can often be managed with closed (manual)
reduction followed by external coaptation (e.g. Velpeau sling for medial luxation; spica splint for
all others). If the joint is grossly unstable even after reduction, or medical management fails, surgi-
cal stabilization is recommended.
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(A) (C) (E)

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(B) (D) (F)
Figure 15.9 Shoulder luxation: (A, B) patient with traumatic medial shoulder luxation; (C, D) patient with
Salter-Harris Type I fracture of the proximal humerus; and (E,F) patient with glenoid dysplasia. (A) The
humeral head (black arrow) is obviously displaced medially to the glenoid cavity (white arrow) of the
scapula on the craniocaudal radiographs, which is (B) less obvious on the lateral view. However, the caudal
aspect of the glenoid has significant overlap with the caudal humeral head, indicating displacement. (C) A
physeal fracture of the proximal humerus may be mistaken for traumatic luxation. The fracture line (white
arrow) and the remaining proximal humerus (black arrow) may mimic the appearance of a luxation.
However, the humeral head within the glenoid cavity can be visualized radiographically (compare (C) to (A));
(D) the lateral view clearly depicts the humeral head within the glenoid cavity, while the diaphysis of the
humerus is displaced caudally. (E) Medial luxation secondary to glenoid dysplasia; the glenoid cavity (white
arrow) is lacking a distinct concave surface (glenoid fossa) and the humeral head (black arrow) is
abnormally shaped (compare (E) to (A)). (F) The lateral view shows significant overlap of the humeral head
over the glenoid and abnormal osseous anatomy.
15.6 Biceps Brachii Tendinopath 237

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Shoulder luxation is generally a consequence of trauma (e.g. vehicular accident), therefore any dog
may be affected. In some cases, the history (including knowledge of any trauma event) may be
unknown. A thorough investigation into preexisting lameness may be indicated, particularly if
congenital conditions are considered as differential diagnoses.

The physical exam on patients with traumatic luxation should prioritize systemic stability of the
patient, given vehicular trauma is likely to create other comorbidities. The luxation itself may be
challenging to appreciate if there is a large amount of soft tissue swelling. The limb is frequently
non-weight-bearing, with flexion of the elbow. The distal limb may be in abduction (medial luxa-
tion) or adduction (lateral luxation). When palpable, the acromion and the greater tubercle of the
head of the humerus will have increased distance between them, relative to normal. Palpation of
these structures on the contralateral limb can give a reference of a “normal” spatial relationship
between landmarks. Patients will be resistant to normal ROM of the shoulder joint. If luxation is
achieved, severe crepitation throughout manipulation may be noted. Increased abduction may be
appreciated for medial luxation, and for very unstable joints, the humeral head may palpably shift
in multiple directions relative to the scapula (e.g. the examiner may elicit cranial drawer with
cranial instability).
15.5.3 Diagnostics
Radiographs clearly demonstrate dislocation of the humeral head from the glenoid cavity
(Figure 15.9). Radiographs should be assessed for any evidence of fractures or underlying/preexisting
disease. In contrast to animals with congenital conditions (glenoid dysplasia), the radiographic
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appearance of the humeral head and glenoid cavity are normal. Further diagnostics are rarely
needed to diagnose the problem, unless mild instability, rather than a true luxation is suspected. If
the joint is extremely unstable, and the clinician is suspicious that the joint is continuously
dislocating and reducing, fluoroscopy (if available) or serial digital radiographs may be utilized to
evaluate the relationship between the humeral head the glenoid cavity. Although MRI or ultra-
sound are generally not necessary, they may benefit assessing the extent of soft tissue damage as
well as aiding surgical planning.
15.6 Biceps Brachii Tendinopathy
Biceps tendinopathy is one of the more common etiologies of shoulder pain. As our diagnostic
capacity has grown and workups of shoulder disease become more advanced, there is question as
to whether this disease has been overdiagnosed (i.e. structural pathology may be an incidental
finding). This condition is frequently referred to as biceps tenosynovitis, although this terminology
may be inappropriate since an inflammatory component is not present in all cases (Gilley et al.
2002). Biceps tendinopathies can be primary or secondary in origin. Primary etiologies include
strains, sprains, or tears (i.e. a primary problem of the biceps brachii). Secondary etiologies include
impingement by extra-articular structures such as an enlarged supraspinatus muscle or intra-articular
structures such as loose bony, fibrous, or cartilage fragments (i.e. pathology of the biceps is
caused by a different underlying condition). In general, biceps tendinopathy indicates a chronic
degenerative condition. However, rupture of the biceps tendon may be acute and can produce
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similar symptoms. Nonetheless, rupture of the biceps tendon is rare and presumed to be of trau-
matic etiology, which can occur within the substance of the tendon or as an avulsion from the
supraglenoid tubercle (Figure 15.5). Complete rupture may be asymptomatic, as the strain on the
injured tissue has been released (Wiemer et al. 2007).
Biceps tendinopathies may be classified as calcifying (i.e. if bony mineralization is present within
the tendon) or non-calcifying, thereby indicating whether the pathologic changes include calcifi-
cation of the muscle or tendon. This is particularly important from a diagnostic point of view since
non-calcifying tendinopathies can be missed if radiographs are used as the only diagnostic tool.
Calcifying tendinopathy implies chronicity. Although it is an anticipated progression of unad-
dressed disease (Bardet 1999), ambiguity remains in the literature as to whether this is a subset of
biceps tendinopathies, or its own entity.
Nonsurgical management (e.g. restricted activity, anti-inflammatories and rehabilitation, and
joint injections) or surgical treatment (e.g. biceps tendon release or tenodesis) has been reported
(Bergenhuyzen et al. 2010). If secondary biceps tendinopathy is present, the primary condition
should be addressed. For example, if impingement of the biceps tendon by the supraspinatus is
present, treating the supraspinatus may alleviate the symptoms associated with the biceps.

Biceps disease is largely associated with large-breed, active dogs, which are middle-to-older aged.
Apart from biceps rupture, a specific traumatic event is rarely noted. The patient may present with
an acute thoracic limb lameness, a chronic lameness that worsens with activity, or an intermittent
lameness. Lameness is generally weight-bearing particularly with chronic cases, but a non-weight-
bearing lameness may be observed with acute tears. Noting the chronicity may give some assis-
tance in choosing an appropriate therapeutic option and predicting prognosis.
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External structures that can generally be distinguished on physical examination of the shoulder
region include the tendon of the biceps brachii, the infraspinatus, supraspinatus, triceps and del-
toid muscles, acromion, scapular spine and body, and the greater tubercle of the humerus. The
biceps tendon may be palpated on physical exam by identifying its site of origin, the supraglenoid
tubercle on the cranial margin of the articular space. A round, thick tendon should be palpable
coursing distally from the supraglenoid tubercle, crossing the bicipital groove of the humeral head
(Figure 15.10). The supraspinatus tendon is more lateral than the biceps but covers the medially
located biceps origin substantially in some dogs (Figure 15.10). Additionally, the transverse liga-
ment covers the origin complicating palpation of the biceps origin. Care should be taken to identify
the correct tendon when possible. If the patient is well muscled, or over conditioned, palpation
may be challenging, and flexion of the shoulder may aid in identifying this structure.
Muscle atrophy of the shoulder, producing a prominent scapular spine, may be present in
chronic lameness cases as frequently seen with biceps tendinopathy. However, this is an unspecific
finding, and a tentative diagnosis of biceps tendinopathy based on physical exam is most com-
monly based on a pain response during manipulation. The sensitivity of the patient’s response to
shoulder manipulation and biceps brachii palpation is highly variable and likely dependent upon
severity, chronicity, and patient disposition. More severely affected individuals may react merely to
palpation of the biceps tendon origin. Many will respond to palpation of the tendon, while the
shoulder is flexed and the elbow simultaneously extended, placing the greatest strain on the tendon
(Figure 15.11 and Video 3.1). This test is generally known as the “biceps test” and palpation of the
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(A) (B) (C)
Figure 15.10 Cadaveric specimen demonstrating the biceps brachii anatomy of the medial aspect of the
shoulder: (A) superficial dissection illustrating the structures overlaying the biceps tendon; (B) exposure of
the biceps after removal of the pectoralis musculature; and (C) after transaction of the transverse humeral
ligament and elevation of the supraspinatus muscle, the entire tendon of the biceps brachii can be seen
deeply seated in the intertubercular groove: (a) supraspinatus muscle; (b) superficial pectoralis; (c) greater
tubercle; and (d) biceps brachii.
entire muscle should be performed in this position. Some dogs may resist this test in a standing
position because of other pathologies in the contralateral limb. As it is typically not known if there
is bilateral disease or not, it is recommended to also perform the same exam with the dog in lateral
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recumbency. A painful response upon stretching of the muscle by itself or when performing direct
palpation indicates potential biceps brachii pathology. If complete rupture of the biceps is present,
the distal limb may be elevated caudodorsally beyond normal, without restriction (Video 15.1).
Video 15.1
Biceps stretch with complete biceps tear.
Other tests described include the shoulder drawer test and the biceps retraction test. The shoul-
der drawer test has been suggested to indicate biceps tendon rupture, although most commonly it
is used to evaluate for craniocaudal shoulder instability. The biceps tendon retraction test is per-
formed to evaluate for a pain response when pulling the tendon caudally with the dog in a weight-
bearing position. A positive response indicates biceps tendinopathy (Rochat 2018).
15.6.3 Diagnostics
The pros, cons, and choice of diagnostics are similar to those described for diagnosing MSI. If the
physical exam findings indicate biceps disease, radiographs are a logical first step to rule out other
diseases and to potentially accomplish a diagnosis. However, if non-calcifying tendinopathy is pre-
sent, radiographs may be completely normal. In chronic stages of the disease, sclerosis of the
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(A) (B) (D)
(C)
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Figure 15.11 Biceps brachii palpation: (A) the biceps tendon can be digitally palpated, just medially to
the greater tubercle; (B) shoulder drawer test is performed by stabilizing the scapula with one hand,
while the other hand attempts to displace the humeral head cranially, relative to the supraglenoid
tubercle; (C) biceps disease can frequently be detected by eliciting a painful response when placing the
shoulder in flexion and hyperextending the elbow, while applying digital pressure to the biceps tendon,
the so-called biceps test; (D) a painful response during the biceps test may be due to elbow disease
since the elbow is hyperextended. This can easily be differentiated by performing isolated elbow
hyperextension.
humeral intertubercular groove and/or mineralization of the biceps tendon and osteophytosis can
be appreciated (Figure 15.12). Skyline views (Figure 15.13) may aid in identifying biceps pathology
in addition to distinguishing biceps disease from supraspinatus disease.
Contrast arthrography has been reported, but because of its invasive nature and due to the
increased use of ultrasound, this technique is less frequently performed. It may reveal incomplete
or narrowed contrast flow within the biceps tendon sheath, irregular biceps tendon definition, or
impingement of the biceps tendon (Davidson et al. 2000).
Ultrasound (Figure 10.2) is a useful tool to diagnose pathology of the biceps tendon, especially if
the ultrasonographer is skilled at musculoskeletal evaluation (Kramer et al. 2001; Barella et al.
2018). Ultrasound is the only imaging modality that can be performed in a dynamic fashion and
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(A) (B) (C)
(D)
(E) (F)
(G)
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Figure 15.12 Imaging features of (A–D) biceps and (E–G) supraspinatus tendinopathy: (A) faint
mineralization present in the bicipital groove, indicating likely biceps tendinopathy; (B) sclerosis along the
bicipital groove, a common finding with chronic bicipital tendinopathy. This dog is also suffering from
severe osteoarthritic changes; (C) arthroscopic view of the biceps tendon showing partial rupture; (D)
skyline view of the shoulder, demonstrating calcification present within the intertubercular groove, this
location is consistent with biceps tendinopathy rather than supraspinatus disease; (E, F) calcification of the
supraspinatus tendon can be visualized at the cranial aspect of the scapulohumeral joint; (G) skyline view
of the shoulder, demonstrating calcification present lateral to the intertubercular groove, this location is
consistent with supraspinatus tendinopathy rather than biceps disease.
thereby allows for the diagnosis of adhesions of the biceps tendon to the tendon sheath or joint
capsule (Cook 2016).
CT of the canine shoulder is frequently performed to rule out other diseases but it is not consid-
ered a primary imaging modality for biceps tendinopathy. CT arthrography is reported to be of
more diagnostic value than CT alone in diagnosing biceps pathology, and CT arthrography with
epinephrine appears to improve image sharpness, particularly if imaging is delayed (De Simone
et al. 2013; Eivers et al. 2018).
MRI (Figure 10.5) is a sensitive diagnostic tool for identifying both primary biceps tendinopathy
and biceps impingement (Murphy et al. 2008).
Arthroscopy has the distinct advantage to be able to combine diagnostic value with potential
immediate therapy (e.g. biceps tendon release).
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Figure 15.13 When obtaining a skyline view of shoulder, position the patient in sternal recumbency with the
patient’s head and neck placed on midline, or toward the contralateral shoulder, to prevent superimposition.
With the shoulder and elbow joints of the limb of interest kept in alignment, flex the elbow, and position the
radius and ulna laterally. The humerus should be parallel to the table top. Center the radiographic beam on
the shoulder joint, collimated to either side and several centimeters cranial and caudal to the shoulder joint.
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15.7 Supraspinatus Tendinopathy
Similar to biceps tendinopathy, supraspinatus tendinopathy has also been described as a calcifying
and non-calcifying tendinopathy (Lafuente et al. 2009; Canapp et al. 2016). While there is some
confusion whether these conditions are separate or a continuum of the disease, the term supraspi-
natus tendinopathy encompasses all conditions affecting the tendon. This may include partial,
complete, or micro-tears of the tendon (tendinosis) as well as the chronic phases which may result
in calcification of the tendon. The condition may go unidentified, or be misdiagnosed as a different
shoulder injury, and therefore may be under-recognized. On the other hand, calcification may be
an incidental finding (Maddox et al. 2013) and therefore radiographic abnormalities must be cor-
related with clinical signs. Although the pathogenesis of supraspinatus tendinopathy is not clearly
understood, repetitive microtrauma has been suggested. Medical management of supraspinatus
tendinopathy is most frequently performed but surgical resection for calcifying supraspinatus
tendinopathy has also been reported (Lafuente et al. 2009).

Supraspinatus tendinopathy most commonly occurs in medium- to large-breed, active dogs, func-
tioning as pet, working, and agility dogs (Lafuente et al. 2009; Canapp et al. 2016). A unilateral
lameness is more common than bilateral, and the disease can present acutely or after a chronic
15.8 Infraspinatus Diseas 243
history. Dogs frequently are reported to have failed medical management therapy and have chronic
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intermittent or waxing and waning lameness.

Patients generally present with a weight-bearing lameness. Pain on direct palpation of the
supraspinatus may be found. Dogs commonly have pain on flexion of the shoulder, since this
stretches the muscle. The entire muscle should be palpated starting with the origin in the supraspi-
natus fossa to the insertion on the greater tubercle. This palpation should be performed while the
shoulder is flexed. Direct palpation of the muscle insertion (i.e. the most common location of
pathology) can be difficult to differentiate from biceps pathology, given their close proximity.
Differentiation between the two conditions may be possible by adding elbow extension to the
manipulation. This maneuver stretches the biceps, which crosses both joints, whereas the
supraspinatus crosses only the shoulder, and thus extension of the elbow should not change the
pain response for supraspinatus pathology.
15.7.3 Diagnostics
Radiographic identification of supraspinatus tendinopathy is only apparent when calcification is
present. In some cases, it can be challenging to determine if the calcification is supraspinatus or
biceps tendon; however, supraspinatus calcification is generally identified more cranial and lateral
than biceps calcification (Figure 15.12). In a recent case series, supraspinatus calcification was
identified in 13% of the cases (Canapp et al. 2016). Radiographs are also useful to rule out other
disease processes such as osseous neoplasia.
Similar to biceps brachii tendinopathy, other modalities used in identifying supraspinatus ten-
dinopathy are ultrasound, MRI, and CT. Ultrasound is the most practical and cost-effective imag-
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ing modality. It allows distinction of supraspinatus disease from biceps disease and detects cases
with minor calcification (Mistieri et al. 2012). Ultrasound findings may include increased diam-
eter of the supraspinatus tendon, increased fluid content, and displacement of the biceps tendon
medially (LaFuente et al. 2009; Mistieri et al. 2012). MRI is also an effective means of diagnosing
supraspinatus tendinopathy, with similar abnormalities identified as ultrasound. Tendon volume
can be measured and was consistently found to be larger in affected than normal supraspinatus
tendons (Spall et al. 2016). CT has not been as thoroughly described for this particular disease but
may be useful to rule out other disease processes. Since the supraspinatus is an extra-articular
structure, arthroscopy is generally not considered a primary diagnostic methodology. However,
intra-articular compression of the biceps tendon, termed a supraspinatus bulge, may be observed
(Canapp et al. 2016).
15.8 Infraspinatus Disease
Infraspinatus disease is an uncommon cause of thoracic limb lameness, generally referred to as

infraspinatus contracture, the result of permanent shortening (i.e. contracture not contraction) of
the muscle. The condition manifests in two phases, the acute phase when the muscle is injured and
the chronic phase once contracture has matured. The latter causes a mechanical lameness that
results in a pathognomonic gait (Video 15.2). Animals are generally presented during the chronic
phase. However, this may change with advances in diagnostic capabilities and knowledge about
the disease progression.
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Video 15.2
Infraspinatus contracture – gait and surgery.
Because of its location within the infraspinous fossa, osteofascial compartment syndrome has
been hypothesized to be a component of the disease process. This condition occurs when muscles
that are confined to a tight osteofascial space are injured. The hemorrhage and inflammation
result in a substantial increase in pressure within the compartment. This pressure is hypothesized
to cause decreased blood supply, necrosis, and ultimately contracture of the muscle (Devor and
Sorby 2006).
Early diagnosis is key since treatment options differ greatly if animals are diagnosed during the
acute phase. The contracted infraspinatus can be treated with tenectomy of the insertion of the
infraspinatus tendon. A good-to-excellent outcome is anticipated for infraspinatus contracture
release, making this condition the only fibrotic myopathy with a favorable prognosis. However,
surgical treatment may potentially be avoided if therapy is initiated during the acute phase.
Therapy for this phase is not well studied but may include a fascial release to decrease the pressure
and avoid progression of the disease (Devor and Sorby 2006).

Hunting dogs are most commonly afflicted with infraspinatus contracture. Frequently, they are
reported to have an acute lameness that resolves with rest and medical therapy, followed by a
recurrent, persistent, static, and non-painful lameness occurring several weeks later. The first stage
is thought to be related to the original pain when the muscle is acutely injured. The inflammation
and associated pain then subside, and the abnormal gait is appreciated when fibrotic changes have
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occurred. Patients typically have a unilateral lameness; bilateral infraspinatus disease is reported
but extremely rare (Franch et al. 2009).

Physical exam findings vary depending on the phase of infraspinatus injury. During the acute
phase, mild swelling and varying degrees of pain may be identified on direct palpation and
stretching of the infraspinatus muscle. The infraspinatus originates in the infraspinous fossa of
the scapula (i.e. caudal to the scapular spine), crosses the shoulder joint, and inserts on the proxi-
molateral surface of the humerus (i.e. on the cranial aspect of the proximal humerus). Given this
location, the concentric action of the muscle varies depending on the shoulder joint position. For
instance, when the shoulder joint is flexed, the muscle extends the joint. But when extended, the
muscle flexes the joint. It is also an abductor and lateral rotator of the joint. Stretching of the
muscle, therefore, can be performed by either extending or flexing the shoulder joint, while
adducting and internally rotating the shoulder. This can be accomplished by examining the
“down” leg in recumbent position (Figure 15.14). If performed during extension and examining
the “up” leg, the entire muscle can be palpated. The emphasis of this palpation should be placed
on the myotendinous portion, which is located approximately at the level of the acromion.
However, this area may not be palpable because of the overlying deltoid muscle, particularly in
well-muscled dogs.
15.8 Infraspinatus Diseas 245
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(A)
(B)
(C)
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(D)
Figure 15.14 Infraspinatus contracture: (A, B) clinical presentation and (C, D) stretching of the
infraspinatus muscle: (A) classic stance showing external rotation of the lower limb with elbow
adduction; (B) severe infraspinatus muscle atrophy; (C) stretching and palpation of the muscle with
extension of the shoulder joint while performing limb adduction and internal rotation; (D) stretching of
the muscle with flexion of the shoulder joint while performing limb adduction and internal rotation, note
that palpation of the muscle is not possible when manipulating the “down” limb to create excessive
adduction and internal rotation.
When infraspinatus contracture occurs, the patient has a very distinctive appearance of their
limb carriage. During ambulation, the elbow is adducted and the patient circumducts the limb,
while flipping the paw to place it (Videos 15.2 and 15.3). When static, the distal antebrachium and
paw can be observed to be externally rotated, while the elbow remains adducted, with varying
degrees of shoulder abduction (Figure 15.14). This may also manifest in an elevated limb (i.e.
abducted) if the patient is placed in lateral recumbency. Severe, visible muscle atrophy isolated to
the infraspinatus muscle is also generally present.
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Video 15.3
Infraspinatus contracture – gait comparison before and after surgery.
Palpation shows that the humerus is incapable of internal rotation (pronation) relative to
the scapula, because the contracted infraspinatus prevents medial rotation. This can be evalu-
ated by stabilizing the scapula and attempting internal rotation of the humerus/limb.
Alternatively, one may internally rotate the limb without stabilizing the scapula: a patient that
has a contracted infraspinatus will show elevation of the caudal scapula during this maneuver.
The contralateral limb, when normal, provides a good reference point for what internal rota-
tion capacity should be.
15.8.3 Diagnostics
Physical exam findings with mature contractures are unique enough that diagnosis of infraspinatus
contracture is generally convincing on physical examination. Although further advanced diagnostics
are typically not required specifically for the contracture, advanced imaging is beneficial to assess for
other soft tissue injuries as well. For example, radiographs are a reasonable initial diagnostic tool to
screen for other shoulder pathology, yet are expected to be normal with infraspinatus contracture.
In contrast, acute injury of the infraspinatus can be challenging to identify on physical exam.
Ultrasound or MRI is a necessary diagnostic tool if the clinician is suspicious of early infraspinatus
injury and seeks a diagnosis prior to contracture to attempt preemptive therapy to avoid progression
of dysfunction. Ultrasound is the most affordable and clinically relevant imaging tool to confirm a
diagnosis of infraspinatus contracture. MRI is reported to have 100% agreement and concordance
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with surgical findings of infraspinatus disease (Murphy et al. 2008).

Osteochondrosis is a disorder of the endochondral ossification process of developing animals.
Normal endochondral ossification is the process whereby cartilage transforms into metaphyseal or
epiphyseal bone. In osteochondrosis, the transformation into bone is disrupted, leaving a defect in
the interface between cartilage and subchondral bone. Over time, this defect may allow the forma-
tion of a fissure or flap of cartilage over its surface, known as osteochondrosis dissecans (OCD). This
flap can dissociate, which typically leads to joint effusion, synovitis, lameness, and arthritis
(Ytrehus et al. 2007). The most likely site of OCD in the canine shoulder is the caudal surface of the
humeral head, however, it has been reported infrequently to occur in the glenoid cavity (Lande
et al. 2014; Bilmont et al. 2018). In general, surgical removal of the flap (osteochondroplasty) is
recommended for treatment of shoulder OCD, which is associated with favorable outcomes.

Given the developmental nature of the disease, most clinical symptoms occur early in the dog’s life,
with most animals presenting between 4 and 8 months of age. Large- and giant-breed dogs are most
commonly affected, and high-protein, high-calorie diets have been implicated as an associated
15.9 Osteochondrosis Dissecan 247
f actor (Richardson and Zentek 1998). On occasion, evidence of osteochondrosis may become appar-
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ent incidentally, as the disease progresses with secondary osteoarthritis, or if OCD affects other
structures (bicipital impingement secondary to joint mouse). Patients are typically lame in one limb,
with the lameness worsening with exercise or intensive activity. In spite of the tendency for unilat-
eral symptoms, approximately half of patients will have bilateral lesions (Rochat 2018).

Most animals present with a mild-moderate weight-bearing lameness. Muscle atrophy may be pre-
sent if symptoms have been noted for a prolonged period. Patients experience pain most com-
monly on flexion of the shoulder joint; however, some dogs react on extension as well. It is
important to carefully examine the contralateral limb, given the frequency of bilaterality.
An absence of pain reaction does not rule out the presence of osteochondrosis or OCD.
15.9.3 Diagnostics
Radiographs are the first-line diagnostic of choice. OCD lesions typically are readily appreciated on
the caudal surface of the humeral head as a defect in the subchondral continuity. The flap is not
actually visualized radiographically unless it has mineralized. Subchondral sclerosis can be appre-
ciated with osteochondrosis or OCD. Positioning of the shoulder joint relative to other structures
should be heeded, as summation may challenge interpretation. The lateral view is best obtained
with the shoulder joint pulled distally away from the neck, and the contralateral thoracic limb
pulled caudally away from the radiographic beam. If OCD is suspected, but not apparent radio-
graphically, lateral views with pronation and supination of the limb can improve visualization of
the caudal humeral head surface and delineate a lesion not otherwise apparent (Figure 15.15; Wall
et al. 2015). In some cases, the OCD flap may be displaced or completely dislodged and relocated
SHOULDER REGION
within the joint space. This is challenging to evaluate radiographically unless the dislodged flap is
mineralized, which can occur with chronicity.
(A) (B) (C)
(D)
Figure 15.15 Shoulder images of a single dog with (A-D) OCD illustrating that radiographic positioning
substantially changes the appearance of the lesion: (A) lateral, supinated radiograph demonstrating
characteristic OCD lesion of the caudal humeral head. There is flattening of the subchondral surface, with
minimal calcification of the flap; (B) lateral, neutral radiograph – note the mild lucency of the caudal humeral
head and flattening of the surface; (C) lateral, pronated view – there is very mild lucency of the caudal
humeral head but the lesion can easily be missed on this view; and (D) arthroscopic view of the OCD flap.
Arthrography, ultrasound, CT, and MRI have all been reported and evaluated for imaging osteo-
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chondrosis/OCD. One study reported reasonable success at identifying cartilage flaps of OCD
lesions with arthrography and ultrasound, when the flap was not mineralized, and thus not identi-
fied radiographically (Vandevelde et al. 2006). Another study reported both ultrasound and MRI
had better sensitivity (but not specificity) than radiographs at accurately diagnosing the presence
or absence of shoulder OCD (Wall et al. 2015). CT is a frequently used imaging modality since it
allows rapid investigation of the two most commonly observed pathologies in juvenile patients:
shoulder OCD and elbow dysplasia. Furthermore, it aids to detect other, less commonly observed
differential diagnoses, such as panosteitis.
Arthroscopy is also an extremely valuable tool in diagnosing OCD, since it allows for evaluation
of the cartilage surface itself. It is also the only diagnostic method that allows therapeutic interven-
tion. Since most OCD lesions are readily identified on radiographs, clinicians will frequently proceed
to arthroscopy as the next diagnostic of choice, to also allow surgical correction of the disease.
15.10 Other Diseases Affecting the Shoulder Region
15.10.1 Caudal Glenoid Fragments

Lameness resulting from a fragment in the area of the caudal glenoid has been reported although
different terminologies have been used. The condition was originally described as accessory caudal
glenoid ossification center (Olivieri et al. 2004) whereas other authors have described it as “calcifi-
cation of the caudal rim of the glenoid” (Van Vynckt et al. 2013). Regardless, these caudal glenoid
fragments may be asymptomatic, if they are not freely movable. The fragment can be identified
radiographically (Figure 15.16), although advanced imaging is prudent to ensure other causes of
lameness are not present. Arthroscopic examination can identify the degree of mobility of the frag-
ment, further validating diagnosis. It can also be utilized to remove the fragment and is reported to
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successfully alleviate lameness in some dogs (Olivieri et al. 2004).
15.10.2 Glenoid Dysplasia

Glenoid dysplasia (i.e. congenital shoulder luxation) describes a congenital deformity of the scapu-
lar glenoid cavity, which eliminates the normal articulation and stability of the shoulder joint. The
resulting consequence is usually medial shoulder luxation in juvenile dogs (Vaughan and Jones
1969). Cases are usually detected in dogs less than a year of age. Miniature and toy Poodles appear
to be a predisposed breed. Physical examination findings include a significant lameness to non-
weight-bearing function of the limb. On palpation, the humeral head is detected medial to the
scapula. Definitive diagnosis is accomplished with radiographs, which depict a distorted glenoid
cavity, displacement of the humeral head, and in some cases, a distorted humeral head (Figure 15.9).
Therapy may include surgical (excisional arthroplasty or shoulder arthrodesis) or nonsurgical
treatment, depending on severity. Identification of this disease process in a mature dog, that has
previously been asymptomatic, warrants a thorough investigation for other causes of lameness, as
this condition has been present for the life of the patient.
15.10.3 Adhesive Capsulitis

Adhesive capsulitis, also termed “frozen shoulder,” describes a condition of pain and loss of ROM
caused by fibrosis of the joint capsule and adhesion formation within the joint. In people, it may
arise spontaneously or secondary to other shoulder conditions or immobilization. Importantly, the
condition has been described to undergo multiple phases, including a final “thaw” phase, with
15.10 Other Diseases Affecting the Shoulder Regio 249
return of shoulder ROM and function regardless of intervention (Eljabu et al. 2016). This condition
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is well described in people and has recently been reported in eight canine patients (Carr et al.
2016). All patients were reported to have a chronic, severe thoracic limb lameness with pain on
shoulder manipulation and severe decrease in ROM. None of the patients responded to treatment.
Diagnostic imaging such as MRI, ultrasound, and arthroscopy may be utilized to identify underly-
ing pathology. A tentative diagnosis is made if excessive joint capsule fibrosis, scar tissue, or adhe-
sion formation is observed (Figure 15.16). If other shoulder conditions are observed, it is difficult
to know whether the observed fibrotic changes are consequences of the other disease processes or
a separate disease process. Successful treatment of adhesive capsulitis has not yet been identified
in dogs. However, the thawing phase in people is reached one to three years after initial onset of
symptoms (Eljabu et al. 2016) and it is unknown when or if this phase occurs in dogs.
15.10.4 Shoulder Region Neoplasia

The most common neoplasia of the shoulder is proximal humeral osteosarcoma. Brachial plexus
neoplasia may also mimic a shoulder lameness. These conditions should be considered as differen-
tial diagnoses in any patient and are described in Chapters 11, 16, and 17.
(A) (C) (E)
(F)
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(B) (D)
(G)
(H)
(I)
Figure 15.16 Other shoulder conditions: (A) caudal glenoid fragment (white arrow); (B) radiograph of a
dog with severe osteoarthritis, biceps disease, and a caudal glenoid fragment; (C) radiograph of a dog with
moderate osteoarthritis (white arrow); (D-H) diagnostic imaging of a dog with adhesive capsulitis, biceps
tendinopathy, and a chronic OCD lesion: (D) lateral radiograph showing flattening of the humeral head
(white arrow), mineralization in the bicipital tendon sheath, and degenerative changes; (E) positron
emission tomography (PET)/CT showing increased uptake (white arrow) of the shoulder; (F) MRI showing a
thickened joint capsule (white arrows); (G) ultrasound; (H) arthroscopy showing extensive synovial
proliferation and adhesions (white arrow) and (I) a normal joint for comparison.

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Avulsion of the supraspinatus and infraspinatus tendon has been reported in a case series of
juvenile Labrador dogs. Radiographs may aid the diagnosis if an osseous avulsion fragment
is present. Ultrasound, CT, or MRI is reasonable next diagnostics to verify the diagnosis
(Mikola et al. 2018).
Ossification of the infraspinatus tendon-bursa has been reported in a case series of adult Labrador
Retrievers (Mckee et al. 2007). Radiographs may demonstrate mineralized bodies lateral to the
humeral head most easily visible on the craniocaudal view. Ultrasound, CT, or MRI can diag-
nose the condition if mineralization is not radiographically apparent.
Medial displacement of the tendon of origin of biceps brachii is recognized to occur following rup-
ture of the transverse humeral ligament, which holds the biceps brachii securely within the
intertubercular groove (Boemo and Eaton-Wells 1995). Medial displacement of the tendon can
typically be detected while palpating the tendon and placing the shoulder through full ROM.
Occasionally, a “popping” noise of the tendon displacing through this ROM may be heard.
Ultrasound may be very useful, as it allows dynamic assessment.
Rupture of biceps tendon sheath has been reported in two cases with thoracic limb lameness. It was
diagnosed by leakage of contrast material from the biceps tendon sheath on contrast arthrogra-
phy (Innes and Brown 2004).
A single case of abnormal ossification of the supraglenoid tubercle and cranial glenoid cavity has
been reported. The dogs showed irregular margination and supraglenoid tubercle separation
from the scapula on CT (De Simone et al. 2013).
A single case report of teres minor myopathy exists (Bruce et al. 1997). Diagnosis was obtained with
ultrasound imaging of the shoulder.
Scapular luxation results from traumatic rupture of the serratus ventralis muscle. This condition is
generally diagnosed by observation of a dorsally displaced scapula (see Video 15.4), but CT or
MRI can further elucidate the degree of damage (Jones et al. 2017; Frye et al. 2018).
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Video 15.4
Scapular luxation.
References
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Canapp, S.O., Canapp, D.A., Carr, B.J. et al. (2016). Supraspinatus tendinopathy in 327 dogs: a
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abduction for diagnosis of shoulder instability in dogs using goniometry and digital image analysis.
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Pathol 50 (2): 264–268.
Davidson, E.B., Griffey, S.M., Vasseur, P.B., and Shields, S.L. (2000). Histopathological, radiographic,
and arthrographic comparison of the biceps tendon in normal dogs and dogs with biceps
tenosynovitis. J Am Anim Hosp Assoc 36 (6): 522–530.
De Simone, A., Gernone, F., and Ricciardi, M. (2013). Imaging diagnosis-bilateral abnormal
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ossification of the supraglenoid tubercle and cranial glenoid cavity in an English Setter. Vet Radiol
Ultrasound 54 (2): 159–163.
Devitt, C.M., Neely, M.R., and Vanvechten, B.J. (2007). Relationship of physical examination test of
shoulder instability to arthroscopic findings in dogs. Vet Surg 36 (7): 661–668.
Devor, M. and Sorby, R. (2006). Fibrotic contracture of the canine infraspinatus muscle. Vet Comp
Eivers, C.R., Corzo-Menendez, N., Austwick, S.H. et al. (2018). Computed tomographic arthrography is
a useful adjunct to survey computed tomography and arthroscopic evaluation of the canine shoulder
joint. Vet Radiol Ultrasound 59 (5): 535–544.
Eljabu, W., Klinger, H.M., and Von Knoch, M. (2016). Prognostic factors and therapeutic options for
treatment of frozen shoulder: a systematic review. Arch Orthop Trauma Surg 136 (1): 1–7.
Fournet, A., Manassero, M., Decambron, A., and Viateau, V. (2018). Needle arthroscopy for shoulder
joint exploration. A cadaveric study in dogs. Proceedings of the 27th Annual Scientific Meeting of the
European College of Veterinary Surgeons, Athens, Greece (4–6 July 2018). Vet Surg, E 37.
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infraspinatus muscle. Vet Comp Orthop Traumatol 22 (3): 249–252.
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lateral, and multidirectional shoulder instability in dogs. Vet Surg 42 (4): 361–364.
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using a needle arthroscope in standing horses. Vet Surg 43 (1): 12–18.
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rehabilitation of exercise-induced dorsal scapular luxation in an ultramarathon endurance sled dog
with magnetic resonance imaging diagnosis of grade II serratus ventralis strain. Can Vet J 59 (12):
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of the medial glenohumeral ligament on shoulder stability in adult Beagles. Vet Comp Orthop
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assessment of the shoulder in Iditarod sled dogs. Proceedings of the International Working Dog
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Innes, J.F. and Brown, G. (2004). Rupture of the biceps brachii tendon sheath in two dogs. J Small
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luxation in three dogs. Vet Comp Orthop Traumatol 30 (1): 75–80.
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diseases of the tendon and tendon sheath of the biceps brachii muscle. Vet Surg 30 (1): 64–71.
Lafuente, M.P., Fransson, B.A., Lincoln, J.D. et al. (2009). Surgical treatment of mineralized and
nonmineralized supraspinatus tendinopathy in twenty-four dogs. Vet Surg 38 (3): 380–387.
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findings in dogs with confirmed shoulder pathology. Vet Surg 37 (7): 631–638.
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16
Neurological Disease of the Thoracic Limb

Lisa Bartner
16.1 Introduction
When presented with a patient displaying a thoracic limb lameness, neurologic dysfunction should
always be considered a differential diagnosis and a systematic approach is necessary to determine the
cause of the gait abnormality. While there are many conditions affecting both thoracic limbs, these
conditions are generally less confusing to differentiate from orthopedic disease than a dog presenting
with monoparesis or unilateral neurogenic lameness (see Chapter 4 for definitions, Box 4.1).
Furthermore, as described in Chapter 4, the same condition may result in monoparesis and/or uni-
lateral neurogenic lameness if the dorsal and ventral nerve roots are affected, because of the close
juxtaposition between sensory and motor components supplied by these two. For example, a nerve
sheath tumor affecting the nerve root may cause inability to support weight (ventral root involve-
ment) and pain during weight support (dorsal root involvement). The focus of this chapter is diseases
that cause symptoms that can easily be confused with orthopedic causes of lameness (in its broader
applied terminology). For nervous system conditions, an anatomic diagnosis must be reached before
making a list of etiologic diagnoses; Chapter 4 described the neurologic examination and localization
(i.e. anatomic diagnosis). Table 16.1 outlines common differential diagnoses and diagnostic steps for
neurological diseases causing monoparesis or neurogenic lameness of the thoracic limb.
Video 16.1
Complete brachial plexus avulsion: clinical exam and presentation.
16.2 Relevant Anatomy
Branches of the sixth, seventh, eighth cervical, and the first and second thoracic spinal nerves fuse
and form the brachial plexus. There is variability among individual animals where some can either
have the fifth cervical and/or or lack the second thoracic spinal nerve(s), sometimes referred to as

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Table 16.1 Key features of select neurologic diseases causing monoparesis or neurogenic lameness of the thoracic limb.
Clinical
Diagnostic test of presentation and Distinguishing exam
Disease Common signalment choice course findings Treatment Clinical pearls
Intervertebral Disc Young- to middle-aged History and Acute, Depends on severity Depends on Common cause of
(IVD) extrusion adults; examination progressive, or and location; spinal clinical signs; lameness or
(Hansen Type I) chondrodystrophic MRI wax/wane hyperesthesia common conservative or monoparesis; frequently
surgical lateralized and acute
Acute non- Older, large-breed History and Peracute, May be painful on Conservative Less commonly results
compressive examination nonprogressive exam but non-painful in lameness or
nucleus pulposus MRI after 24 h after 24 h; symmetric monoparesis; more often
extrusion (ANNPE) or asymmetric signs affects multiple limbs
Fibrocartilaginous Young- to middle- History and Peracute, Usually non-painful Conservative Occasionally results in
embolism (FCE) aged, large- and examination nonprogressive and asymmetric signs lameness or paresis
giant-breed MRI after 24 h (mono- or hemiparesis)
Neoplasia of the Older but any age History and Acute or chronic, Sensory exam Conservative; Common cause of
spinal nerve or examination progressive (cutaneous testing) surgical; and monoparesis or
spinal cord Radiographs and muscle atrophy radiation therapy lameness
MRI
CT
Electrodiagnostics
Brachial plexus Any History and Peracute to acute Sensory exam Conservative; Commonly causes
injury examination Nonprogressive (cutaneous testing) typically lameness or
MRI after 24 h and muscle atrophy amputation in monoparesis (if history
Electrodiagnostics severe cases supports)
Peracute = several hours; acute = several days; chronic = weeks or longer.

CT, computed tomography; CSF, cerebrospinal fluid; and MRI, magnetic resonance imaging.
0004507099.INDD 256 12/10/2019 1:36:47 PM

16.3 Neurological Diseases Affecting the Thoracic Lim 257
a pre- or post-fixed plexus, respectively. Nevertheless, two or three spinal nerve branches combine
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to form the major named nerves of the brachial plexus, specifically the suprascapular, subscapular,
axillary, musculocutaneous, radial, median, ulnar, and lateral thoracic nerves. Table 16.2 provides
a summary of each nerve and the spinal cord segments from which they arise. Wide variations
exist among individuals but as a general guideline, nerves exiting cranially in a plexus will inner-
vate more cranial and proximal muscle groups of the limb, while more caudally exiting nerves will
innervate caudal and distal muscle groups of the limb.
The flexors of the shoulder joint (infraspinatus, teres major, deltoideus, and teres minor) are
innervated by the suprascapular and axillary nerves with small contributions from the radial nerve
(Hermanson 2013). Elbow flexion is facilitated through activation of the biceps brachii and bra-
chialis muscles innervated by the musculocutaneous nerve. Lastly, carpal and digit flexion are
mediated by median and ulnar nerve innervation to the palmar antebrachial muscles (flexor carpi
radialis and flexor carpi ulnaris muscles, and superficial digital flexor and interosseous muscles).
Muscles and their respective nerves responsible for extension of the thoracic limb include the
shoulder extensors (supraspinatus, biceps brachii, and coracobrachialis) supplied by suprascapu-
lar, axillary, and musculocutaneous nerves; the elbow extensors in the caudal brachial muscle
group (triceps brachii, anconeus, tensor fasciae antebrachia, and extensor carpi radialis) all inner-
vated by the radial nerve; and the carpal and digital extensors belonging to the craniolateral ante-
brachial muscles (extensor carpi radialis, ulnaris lateralis, common digital extensor, lateral digital
extensor, extensor digiti, and pollicis longus) supplied by the radial nerve (Hermanson 2013).
Compromise to these muscles and/or nerves, particularly the radial nerve responsible for elbow
extension, will affect the weight-bearing abilities of the limb. Injury to the other nerves may cause
gait abnormalities but the animal will be able to support its own weight.
16.3 Neurological Diseases Affecting the Thoracic Limb
Signalment and clinical progression are key factors in considering likely causes of monoparesis or
lameness affecting the thoracic limb. Commonly encountered conditions include Type I interver-
tebral disc (IVD) extrusion, neoplasia, fibrocartilaginous embolism (FCE), myelitis/meningomy-
elitis, and brachial plexus injury (Table 16.1).
16.3.1 Myelopathies and Radiculopathies

Unilateral injury or damage to the C6–T2 spinal cord segments forming the cervical intumescence
(i.e. a myelopathy) or to the associated nerve roots (i.e. a radiculopathy) can cause gait abnormali-
ties that are either restricted to only one thoracic limb, such as a lameness or monoparesis, or that
are more pronounced in both thoracic limbs (e.g. short-strided gait).
Damage to the motor neuron cell bodies in the ventral gray matter of the cervical intumescence
causes a lower motor neuron (LMN) paresis in the thoracic limbs characterized by a stiff, short-
strided gait with symmetric lesions, or a monoparesis if the lesion is unilateral. Cervical myelopa-
thies often also involve the white matter, containing the caudally directed general proprioceptive/
upper motor neuron (GP/UMN) pathways to the ipsilateral pelvic limb causing a hemiparesis, or
to both pelvic limbs causing a paraparesis (Figure 4.1); a GP ataxia may also be noted in either
scenario. Deficits to GP/UMN tracts manifest as a long-strided gait in the pelvic limbs and, when
present with a short choppy LMN thoracic limb stride, this combination is referred to as a
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Table 16.2 Summary of the major motor and sensory distribution of the brachial plexus.
Spinal cord Segmental spinal

Nerve segments Muscle innervated Motor function Cutaneous areas reflex Signs of dysfunction
Suprascapular C6, C7 Supra- and infraspinatus Extension and None None Little gait abnormality
lateral support Pronounced atrophy of
of the supraspinatus and
shoulder infraspinatus muscles
Brachiocephalicus C5, C6, C7 Cleidobrachialis Advance limb Lateral, cranial, and None Little gait abnormality
medial brachium Anesthesia of cranial brachium
Musculocutaneous C6, C7, C8 Biceps brachii, Flexion of the Craniomedial Biceps reflex, Little gait abnormality and
brachialis, and elbow antebrachium and withdrawal reflex weakened flexion of the elbow
coracobrachialis palmar aspect of the (flexion of elbow) Anesthesia of medial
paw antebrachium
Axillary C6, C7, C8 Deltoid and teres major Flexion of the None None Little gait abnormality
and minor shoulder Decreased shoulder flexion
during withdrawal reflex
Anesthesia of lateral brachium
Radial C6, C7, C8, Triceps brachii and Extension of Cranial aspect of Triceps reflex Loss of weight-bearing
T1, T2 extensors of carpus and the elbow, the antebrachium and (proximal) and Knuckling of paw
digits carpus, and dorsal aspect of paw extensor carpi Decreased extensor carpi
the digits radialis (distal) radialis and triceps reflexes
Anesthesia of cranial surface
distal to elbow
0004507099.INDD 258 12/10/2019 1:36:47 PM

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Median and ulnar C8, T1, T2 Flexors of carpus and Flexion of the Caudal aspect of Withdrawal reflex Little gait abnormality, slight
digits carpus and antebrachium, palmar (flexion of carpus sinking of the carpus
the digits aspect of paw, and and digits) Loss of carpal flexion on flexor
lateral aspect of fifth reflex
digit Partial loss of pain perception
of the palmar surface of the
foot and caudal medial
antebrachium (distal third)
Lateral thoracic C8, T1 Cutaneous trunci muscle Cutaneous Respective dermatome Cutaneous trunci Absent ipsilateral cutaneous
muscle of the to each spinal nerve reflex trunci reflex
trunk Normal sensory evaluation
Sympathetica T1, T2, T3 Dilator pupillae, orbitalis Dilation of None Pupillary light Miosis, ptosis, enophthalmos,
membrana nictitans, and the pupil reflex and presence and protrusion of third eyelid
ciliary muscle of Horner syndrome
The major spinal cord segments that contribute to the nerve are underlined.
a
The sympathetic nerve is included since it travels along the roots of the brachial plexus, but it is not considered part of the brachial plexus.
0004507099.INDD 259 12/10/2019 1:36:47 PM

260 16 Neurological Disease of the Thoracic Limb
two-engine gait. The presence of a two-engine gait is localizing to the cervical intumescence (C6–
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T2 spinal cord or caudal cervical myelopathy).

If only the C6–T2 nerve roots are injured (i.e. a radiculopathy), a thoracic limb root signature
lameness and/or monoparesis usually results and the pelvic limbs will be normal. Whether lame-
ness or monoparesis predominates in a radiculopathy depends on the pathologic involvement of
the dorsal or ventral rootlets, respectively. This distinction is far less important than realizing that
both lameness and/or monoparesis can occur with a radiculopathy.
Differential etiologic diagnoses causing caudal cervical myelopathies and radiculopathies are
outlined below and summarized in Table 16.1. An etiologic diagnosis is established based on sig-
nalment, history, clinical signs, and results of diagnostic tests, where available. Advanced imaging
modalities such as computed tomography (CT), or preferably magnetic resonance imaging (MRI)
in most cases, combined with cerebrospinal fluid (CSF) analysis most accurately confirms the neu-
rologic cause, establishes the anatomic diagnosis, and many times, determines an etiologic cause.
Treatment and prognosis are highly variable depending on severity and cause, ranging from
emergency surgical intervention to conservative management. In general, conditions that are
acute, severe, and/or progressive typically warrant more definitive therapy. For example, decom-
pressive surgery for a Type I IVD extrusion and recovery may be more complete. Whereas, condi-
tions that are chronic, mild, and/or slowly progressive can often be managed with conservative
therapy. However, recovery tends to be incomplete with residual neurologic deficits. Judicious use
of corticosteroids is important as they can falsely alter test results (e.g. MRI and CSF) and poten-
tially affect future prognosis if an animal is being undertreated (e.g. meningomyelitis or lym-
phoma) or incorrectly treated (e.g. discospondylitis).
16.3.1.1 Degenerative Intervertebral Disc Disease and Herniation

Degenerative changes of the IVD and subsequent herniation is one of the most common neuro-
logic disorders in dogs (Brisson 2010). IVD degeneration is known to predispose to intervertebral
disc herniation (IVDH), as either extrusion or protrusion of disc material. However, IVD degenera-
tion must not be thought of as synonymous with IVD herniation, as it is also a common incidental
finding in dogs without clinical signs.
The pathophysiology of IVD degeneration can be divided into chondroid metaplasia causing a
Hansen Type I IVD extrusion and fibrous metaplasia causing Hansen Type II IVD protrusion.
Chondroid metaplasia describes the process of premature degeneration frequently seen in young
chondrodystrophic breeds but medium- to large-breed dogs can also be affected. Type I IVD
extrusion is a common cause for a root signature lameness or monoparesis. The extruded disc
material can be lateralized in the vertebral canal and/or extend into the intervertebral foramen,
causing unilateral compression of the C6–T2 spinal cord and/or nerve roots, respectively.
Alternatively, a short-strided, choppy thoracic limb gait (i.e. LMN paresis) can occur with a
midline IVD Type I extrusion or Type II protrusion. Fibrous metaplasia describes the process of
natural degeneration frequently seen in middle-aged dogs; as such, symptoms are more likely to
be slowly progressive.
Dogs with a Type I IVD extrusion tend to present more acutely and have more spinal hyperes-
thesia compared to dogs affected by Type II IVD protrusions. Dogs with Type I IVD more often
show lateralized symptoms deficits although symmetrical symptoms are also common. A more
insidious onset and slow progression (days to several months) with various degrees of spinal
hyperesthesia is seen with Type II IVD protrusions and cervical spondylomyelopathy (CSM; see
Section 16.3.1.4). However, Type II IVD protrusions can have sudden worsening of the otherwise
slowly progressive signs.
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(A) (B)
(C) (D)
Figure 16.1 Imaging abnormalities illustrating a cervical fracture, radiographic changes of degenerative
intervertebral disc disease, and diffuse idiopathic skeletal hyperostosis (DISH): (A) lateral survey radiograph
illustrating a comminuted fracture of C2 with minimal displacement; (B) CT of same patient highlighting an
incomplete fracture through the cranial to mid-aspect of the left lamina of C2; (C) narrowed disc space,
sclerotic end plates, and spondylosis deformans at C6–C7 suggestive of degenerative disc disease; and (D)
classic radiographic appearance of DISH; note this condition generally does not cause clinical symptoms.
The imaging modality of choice in patients with IVDH is MRI, given its superior anatomic detail,
allowing determination of the affected disc space(s), the lateralization, and dispersion pattern (i.e.
dispersed versus non-dispersed) of the herniated disc material. Comparably, CT has the advantage
of being a faster imaging modality and can diagnose herniation of calcified discs in chondrodys-
trophic dogs. However, if there is no IVDH found on plain CT, CT myelography is necessary to
diagnose compressive lesions. CT with contrast medium may be necessary to identify parenchymal
lesions that contrast enhance, such as nerve sheath tumors or meningiomas. Radiographs can be
used to evaluate for other diseases such as osseous neoplasia and signs that may be associated with
IVDH (e.g. calcified disc material and narrowed disc spaces; Figure 16.1C). Unfortunately, such
findings do not imply compression of the spinal cord making radiographs of limited use.
16.3.1.2 Acute Non-Compressive Nucleus Pulposus Extrusion

In recent years, another type of IVDH has been identified where there is acute extrusion of well-
hydrated disc material that does not cause a compressive myelopathy: acute non-compressive
nucleus pulposus extrusion (ANNPE; De Decker and Fenn 2018). Other terms to describe this
condition include traumatic disc extrusion, high-velocity low-volume disc extrusion, and Hansen
Type III disc extrusion. ANNPE is hypothesized to occur when supraphysiologic forces cause a
small tear in the annulus fibrosus (e.g. during intense exercise or trauma, allowing sudden
extrusion of gelatinous disc material). The force of extrusion into the vertebral canal causes focal
contusive injury to the spinal cord. Unlike Type I and II IVDH, the disc material herniated during
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an ANNPE is nondegenerated, highly hydrated, and gelatinous so it rapidly dissipates leaving min-
imal to no spinal cord compression. For a visual, this can be likened to a water pistol being dis-
charged towards a person’s soft abdomen, leaving a bruise.
Affected patients are frequently older, large-breed dogs. Typically, vocalization during intense
activity is reported along with a characteristic clinical presentation: peracute onset of often severe,
asymmetric neurologic deficits that are nonprogressive after the initial 24–48 hours. The clinical
signs in most cases are lateralized and while a monoparesis can occur, other limbs are commonly
affected to a lesser severity. Approximately 40% will have moderate spinal hyperesthesia on exami-
nation. Most dogs will regain complete or near-complete neurologic function with conservative
therapy. Since these are non-compressive lesions, surgery is typically not indicated.
The imaging modality of choice to diagnose ANNPE is MRI, with the following criteria used:
focal spinal cord signal changes (indicating pathology like inflammation and edema), a lesion that
is located over the IVD space and is often lateralized, reduction in size of the well-hydrated nucleus
pulposus, mild narrowing of the IVD space, and a small volume of IVD material with minimal to
no spinal cord compression.
16.3.1.3 Fibrocartilaginous Embolism

Infarction from an FCE or other vascular-related diseases (e.g. arterial embolism causing ischemic
neuromyopathy) are common causes for hemiparesis but can also produce a thoracic limb mono-
paresis if the cervical intumesce gray matter is involved. Histologically, the embolus is identical to
the nucleus pulposus of the IVD, indicating that penetration of this material into spinal vessels
causes the embolism and associated ischemia of the spinal cord (Nakamoto et al. 2008). The clini-
cal presentation, diagnostic steps, and treatment of dogs with FCE and ANNPE are very similar;
however, dogs with FCE are generally non-painful after 24 hours and therefore show spinal hyper-
esthesia less frequently on examination. Other differentiating features of ANNPE and FCE include
the following clinical features: dogs with ANNPE are significantly older and are more likely to
have history of vocalization at the onset of clinical signs. While any age and breed can be affected,
large and giant breeds seem overrepresented with FCE. Additionally, dogs with ANNPE had
lesions affecting the C1–C5 spinal cord segments more often than FCE (Fenn et al. 2016).
Differentiating these two is not necessarily of clinical importance; however, ruling out other dis-
eases (such as acute bleeding from a tumor or compressive lesion) can be important. Since it can
be difficult to differentiate lesions on CT that do not contrast enhance, MRI is the modality of
choice to diagnose both FCE and ANNPE (De Risio and Platt 2010).
16.3.1.4 Cervical Spondylomyelopathy

CSM (“Wobbler Syndrome”) is a common cause of cervical myelopathy in medium- to giant-breed
dogs, where dynamic and static compressive factors leading to a chronic progressive (typically over
weeks to months) proprioceptive ataxia, with varying degrees of cervical hyperesthesia and paresis
(Da Costa 2010). Two pathophysiologic processes have been described, with some amount of over-
lap. Osseous-associated compression is more common in young adult giant-breed dogs (e.g. Great
Danes). It typically affects the C1–C5 spinal cord region, therefore resulting in symmetric, UMN
clinical signs. Disc-associated compression commonly affects the C6–T2 spinal cord region. Middle-
aged large-breed dogs, especially Doberman Pinschers are overrepresented. Classically, these dogs
will have ventral compression from encroachment of Type II IVDH resulting in the classic sym-
metric tetraparesis with a stiff short-strided, LMN thoracic limb gait and GP/UMN pelvic limb gait.
However, rarely CSM may cause asymmetric clinical signs that could be confused with lameness.
16.3.1.5 Other Causes of Cervical Myelopathies and Radiculopathies

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Other conditions that can cause cervical myelopathies include trauma, discospondylitis, inflam-
matory conditions, extradural synovial cysts, spinal arachnoid diverticulum, and neoplasia
(Chapter 17).
If there is witnessed severe external trauma, vertebral fracture and luxation (VFL) is considered,
with supportive clinical evidence (e.g. severe pain and radiographic confirmation). However, the
cervical spine is an uncommon region for VFL, apart from those affecting the axis. ANNPE should
also be a differential, particularly if diagnostic imaging does not show osseous abnormalities.
Traumatic injuries resulting in fractures can frequently be diagnosed with radiography, but if they
are minimally displaced, advanced imaging may be necessary (Figure 16.1A, B). Advanced imag-
ing also allows for less manipulation and 3D reconstruction potentially required for surgical
planning.
Discospondylitis is more likely to affect gait in the pelvic limbs (Chapter 21); however, it should
be considered as a differential diagnosis for any patient presenting with spinal pain as part of the
presenting history, particularly if neurologic deficits are absent or mild.
Inflammatory conditions involving the brain (meningoencephalitis) and/or spinal cord (myelitis,
meningomyelitis, and steroid-responsive meningitis–arteritis [SRMA]) can have infectious, or
more commonly, idiopathic (likely immune-mediated) etiologies (Coates and Jeffery 2014).
Idiopathic inflammatory conditions occur most frequently in young adult, small-breed dogs, caus-
ing CNS dysfunction that is usually multifocal. If the cervical intumescence is involved, thoracic
limb gait dysfunction could be recognized. Infectious etiologies typically have progressive signs
that are also multifocal but focal infections, for example tetanus, are reported.
Extradural cystic abnormalities are reported in the spinal column of dogs (Da Costa and Cook
2016). While many times these are incidental findings, they can cause lameness or monoparesis.
Extradural synovial cysts arising from the periarticular joint tissue are commonly associated with
osteoarthritic changes as well as CSM. Spinal arachnoid diverticulum (previously known as cysts)
is focal, fluid-filled dilation of the subarachnoid space, and is common in the cervical regions of
the spinal cord, especially in large-breed dogs. Collectively, these conditions have a progressive
clinical course with variable spinal hyperesthesia.
16.3.2 Neuropathies (Nerves and Brachial Plexus)

While disorders of the peripheral nervous system (PNS) are less common than those affecting
the brain or spinal cord, they are by no means rare as a group. As such, the clinician should be
able to readily recognize the characteristic neurologic presentation localizing to PNS disease.
Many of these disorders are diffuse diseases (e.g. polyradiculoneuritis), but they can present
with lameness or monoparesis prior to generalizing; other conditions remain focal (e.g. bra-
chial plexus neuritis).
Unique to this level in the spinal column is the brachial plexus, where injury or disease can
have severe consequences on mobility of the limb, many of which present an LMN paresis and/
or an apparent lameness. Cutaneous sensation will aid in mapping which nerves are affected
(Chapter 4).
The list of causes of neuropathies is extensive, continues to grow, and many causes remain
unknown. Common causes of acute mononeuropathies include nerve root tumors (Chapter 17
and Video 4.1), traumatic neuropathies, and neuritis. Other causes such as degenerative, paraneo-
plastic, or metabolic usually have a chronic insidious onset history and usually cause generalized,
symmetric clinical signs.
16.3.2.1 Neoplasia
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Tumors affecting the nervous system of the thoracic limb, particularly neoplasia of spinal nerves
(Video 4.1), occur commonly and are an important differential diagnosis for thoracic limb lame-
ness. These are discussed in Chapters 11 and 17.
16.3.2.2 Traumatic Neuropathies
16.3.2.2.1 Brachial Plexus Injuries Brachial plexus injuries are the most common traumatic
neuropathies in veterinary medicine (Gemmill and Mckee 2012). The term brachial plexus avulsion
is often used to describe these injuries, but the term brachial plexus injury is more appropriate as
there is not always a true avulsion (i.e. physical separation). They are most often due to severe
traction of the thoracic limb or abduction of the scapula as the result of severe trauma, for example
vehicular, falls from a height, gunshot, and bite wounds. These injuries may result from
compression, stretching, tearing, crushing, laceration (from fractures), or complete transection of
the nerves or nerve roots. Most commonly the damage occurs at the level of the spinal nerve roots
where there is less resistance to stretch than in more peripheral regions of nerves owing to the lack
of epineurium. The ventral (motor) roots appear to be more susceptible to injury than the dorsal
(sensory) root (Steinberg 1988; Platt and Da Costa 2012).
A clinical diagnosis is often made based on history of a traumatic injury, clinical presentation,
and neurologic examination. Depending on the extent of the trauma, all or only part of the bra-
chial plexus may be injured. Clinical signs will vary depending on which nerves are involved and
the severity of the injury. The major motor and sensory distribution of the brachial plexus is out-
lined in Table 16.2.
Partial injuries most commonly involve the caudal plexus, originating from the ventral branches
of C8, T1, and sometimes T2 spinal nerves. The muscles innervated by these nerves are involved in
elbow extension which is essential for weight-bearing and locomotion, as well as the cutaneous
trunci muscle. Clinically the animal cannot bear weight and stands with the elbow and shoulder
flexed and dropped; the carpus is knuckled (Video 16.1). Cutaneous sensation may be lost distal to
the elbow and over the caudolateral aspect of the antebrachium. If the avulsion is severe enough, it
may damage spinal cord pathways causing ipsilateral pelvic limb deficits. A partial Horner syn-
drome, characterized by anisocoria due to ipsilateral sympathetic dysfunction and resulting miosis,
can develop if the T1 nerve root is involved. Complete Horner syndrome is not commonly seen in
brachial plexus injuries in dogs. If the C8 and T1 nerve roots supplying the lateral thoracic nerve are
affected, there will be ipsilateral loss of the cutaneous trunci (panniculus) muscle reflex (Chapter 4).
Injury to the cranial plexus roots of C6 and C7 causes loss of elbow flexion and shoulder move-
ment; however, the animal can still support weight since the elbow extensors are spared. Loss of
cutaneous sensation may be appreciated cranially and medially. Complete injury to all brachial
plexus roots (C6–T2 nerve roots) causes flaccid LMN paresis or paralysis, inability to support
weight, and loss of cutaneous sensation over the entire limb.
Orthopedic injuries, particularly humeral fractures can cause nerve damage, and therefore radi-
ographs are indicated to rule out osseous pathology. Electrodiagnostics may assist in identifying
the affected nerves, although spontaneous electrical activity (indicating denervation) cannot be
detected until five to seven days after the injury. An MRI may demonstrate the abnormalities in the
nerves, intumescence, or surrounding soft tissues that are consistent with focal inflammation,
edema, and/or hemorrhage, but this is not often performed when there is definite history of trauma
since the treatment is unlikely to change. Nevertheless, MRI is recommended if there is no wit-
nessed trauma nor any apparent cause to explain the clinical signs.
In general, the prognosis for brachial plexus injury is fair to be guarded. Nociception is the most
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important prognostic factor and, if absent, is associated with poor prognosis for recovery. The suc-
cess of nerve regeneration is largely determined by the degree of disruption of the neuronal ele-
ments. Nerve injury can be classified into three broad categories, from least to most severe:
neuropraxia, axonotmesis, and neurotmesis (Welch 1996). Neuropraxia is a transient nerve dys-
function (physiologic conduction block) with little to no structural damage. It may be due to tran-
sient ischemia or mild demyelination but typically resolves over one to two months. Sensation is
often persevered because large diameter sensory axons are often spared. Axonotmesis is disruption
of axons but the nerve sheath remains intact. Both motor and sensory deficits are common along
with typical LMN signs. Spontaneous recovery occurs, although not as rapidly as neuropraxia.
Lastly, neurotmesis is complete disruption and/or separation of the nerve (i.e. avulsion). Complete
paralysis of the denervated muscle and absent nociception is expected. Spontaneous recovery only
occurs rarely.
Treatment for brachial plexus injury most commonly consists of conservative treatment with a
focus on rigorous physical therapy and general supportive care to prevent complications such as
self-mutilation due to abnormal sensation, excoriation of the digits, neurotrophic ulcers, and mus-
cle contracture.
16.3.2.2.2 Radial Nerve Injury Traumatic injury to the radial nerve is usually associated with
first rib fractures causing proximal nerve injury or humeral fractures affecting the distal
portion. Clinically, the elbow is dropped and the animal walks with the carpus and digits
knuckled. If the nerve branches supplying the triceps muscle are not involved, elbow extensor
function may be preserved. Clinical history (of trauma) usually aids in establishing the
diagnosis. Appropriate therapy of the orthopedic injuries is essential. Treatment of the
neurological injury is typically conservative as described for brachial plexus injury. Similarly,
the prognosis varies depending on the severity of neuronal injury. Neuropraxia is more
common in cases of radial nerve injury; thus, most animals recover in one to two months.
Cutaneous sensation, including nociception, is the most significantly guiding factor where
loss of sensation carries a poor prognosis.
16.3.2.3 Neuritis
Brachial plexus neuritis is a rare multiple mononeuropathy, meaning multiple nerves within the
same limb are affected. This distinguishes this relatively focal disease from more generalized dys-
function of multiple nerves on different limbs and/or cranial nerves called polyneuropathies (e.g.
idiopathic polyradiculoneuritis). The disease can be unilateral or bilateral but if it is bilateral,
signs are usually asymmetric; less severe forms have been reported with a shifting leg lameness.
The pathogenesis is unknown but, given the similarities to a disease described in humans called
serum neuritis, a hypersensitivity reaction to an immunogen (e.g. rabies vaccine and feeding
horse meat) leading to axon and myelin loss has been proposed (Dewey and Talarico 2016). A
tentative diagnosis can be made based on history, especially if there is exposure to a possible
immunogen, and clinical findings of acute unilateral or bilateral LMN paresis or plegia.
Neuroimaging such as CT or MRI may show nerve pathology (e.g. enlargement, increased signal
intensity, and contrast enhancement). Electrodiagnostic testing and muscle and/or nerve biopsies
would support, and possibly confirm, the diagnosis further. With only a few reported cases, little
is known about the prognosis, but recovery appears to be very protracted (Steinberg 1988;
Summers et al. 1995). There is no specific treatment for this disorder, although glucocorticoid
therapy has been used.
16.3.3 Myopathies and Junctionopathies

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Myopathies include disorders of skeletal and smooth muscle that can be acquired, hereditary, and
congenital (Taylor 2000). More commonly encountered conditions causing shifting lameness
include polymyositis, endocrine myopathies, and infectious myopathies. Fibrotic myopathies such
as infraspinatus contracture may also cause a unilateral lameness; this condition is commonly
confused with neurologic origin (Chapter 15).
Junctionopathies refer to conditions altering the neuromuscular junction, with myasthenia gravis
being the most reported and investigated. These are typified by generalized paresis, fatiguability,
and stiff and stilted gait. Occasionally a shifting or unilateral leg lameness, particularly during the
early stages, is reported but more commonly affects the pelvic limbs first (Chapter 21).
Diagnosis of myopathies and junctionopathies is supported by clinical presentation and exami-
nation and, in many cases, is confirmed by muscle and/or nerve biopsies. Serum muscle enzyme
levels (creatine kinase, lactate dehydrogenase, and aspartate aminotransferase) are elevated in
myositis while elevated titers of acetylcholine receptor antibodies confirm a diagnosis of myasthe-
nia gravis (Chapter 21). Treatment and prognosis are highly variable and will depend on the spe-
cific condition present.
16.3.4 Other Spinal Diseases Affecting the Thoracic Limb

While not a neurologic condition, dogs with immune-mediated polyarthritis (IMPA) can first pre-
sent with spinal hyperesthesia (Shaughnessy et al. 2016). Since affected animals may not show
accompanying peripheral joint effusion or pain upon range of motion (Chapter 13), this disease
can be confused with a neurologic problem. A shifting leg lameness and short-stilted gait may also
first appear in a single limb prior to becoming more generalized. The neurologic exam is usually
normal. Joint fluid analysis is necessary to establish a diagnosis (Chapter 9). Additionally, IMPA
can occur concurrently with SRMA in some dogs, another cause of cervical spinal pain.
The following conditions rarely cause neurologic deficits and clinical signs unless nerve roots
are involved, in which case a lameness or monoparesis may be seen:
Spondylosis deformans is a noninflammatory, degenerative disease of the vertebral column thought
to be caused by degeneration of the annulus fibrosis and its bony attachments (Romatowski
1986). Typical radiographic features include focal new bone formation and osteophytes on the
ventral and lateral aspects of the vertebrae (Figure 21.1F). Spondylosis deformans is a frequently
encountered condition and while it may be associated with IVD protrusions and foraminal ste-
nosis, almost always, it is an incidental finding. As such, a radiographic diagnosis of this condi-
tion should not be overinterpreted as a clinical problem. Importantly, while the term spondylosis
sounds similar to spondylitis (i.e. discospondylitis), these two conditions are entirely different
and must be differentiated. Most readily, the vertebral end plates in spondylosis are radiographi-
cally smooth and regular in contrast to the lytic and irregular end plates of discospondylitis
(Chapter 21).
Diffuse idiopathic skeletal hyperostosis (DISH) is a rare condition that affects the axial and appen-
dicular skeleton of young dogs. It causes extensive ossification of soft tissues along the vertebral
bodies, including the spinal ventral longitudinal ligament (Figure 16.1D). There is resulting
bridging of the disc spaces without evidence of IVD degeneration (Kranenburg et al. 2011).
DISH is rarely associated with clinical signs, but nerve root entrapment from foraminal stenosis
has been described (Taylor-Brown and De Decker 2017).
Multiple cartilaginous exostosis (MCE), also termed osteochondromatosis, is a skeletal disorder of

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young dogs causing multifocal, benign, and proliferative lesions near sites of normal endochon-
dral ossification (Franch et al. 2005). The vertebrae, ribs, and long bones are most frequently
affected. Clinical signs are related to anatomic malformations, disfigurement, and compression
of surrounding structures. Neurologic abnormalities can develop if bony tissue causes compres-
sion of neural structures (Figure 16.2). Treatment in dogs with subclinical disease is usually not
necessary since MCE is usually self-limiting after skeletal maturity. Growth after maturity sug-
gests neoplastic transformation.
Spinal dural ossification is a relatively common metaplastic and degenerative finding in dogs, espe-
cially those that are middle-aged or older (Morgan 1969). It rarely is associated with clinical
signs but is commonly encountered on advanced imaging (Jones and Inzana 2000).
(A) (B)
(C) (D) (E)
Figure 16.2 Images of a puppy diagnosed with multiple cartilaginous exostoses (MCE) affecting the
shoulder and cervical vertebrae: (A) lateral survey radiograph showing multiple mineral opacities
within interspinous soft tissue between C1–C2; (B) CT illustrating the mass causing compression of the
spinal cord; (C) ventrodorsal survey radiograph of the cervical spine; and (D, E) lateral and craniocaudal
shoulder radiographs showing a large, amorphous mineral opacity at the medial aspect of the
shoulder joint.
R
eferences
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Brisson, B.A. (2010). Intervertebral disc disease in dogs. Vet Clin North Am Small Anim Pract 40 (5):
829–858.
Coates, J.R. and Jeffery, N.D. (2014). Perspectives on meningoencephalomyelitis of unknown origin.
Vet Clin North Am Small Anim Pract 44 (6): 1157–1185.
Da Costa, R.C. (2010). Cervical spondylomyelopathy (wobbler syndrome) in dogs. Vet Clin North Am
Da Costa, R.C. and Cook, L.B. (2016). Cystic abnormalities of the spinal cord and vertebral column. Vet
Clin North Am Small Anim Pract 46 (2): 277–293.
De Decker, S. and Fenn, J. (2018). Acute herniation of nondegenerate nucleus pulposus: acute
noncompressive nucleus pulposus extrusion and compressive hydrated nucleus pulposus extrusion.
Vet Clin North Am Small Anim Pract 48 (1): 95–109.
De Risio, L. and Platt, S.R. (2010). Fibrocartilaginous embolic myelopathy in small animals. Vet Clin
North Am Small Anim Pract 40 (5): 859–869.
Dewey, C.W. and Talarico, L. (2016). Disorders of the peripheral nervous system: mononeuropathies
and polyneuropathies. In: Practical Guide to Canine and Feline Neurology, 3e (eds. C.W. Dewey and
R.C. Da Costa), 445–479. Ames: Wiley-Blackwell.
Fenn, J., Drees, R., Volk, H.A., and De Decker, S. (2016). Comparison of clinical signs and outcomes
between dogs with presumptive ischemic myelopathy and dogs with acute noncompressive nucleus
pulposus extrusion. J Am Vet Med Assoc 249 (7): 767–775.
Franch, J., Font, J., Ramis, A. et al. (2005). Multiple cartilaginous exostosis in a Golden Retriever
cross-bred puppy. Clinical, radiographic and backscattered scanning microscopy findings. Vet Comp
Gemmill, T. and Mckee, M. (2012). Monoparesis and neurological causes of lameness. In: Small
Animal Neurological Emergencies (eds. S.R. Platt and L.S. Garosi), 299–315. London: Manson/The
Veterinary Press.
Hermanson, J.W. (2013). The muscular system. In: Miller’s Anatomy of the Dog, 4e (eds. H.E. Evans,
A. DeLahunta and M.E. Miller), 185–280. Philadelphia, PA: Saunders.
Jones, J.C. and Inzana, K.D. (2000). Subclinical CT abnormalities in the lumbosacral spine of older
large-breed dogs. Vet Radiol Ultrasound 41 (1): 19–26.
Kranenburg, H.C., Voorhout, G., Grinwis, G.C. et al. (2011). Diffuse idiopathic skeletal hyperostosis
(DISH) and spondylosis deformans in purebred dogs: a retrospective radiographic study. Vet J 190
(2): e84–e90.
Morgan, J.P. (1969). Spinal dural ossification in dog: incidence and distribution based on a
radiographic study. J Am Vet Radiol Soc 10: 43–48.
Nakamoto, Y., Ozawa, T., Katakabe, K. et al. (2008). Usefulness of an early diagnosis for the favorable
prognosis of fibrocartilaginous embolism diagnosed by magnetic resonance imaging in 10 small- to
middle-sized dogs. Vet Res Commun 32 (8): 609–617.
Platt, K.B. and Da Costa, R.C. (2012). Brachial plexus trauma. In: Veterinary Surgery: Small Animal
(eds. K.M. Tobias and S.A. Johnston), 424–430. St. Louis: Elsevier/Saunders.
Romatowski, J. (1986). Spondylosis deformans in the dog. Compend Contin Educ Pract Vet 8: 531–535.
Shaughnessy, M.L., Sample, S.J., Abicht, C. et al. (2016). Clinical features and pathological joint
changes in dogs with erosive immune-mediated polyarthritis: 13 cases (2004-2012). J Am Vet Med
Assoc 249 (10): 1156–1164.
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Summers, B.A., Cummings, J.F., and DeLahunta, A. (1995). Diseases of the peripheral nervous system.
In: Veterinary Neuropathology (eds. B.A. Summers, J.F. Cummings and A. DeLahunta), 402–501.
St. Louis: Mosby.
Taylor, S.M. (2000). Selected disorders of muscle and the neuromuscular junction. Vet Clin North Am
Taylor-Brown, F. and De Decker, S. (2017). Diffuse idiopathic skeletal hyperostosis causing L4 and L5
nerve root entrapment. J Small Anim Pract 58 (12): 724–724.
Welch, J.A. (1996). Peripheral nerve injury. Semin Vet Med Surg (Small Anim) 11 (4): 273–284.
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17
Neoplastic Conditions of the Thoracic Limb

Bernard Séguin
Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Flint Animal Cancer Center, Colorado
State University, Fort Collins, CO, USA
17.1 Introduction
One of the most important neoplastic differential diagnoses for thoracic limb lameness includes
osteosarcoma of the distal radius and proximal humerus. However, other neoplastic conditions,
such as brachial plexus tumors and soft tissue tumors affecting the triceps, should also be consid-
ered. Although these latter tumors are rare, establishing a diagnosis early during the course of
progression is crucial to provide the best treatment and outcome possible. Please refer to Chapter 11
for details regarding the diagnostic workup of neoplasia.
17.2 Neoplasia of Specific Regions
17.2.1 Distal Limb Region

Tumors of the distal region of the limb commonly lead to visible swelling and/or palpable mass
formation, thereby making them visible to owners. On the other hand, absence of swelling or a
mass does not rule out neoplasia. Dogs may also present with lameness. Pain on palpation is a com-
mon finding but because some dogs do not tolerate palpation of their digits or manus/pes, inter-
pretation of the physical exam findings in these dogs can sometimes be difficult. Radiographs
should be considered whenever any subcutaneous tumors or non‐movable masses or swellings are
identified. Digital lesions causing bone lysis are more likely to be a malignant neoplasm (Marino
et al. 1995); however, common differential diagnoses include osteoarthritis and osteomyelitis. To
obtain a diagnosis, a fine‐needle aspirate (FNA) can be performed for non‐osseous tumors or osse-
ous tumors with lysis. A biopsy is generally necessary for non‐lytic osseous tumors or when a
nondiagnostic sample is acquired from FNA. Once a diagnosis of neoplasia is suspected or con-
firmed, chest radiographs and FNA of the regional lymph node(s) should be considered.
Neoplasia of the distal limb can be arbitrarily divided into tumors that affect the digits and those
that affect other tissues (i.e. non‐digital tumors). Regarding the latter, the most common non‐digital
tumors include mast cell tumor and soft tissue sarcoma, and the diagnostic approach to these

272 17 Neoplastic Conditions of the Thoracic Limb
tumors is consistent with other regions. Of tumors affecting the digits, the majority are malignant,
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with squamous cell carcinoma being the most common type followed by malignant melanoma
(Marino et al. 1995; Henry et al. 2005; Wobeser et al. 2007). Secondary infections may accompany
digital tumors and lead to increased pain and lameness. On examination, the digit may be swollen
or malformed or may have been sloughed, and discharge may be present. These signs are easily
mistaken for a primary infectious paronychia.
Digital squamous cell carcinoma affects the thoracic limb twice as often as the pelvic limb. Most
squamous cell carcinomas arise from the subungual epithelium, which typically will cause bone
lysis of the third phalanx (Figure 17.1), whereas only 5% of melanomas cause radiographically
evident bone lysis (Marino et al. 1995). Squamous cell carcinoma arising from the subungual epi-
thelium has a better prognosis than other locations on the digit. Dogs with multiple squamous cell
carcinomas of the digits are typically large-breeds with black skin and haircoat. Breeds at higher
risk to get squamous cell carcinoma are standard Poodles, Labradors, Giant Schnauzers, Gordon
Setters, Rottweilers, Dachshunds, Flat‐Coated Retrievers, Beaucerons, and Briards. Dogs with digi-
tal malignant melanoma are overrepresented by Scottish Terriers, and in females more often than
males. Both digital squamous cell carcinoma and malignant melanoma can affect multiple digits;
however, this is uncommon.
Osteosarcoma accounts for 2–6% of digital tumors (Henry et al. 2005; Wobeser et al. 2007).
Other malignant tumors of the digit include mast cell tumor, undifferentiated sarcoma, fibro-
sarcoma, synovial cell sarcoma, plasma cell tumor, hemangiosarcoma, adenocarcinoma, and
(A) (B) (C)
Figure 17.1 Digital neoplasia: (A–C) radiographs of the distal limb of three patients affected by digital
neoplasia, and white arrows indicate the affected distal phalanx and evident bone lysis. The most likely
differential diagnoses would be squamous cell carcinoma, although malignant melanoma and osteomyelitis
should be considered as differential diagnoses (but are less likely to cause the depicted degree of bone
lysis). (C) Oblique views can be helpful to clearly outline radiographic abnormalities.
17.2 Neoplasia of Specific Region 273
chondrosarcoma. Benign tumors and lesions include epithelial inclusion cyst, histiocytoma,
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hemangiopericytoma, fibroma, sebaceous gland adenoma, keratoacanthoma, adnexal dyspla-

sia, follicular cyst, keratoma, hamartoma, plasmacytoma, trichoblastoma apocrine gland cyst,
basal cell epithelioma, fibroma, hemangioma, and sebaceous hyperplasia.
Although osteosarcoma distal to the antebrachiocarpal and tarsocrural joint occurs, it appears to
be rare (Gamblin et al. 1995). While the metacarpal or metatarsal bones are the most common
sites, there does not appear to be a predilection for the thoracic or pelvic limb. Treatment options
for malignant tumors of the pes and manus include digit amputation, partial foot amputation,
partial limb amputation with prosthesis, and full limb amputation. The type of surgery will depend
on size and location of the tumor. Non‐osseous malignant tumors can be treated with marginal
excision and adjuvant radiation therapy when amputation is not possible or allowed.
17.2.2 Carpal Region

The carpal region, and more specifically the distal radius, is one of the two most common anatomic
sites for osteosarcoma (Section 11.3.3). Osteosarcoma of the distal radius remains the most frequent
neoplastic cause of lameness in this region for large‐ and Giant‐breed dogs. Because of the paucity of
soft tissues around the distal aspect of the radius, particularly on the cranial surface, it is common for
owners and veterinarians to see a “swelling” or mass effect in that region when neoplasia is present.
This holds true for osseous (i.e. osteosarcoma; Figure 13.13) or soft tissue (such as soft tissue or joint
capsule tumors) swelling. Tumors of the joint capsule are uncommon in the carpal area, nonetheless
villonodular synovitis (Section 11.3.4), histiocytic sarcoma, and synovial cell sarcoma should all be
considered as differential diagnoses. Treatment of carpal region neoplasia depends on the specific
diagnosis and extent. Options include local excision, radiation therapy, full or partial limb amputation,
as well as a variety of limb‐sparing surgeries for primary bone tumors specific to the distal radius.
17.2.3 Elbow Region

Although osteosarcoma of the distal humerus, as well as of the proximal radius and ulna, occurs, it is
rare (Liptak et al. 2004) and the maxim, “osteosarcoma occurs away from the elbow” generally holds
true. Several other rare neoplastic conditions have been described for this region: primary osteosar-
coma of the synovium of the elbow has been reported in a Labrador Retriever and should be differenti-
ated from calcinosis circumscripta (Section 14.14.1). While tumors of the synovium typically display
lytic changes in the bones on “both sides” of the joint, radiographs of this case of osteosarcoma of the
joint capsule did not reveal periarticular bone lysis (Thamm et al. 2000). Additionally, the elbow is one
of the three most common joints to develop periarticular histiocytic sarcoma. Other reported types of
sarcomas originating from the synovium in canines include malignant fibrous histiocytoma, fibrosar-
coma, and undifferentiated sarcoma (Craig et al. 2002). Synovial osteochondromatosis with malignant
transformation to chondrosarcoma has also been reported in another Labrador Retriever (Aeffner
et al. 2012). Treatment of tumors of the elbow region is challenging due to the limited soft tissues and
therefore frequently requires full limb amputation for malignant tumors.
17.2.4 Shoulder Region

The shoulder region, and more specifically the proximal humerus, is one of the two most common
anatomic sites for osteosarcoma, making it a frequent cause of lameness in large‐ and Giant‐breed
dogs. In general, scapular tumors are uncommon but, when they do occur, they are most often
malignant due to osteosarcoma. Other tumor types include chondrosarcoma, fibrosarcoma, soft
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tissue sarcoma, hemangiosarcoma, and histiocytic sarcoma. In fact, the shoulder is one of the three
most common joints to develop periarticular histiocytic sarcoma. Villonodular synovitis of the
shoulder has also been described in four dogs. Although an infrequent cause of lameness, lipomas
in the axillary area can become large enough to interfere with normal range of motion.
Palpation of this region must include the proximal humerus and scapula, which can reveal a
mass effect or pain in the presence of a tumor. The axillary region needs to be carefully palpated,
by sliding a hand in between the body wall and scapula from caudal to the scapula. Deep palpation
of the area may reveal a mass effect or pain, which is suggestive of tumors of the brachial plexus
(Section 17.2.5).
Compared to lesions of the distal radius, subtle lesions of the bones of the shoulder region can
be more easily missed on radiographs (Figure 17.2). This is due to the larger muscles surrounding
the area and greater difficulty positioning the dog to take radiographs, which often leads to super-
imposition of the shoulder region over the chest. As such, sedation to allow for appropriate posi-
tioning or advanced imaging such as CT should be considered if osseous neoplasia is a differential
diagnosis. Similarly, if a mass (suspected primary bone tumor) cannot be confidently palpated,
FNAs of the bone may require ultrasound guidance to direct the needle through the large muscle
coverage into the bone. Minimally invasive biopsy procedures of the bone performed with a
Jamshidi needle are best performed with image guidance via fluoroscopy, radiographs, or CT.
Given the proximal location, osseous neoplasia of the region is most frequently treated with
either radiation therapy or full limb amputation. Scapulectomy is a treatment option for scapular
tumors (Montinaro et al. 2013).
17.2.5 Nervous System

Tumors affecting the nervous system can be divided into those affecting the intracranial nervous
tissues, the spinal cord, or peripheral nerves. The latter two may cause unilateral symptoms and
are therefore important differential diagnoses for patients with lameness.
17.2.5.1 Spinal Cord Tumors

Spinal tumors are uncommon in dogs (McEntee and Dewey 2013). The clinical signs can be insidious,
chronic, and progressive (e.g. slow growing tumors), but can also be acute (e.g. acute hemorrhage of a
chronic tumor). The neurologic signs vary according to the location of the tumor and their severity
depends on the degree of compression, neural tissue destruction, edema, and hemorrhage, as well as
the degree of compensation of the spinal cord. Similarly, neurologic signs attributed to the presence of
spinal neoplasia can be unilateral, bilateral symmetrical, or asymmetrical. Spinal hyperesthesia is
common in instances where the tumor is found in the extradural or intradural‐extramedullary loca-
tion (see below) and may be the only abnormal finding. Animals with intramedullary tumors may not
have spinal hyperesthesia as there are no nociceptors within the spinal parenchyma. If the mass
expands to the point of stretching the meninges, or nerve roots, focal spinal hyperesthesia may result.
Advanced imaging (most frequently MRI) is generally required to detect tumors affecting the
function of the spinal cord. The only exception is tumors that cause significant lytic or proliferative
changes to the vertebrae, which can be seen on radiographs. FNAs and biopsies can be challenging
to acquire depending on the location of the lesion with respect to the nervous tissue. Cerebrospinal
fluid (CSF) analysis is typically abnormal (e.g. increased protein concentration, with or without
elevated cell count) but usually does not provide specific information about the tumor type since
neoplastic cells are rarely found unless the tumor is intradural or involves the meninges. Lymphoma
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(A) (C) (E) (G)
(B) (D) (F) (H)
Figure 17.2 Proximal humeral osteosarcoma: (A) lateral and (B) craniocaudal radiographs display a subtle
lesion (white arrows) that may be missed without performing orthogonal views; (C, D) predominant
osteolytic changes extending throughout the proximal one‐quarter of the humerus are visible; (E, F)
osteolytic and proliferative changes extend throughout the proximal one half of the humerus; (G) osteolytic
and osteoproductive changes, irregular osseous production along the cranial aspect of the proximal
humerus, as well as a smooth periosteal reaction along the caudal aspect of the humerus; and (H)
pathologic fracture due to osteosarcoma. Note the periosteal reaction, punctate lysis of the cortices and
patchy, heterogenous, and moth‐eaten appearance to the medullary cavity of the humerus.
is the one tumor type where tumor cells are most likely to be seen in the CSF. A sample collected
from the lumbar cistern has been reported to be more likely to be diagnostic than one collected
from the cerebellomedullary cistern (Thomson et al. 1990).
Tumors of the spinal cord are categorized into intramedullary, intradural‐extramedullary, and
extradural based on their location with respect to the spinal cord tissue itself and meninges:
Intramedullary neoplasms are located within the spinal cord substance and can be primary spinal
parenchymal tumors or metastatic. Primary tumors are more common in the C6–T2 segment and are
predominantly of glial cell origin; astrocytoma and ependymoma are the most frequent but other
types reported include oligodendroglioma, undifferentiated sarcoma, choroid plexus papilloma, and
meningeal sarcoma. Tumors reported to metastasize to the substance of the spinal cord are heman-
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giosarcoma, mammary gland carcinoma, malignant melanoma, and thyroid carcinoma. Antemortem
confirmation of a diagnosis of an intramedullary tumor can be challenging and carries risks of wors-
ening the neurologic status. For these reasons, it is rarely attempted. Nonetheless when it is attempted,
it may be done with a needle aspirate or biopsy. A small gauge needle is preferred but it limits the
diagnostic ability of the procedure. A biopsy can be obtained through a laminectomy or hemilami-
nectomy approach followed by a durotomy.
Intradural‐extramedullary neoplasms arise outside the spinal cord but are within the subdural
space. The most common tumors are nerve sheath tumor, meningioma, and hemangioma.
Antemortem diagnosis is possible with a needle aspirate or biopsy; minimally invasive CT‐guided
techniques may be feasible in selected cases. A biopsy also requires a laminectomy or hemilami-
nectomy approach to the lesion.
Extradural neoplasms originate outside the dura mater and include osseous and soft tissue neo-
plasia. Lymphoma is the most common soft tissue extradural tumor. Other soft tissue tumors
found in this location include meningioma, nerve sheath tumors, myxoma, myxosarcoma, plasma
cell tumor, and lipoma.
Osseous tumors include osteosarcoma, fibrosarcoma, hemangiosarcoma, multiple myeloma,
and chondrosarcoma. Osteosarcoma, fibrosarcoma, and hemangiosarcoma of the vertebrae may
also be a metastasis and therefore evaluation for a primary neoplasm should be performed. Other
tumors may metastasize to soft tissues adjacent to the vertebrae and cause secondary spinal inva-
sion and eventually compression. Malignancies can also metastasize directly to the vertebrae via
the hematogenous route. An example of the former would be metastasis from prostatic adenocar-
cinoma to the sublumbar lymph nodes and eventually invasion into the lumbar vertebrae.
Numerous other neoplasms can metastasize to vertebrae and include mammary carcinoma, peri-
anal gland adenocarcinoma, transitional cell carcinoma, Sertoli cell carcinoma, thyroid carcinoma,
and pheochromocytoma. The lumbar area is the most common site for spinal metastasis, but the
cervical and thoracic segments can also be affected.
Extradural spinal cord tumors can generally be diagnosed with a needle aspirate or biopsy. Either
procedure can be performed with a surgical approach to the lesion or image guidance with either
CT or ultrasound.
17.2.5.2 Peripheral Nerve Tumors

Tumors originating from the peripheral nervous system are termed peripheral nerve sheath
tumors. These include schwannoma, neurofibroma, perineurioma, and malignant peripheral
nerve sheath tumors (MPNST). The majority of tumors are MPNST and are biologically aggressive
by exhibiting local invasion but rarely metastasize. Being that MPNST are soft tissue sarcomas,
grade is prognostic for local recurrence and metastatic potential. These tumors can be affecting a
nerve root, spinal nerve, or the brachial plexus or be distal to the brachial plexus. The location rela-
tive to the brachial plexus (distal, within, or proximal) has prognostic value with tumors distal to
the plexus having the best prognosis (Brehm et al. 1995).
Diagnosing these tumors can be challenging, since the only clinical sign can be lameness, which
can be mild or severe. Some dogs will show a lack of weight‐bearing while standing (i.e. lift their
leg, Video 4.1), yet the lameness improves during ambulation. This has been termed “nerve root
signature lameness” and is thought to be due to compression of inflammation of a nerve root. Pain
while manipulating the neck can be detected if the tumor is present in the spinal canal and causing
cord compression. Presence of a partial Horner syndrome or loss of panniculus reflex will raise
the suspicion of a lesion proximal to the brachial plexus (Chapter 4) but their absence does not
rule it out. Muscle atrophy is usually significant (neurogenic atrophy), in fact moderate‐to‐severe
Reference 277
uscle atrophy was the most common physical exam finding (>90% of cases) in one study (Brehm
m
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et al. 1995). The muscles affected will depend on which nerve root or nerve is affected by the tumor.
Deep palpation of the axillary area can elicit pain or the observer may be able to palpate a mass
effect if the tumor involves the distal aspect of the brachial plexus. In the latter cases, ultrasound
can be helpful to establish a diagnosis; however, MRI is the imaging modality of choice, with CT
being a less desirable alternative. Early tumors can cause visible lameness with no pain detected on
physical exam and in some dogs, no changes may be observed on MRI. These cases require sequen-
tial MRIs to accomplish a diagnosis (i.e. initially the tumor is too small to see on MRI). FNA or
biopsy is needed to provide a definitive diagnosis. Yet, since these tumors are mesenchymal in
origin, an FNA may yield a nondiagnostic sample (which does not rule out a malignant tumor). A
biopsy will be needed in these instances to provide an accurate diagnosis.
Early diagnosis of these tumors is critical since cases with distal tumors can be cured with ampu-
tation if treated prior to developing metastatic disease. The location and extent of the tumor with
respect to the plexus will influence the treatment options. Tumors in or distal to the plexus can be
treated with amputation alone, while tumors invading the spinal canal should be treated with a
hemilaminectomy, and radiation therapy in addition to amputation. Local excision can be possible
in some cases and stereotactic radiation therapy is an alternative treatment.
References
Aeffner, F., Weeren, R., Morrison, S. et al. (2012). Synovial osteochondromatosis with malignant
transformation to chondrosarcoma in a dog. Vet Pathol 49 (6): 1036–1039.
Brehm, D., Vite, C., Steinberg, H. et al. (1995). A retrospective evaluation of 51 cases of peripheral
nerve sheath tumors in the dog. J Am Anim Hosp Assoc 31 (4): 349–359.
Craig, L.E., Julian, M.E., and Ferracone, J.D. (2002). The diagnosis and prognosis of synovial tumors in
dogs: 35 cases. Vet Pathol 39 (1): 66–73.
Gamblin, R., Straw, R., Powers, B. et al. (1995). Primary osteosarcoma distal to the antebrachiocarpal
and tarsocrural joints in nine dogs (1980–1992). J Am Anim Hosp Assoc 31 (1): 86–91.
Henry, C.J., Brewer, W.G. Jr., Whitley, E.M. et al. (2005). Canine digital tumors: a veterinary
cooperative oncology group retrospective study of 64 dogs. J Vet Intern Med 19 (5): 720–724.
Liptak, J.M., Dernell, W.S., Ehrhart, N., and Withrow, S. (2004). Canine appendicular osteosarcoma:
diagnosis and palliative treatment. Compend Contin Educ Vet 26 (3): 172–182.
Marino, D.J., Matthiesen, D.T., Stefanacci, J.D., and Moroff, S.D. (1995). Evaluation of dogs with digit
masses: 117 cases (1981–1991). J Am Vet Med Assoc 207 (6): 726–728.
Mcentee, M.C. and Dewey, C.W. (2013). Tumors of the nervous system. In: Withrow and MacEwen’s
Small Animal Clinical Oncology, 5e (eds. S. Withrow, D. Vail and R. Page), 583–596. St‐Louis: Elsevier.
Montinaro, V., Boston, S.E., Buracco, P. et al. (2013). Clinical outcome of 42 dogs with scapular tumors
treated by scapulectomy: a Veterinary Society of Surgical Oncology (VSSO) retrospective study
(1995–2010). Vet Surg 42 (8): 943–950.
Thamm, D.H., Mauldin, E.A., Edinger, D.T., and Lustgarten, C. (2000). Primary osteosarcoma of the
synovium in a dog. J Am Anim Hosp Assoc 36 (4): 326–331.
Thomson, C.E., Kornegay, J.N., and Stevens, J.B. (1990). Analysis of cerebrospinal fluid from the
cerebellomedullary and lumbar cisterns of dogs with focal neurologic disease: 145 cases (1985–
1987). J Am Vet Med Assoc 196 (11): 1841–1844.
Wobeser, B.K., Kidney, B.A., Powers, B.E. et al. (2007). Diagnoses and clinical outcomes associated
with surgically amputated canine digits submitted to multiple veterinary diagnostic laboratories. Vet
Pathol 44 (3): 355–361.
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Part V
Pelvic Limb Lameness

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18
Tarsal Region
TA R S A L R E G I O N
Kathleen Linn1 and Felix Michael Duerr2
1
Department of Small Animal Clinical Sciences, Western College of Veterinary Medicine, University of Saskatchewan,
Saskatoon, Saskatchewan, Canada
2
The tarsus is a joint with minimal soft tissue covering, making the bones and ligaments susceptible
to traumatic injuries such as fractures and ligament disruption. This lack of soft tissue covering is
a boon for diagnosis of lameness, because even subtle swellings, bone displacements, or instabili-
ties are readily palpable. Injuries to components of the common calcanean tendon (CCT) comprise
the other major cause of lameness attributable to the tarsal region. As dogs walk with a degree of
tarsal flexion through most of each stride, this extensor apparatus is critical in preventing collapse
when the limb is weight-bearing. Extensor tendon injuries are rare and seldom a cause of more
than transient lameness as they do not have to counteract the same magnitude of force.
Since there is no “tarsal dysplasia,” osteoarthritis (OA) of the tarsus is less often encountered
than, for example, hip or elbow OA. The only developmental disease of the region that is associated
with the development of OA is osteochondritis dissecans (OCD), which is rarely encountered.
Other causes for tarsal OA include traumatic injury and instability. Being a distal joint, immune-
mediated polyarthritis (IMPA; Chapter 13) also needs to be considered as a differential diagnosis.
Therefore, arthrocentesis and synovial fluid evaluation should be considered in cases where
inflammatory arthritis is possible.
The most commonly employed tests include radiographs and computed tomography (CT) for the
diagnosis of osseous disease and ultrasound for the diagnosis of pathology involving the CCT. Figure 18.1
and Table 18.1 outline common differential diagnoses and diagnostic steps for the tarsal region.
18.2 Normal Anatomy
The tarsus is a complex joint that works largely as a hinge, with 90% of its motion occurring at the
junction of the talus with the tibia and fibula (tarsocrural joint). A normal canine tarsus can move
from approximately 35° in full flexion to 155° in full extension, although the gastrocnemius apparatus

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Table 18.1 Key features for selected diseases affecting the tarsal region.
Diagnostic test of
Disease Common signalment choice Exam findings Treatment Clinical pearls Terminology
Fractures Any dog with trauma; Radiographs: Pain, swelling Depends on location Central and fourth tarsal
Greyhounds and (orthogonal and over injured bone; bones commonly fracture
Border Collies prone often oblique sometimes tarsal together. Malleolar
to stress fractures of views needed); deformity; fractures are often
the central and fourth CT can be helpful non-weight- accompanied by
tarsal bones during bearing lameness mediolateral tarsocrural
exertion instability
Luxations and Any dog with trauma Radiographs: Moderate to Collateral ligament Luxations may happen at Idiopathic tarsal
subluxations but may also occur orthogonal and non-weight- repair or any of the tarsal joints. Both hyperflexion
secondary to stressed views bearing lameness, replacement; partial medial and lateral collateral describes
immune-mediated deformity, and or pantarsal ligaments may be injured subluxation
disease or idiopathic sometimes arthrodesis may be with tarsocrural luxation. without an
(Shetland Sheepdogs palpable needed Evaluation of plantar and underlying cause.
and Collies) instability dorsal instability as well as The term
mediolateral instability “dorsiflexion” is
should be performed. sometimes used
Carpal hyperextension may for hyperflexion
also be present in dogs with
idiopathic hyperflexion
Tarsal Young dogs, with Orthogonal Tarsus can be Generally no Treatment of concurrent Subluxation of the
hyperextension concurrent pelvic radiographs extended to or treatment needed orthopedic problems tarsus due to
limb abnormalities or generally normal beyond 180° but is unless tarsal OCD relieves pain, but tarsal dorsal instability;
idiopathic (unless tarsal usually non- present hyperextension generally “slipped hock”;
OCD is present); painful. Ipsilateral persists sometimes referred
plantaro-dorsal hip or stifle to as tarsal
stress view show abnormalities are “plantarflexion”
hyperextension frequently evident
Immune- Large-breed Radiographs and Effusion, pain, Immunosuppressive Instability suggests that
mediated (nonerosive) and arthrocentesis and hyperflexion drugs and partial or polyarthritis is erosive; pain
polyarthritis small-breed (erosive) pantarsal or effusion may not always
arthrodesis be present
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Talar Labrador Retrievers, Radiographs; CT Short-strided gait Fragment removal; This condition is often Talar ridge OCD
osteochondrosis/ Rottweilers, helpful in affected advantage of bilateral. Tarsal
osteochondritis Bullmastiffs; young limb(s); surgery over hyperextension may be
dissecans dogs >4.5 months; tarsocrural joint is conservative present
females predisposed effusive, management
especially remains
medially and controversial
caudolaterally
Common Dogs of any age or Physical exam Plantigrade Suturing of tendon With this injury, the Achilles tendon
calcanean breed findings generally stance; with stifle combined with affected limb is generally laceration;
tendon sufficient for held in extension external coaptation fully plantigrade; an traumatic rupture;
laceration diagnosis tarsus can be fully or rigid external obvious skin laceration may Type I common
flexed fixation not be present calcanean tendon
lesion
Gastrocnemius Middle-aged Radiographs: soft Excessive tarsal Surgical Stance is rarely fully Type IIc common
tendinopathy medium- to large- tissue swelling flexion and re-apposition with plantigrade; excessively calcanean tendon
breed dogs, and often crab-claw external support; flexed digits imply presence lesion;
Dobermans and mineralization; appearance of orthosis of intact superficial digital Partial avulsion or
Labradors ultrasonography digits when flexor tendon strain of the
predisposed helpful weight-bearing gastrocnemius
tendon
Superficial Shelties and Collies Ultrasonography; Soft tissue swelling Suturing of Luxation can be either Superficial digital
digital flexor overrepresented; radiography over tuber retinacular tear lateral or medial. In chronic flexor tendon
tendon young adults calcanei; tendon cases, the displaced tendon luxation
displacement can be luxated and may not be mobile
replaced
Tarsal Middle-aged Radiographs Firm tarsal Management as for Osteoarthritis is a common Degenerative joint
osteoarthritis medium- and swelling, osteoarthritis in sequela to talar OCD disease
large-breed dogs decreased range other locations;
of motion; tarsal arthrodesis if
crepitus may be response to
present treatment is
inadequate
0004507101.INDD 283 12/10/2019 1:41:30 PM

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Septic
Tarsal luxation
arthritis
Visible
History of trauma
abnormality Immune-
Fracture Consider to establish mediated
Tarsal joint
diagnosis polyarthritis
dislocation
Collateral Fracture/fissure Arthrocentesis Soft tissue

ligament/ X-rays X-rays injury
line
shearing injury abnormal normal
Medial/lateral soft
CCT Ultrasound/MRI Dorsal/plantar
tissue swelling
tendinopathy/ tarsal joint
SDF-luxation instability
History of trauma
Soft tissue swelling
at CCT-insertion
Stress radiographs Collateral
Pain in ligament injury
Osteoarthritis Articular
degenerative
tarsal
changes region
Osseous CT Minimally
deformities/ Angular limb displaced
premature deformity fracture
physeal closure
Defects or Visual observation
osteochondral flap Regional myotendinopathies: examination OCD
OCD • Gastrocnemius
• Superficial digital flexor
Lytic lesions (may also luxate)
FNA Idiopathic tarsal
Osseous hyperflexion/
neoplasia Soft tissue -extension
calcification
Soft tissue
DDF joint mouse/
neoplasia
chronic CCT
injury
Figure 18.1 Schematic of common diseases affecting the tarsal region and the steps necessary to establish a diagnosis.
limits its ability to flex when the stifle is extended (Chapter 5). The mean tarsal standing angle for dogs
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is around 137°, but there is considerable variation due to breed, with an average angle of 116° for
German Shepherds and 140–147° for other large-breed dogs (Sabanci and Ocal 2018). Tarsal extension
is maintained by the CCT.
When the angle between the cranial aspect of the tibia and the dorsal aspect of the pes decreases,
the tarsocrural joint (and thus the tarsus as a whole) is in flexion. There is no consensus on termi-
nology for dorsoplantar movement of the joint levels distal to the tarsocrural joint, since normally
the tarsal bones remain in a straight line and move very little relative to each other. In this chapter,
movement of the tarsus (regardless of joint level) and pes towards the cranial aspect of the tibia
will be called flexion (or hyperflexion if the angulation at that level is excessive). When the pes
angles away from the cranial aspect of the tibia, the tarsus will be said to be extended (or hyperex-
tended if degree of angulation is abnormal).
The tarsus is composed of seven bones that are stacked to form joints at four levels on the medial
side and two on the lateral side (Figure 18.2). Two small, variably present sesamoids have been
described in Greyhounds (Wood and McCarthy 1984). These sesamoids are located on the lateral
(termed lateral plantar tarsometatarsal sesamoid bone) and medial (termed intra-articular tarso-
metatarsal sesamoid bone) side of the tarsometatarsal joint. These sesamoids are rarely described
in the current literature and generally not visible on radiographs; however, with the increased use
of advanced imaging, they are more frequently observed in other breeds as well (Deruddere et al.
2014). The tarsocrural joint, which is responsible for almost all of the motion in the tarsus, is
formed by the junction of the trochlea of the talus with the tibia and the fibula. The malleoli of
these bones overhang the talus to provide mediolateral stability. The talar trochlea has two nearly
circular ridges that correspond with two recesses in the tibial articular surface that are divided by
an intermediate ridge. The calcaneus does not participate in the tarsocrural joint but instead has a
long proximal projection, the tuber calcanei, that serves as an attachment point for the powerful
CCT. The sustentaculum tali of the calcaneus is a shelf on the plantar aspect of the tarsus that
hosts the lateral digital flexor muscle and is closely bound to the talus. Both bones end distally at
the proximal intertarsal joint, which is a collective joint formed by the junction of the talus with
the central tarsal bone (the talocalcaneal central joint) on the medial side and the junction of the
calcaneus and the fourth tarsal bone (the calcaneoquartal joint) on the lateral side (Figure 18.2).
The proximal intertarsal joint allows for a small amount of flexion/extension as well as motion in
the mediolateral plane.
The medially located central tarsal bone has a small articulation with the calcaneus, but it is
most broadly mated with the head of the talus proximally, the fourth tarsal bone laterally, and the
first, second, and third tarsal bones distally. Its junction with tarsal bones I–III is called the centro-
distal or the distal intertarsal joint. Unlike the proximal intertarsal joint, the distal intertarsal joint
is only present on the medial side, since the long fourth tarsal bone spans this level on the lateral
side. All of the bones of the tarsus are bound to their neighbors on either side with short, strong
ligaments in what are termed vertical intertarsal joints. Finally, the numbered tarsal bones articu-
late with corresponding metatarsal bones at the collective tarsometatarsal joint.
Each tarsal bone forms from a single ossification center except for the calcaneus, which also has
an apophysis, the tuber calcanei. Ossification centers of the talus and the body of the calcaneus
are present at birth, with the central and numbered tarsal bones (along with the ossification
center of the tuber calcanei) appearing between 3 and 6 weeks of age on radiographs (Thrall and
Robertson 2016). There are several growth plates around the tarsus that can complicate radio-
graphic interpretation in young animals. The distal tibia has a physis that closes between 5 and
15 months of age, while its attached medial malleolus has its own growth plate that closes by
286 18 Tarsal Region
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(A) (C) (E) (G)

(B) (D) (F)
Figure 18.2 (A–G) Normal radiographic anatomy of the tarsal region (Note: for all dorsoplantar images
lateral is on the right): (A, B) lateral and dorsoplantar views of the tarsus of an immature dog; note that the
physes of the tuber calcanei and medial malleolus have already closed in this dog; (C) lateral; (D)
dorsoplantar; (E) dorsomedial plantaro-lateral oblique (DMPLO); and (F) dorsolateral plantaro-medial
oblique (DLPMO) views of an adult dog; (a) tibia; (b) fibula; (c) talus; (d) calcaneus; (e) central tarsal bone;
(f) fourth tarsal bone; (g) third tarsal bone; (h) second tarsal bone; (i) first tarsal bone; (j) first metatarsal
bone; (k) second metatarsal bone; (l) third metatarsal bone; (m) fourth metatarsal bone; (n) fifth metatarsal
bone; (o) distal tibial physis; (p) distal fibular (lateral malleolar) physis; (q) tarsocrural joint; (r) proximal
intertarsal joint (formed by joints u, and v); (s) centrodistal (or distal intertarsal) joint; (t) tarsometatarsal
joint; (u) talocalcaneal central joint; and (v) calcaneoquartal joint.
5 months of age. The fibular lateral malleolar growth plate closes by 11 months, and the growth
plate of the apophysis of the tuber calcanei closes by 8 months after birth. The only metatarsal
bone with a proximal physis is the first; growth plate closure here happens by 7 months of age
(von Pfeil and Decamp 2009; Thrall and Robertson 2016).
The tarsal joint capsule originates on the distal tibia and fibula and inserts on the proximal
extents of the metatarsal bones, with fibrous attachments to each of the tarsal bones. There are
three lateral and four medial joint sacs. The proximal (tarsocrural, talocalcaneocentral, and calca-
neoquartal) joints communicate with each other and with the sheath of the lateral digital flexor
tendon, but they are separate from the conjoined centrodistal and tarsometatarsal joints. Although
intra-articular anesthesia (Chapter 8) is rarely used for diagnosis of tarsal lameness in dogs, these
joint divisions should be considered when performing injections in the tarsal region.
The medial collateral ligament limits valgus and the lateral collateral ligament limits varus angu-
lation of the tarsus. Both medial and lateral collateral ligaments have a superficially located long
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(A) (B) (C) (D)
Figure 18.3 Ligaments of the tarsal joint: (A) medial aspect illustrating the (a) medial long collateral and
the (b, c) medial short collateral complex which includes the (b) tibiotalar short collateral and (c) tibiocentral
short collateral; (B) lateral aspect illustrating the (d) lateral long collateral, (e) calcaneoquartal ligament and
the (f, g) lateral short collateral complex which includes the (f) calcaneofibular short collateral, and (g)
talofibular short collateral; (C) plantar aspect illustrating the (h) long plantar ligament, (i) calcaneocentral
ligament, (j) plantar centrodistal ligament, and (k) tarsal fibrocartilage; and (D) dorsal aspect illustrating the
(l) crural extensor retinaculum.
component that runs from the appropriate malleolus to the base of metatarsals I and II on the
medial side and V on the lateral side, attaching to each tarsal bone the ligament passes on the way
(Figure 18.3). This long component is taut when the tarsocrural joint is extended. On both sides,
there are two short components located deep to the long component (Aron and Purinton 1985);
these are taut when the tarsocrural joint is flexed. As most dogs walk with a few degrees of valgus
angulation that places tensile stress on the medial aspect of the tarsus, medial collateral injuries
are more likely to result in persistent lameness than lateral collateral injuries (Decamp et al. 2016).
The tarsocrural joint flexes to varying degrees during gait, but the rest of the tarsus remains
straight because of the support provided by the strong plantar ligaments. The middle (or long) plan-
tar ligament originates on the body of the calcaneus and attaches to the fourth tarsal bone before
inserting on the fourth and fifth metatarsal bones. The medial plantar ligament runs from the sus-
tentaculum tali to the central tarsal bone to attach to the first through third metatarsal bones. Before
reaching their metatarsal insertions, both of these ligaments attach to a thickened portion of the
joint capsule called the tarsal fibrocartilage. The lateral (or calcaneoquartal) plantar ligament origi-
nates on the plantarolateral surface of the calcaneal body and joins the long part of the lateral col-
lateral ligament before inserting on the fifth metatarsal bone (Carmichael and Marshall 2018).
Dorsal support of the tarsus is provided by a slender band running from the crural extensor reti-
naculum to the talus, where it joins with a shorter, denser ligament (the dorsal centrodistal) run-
ning from the talar neck to the second, third, and fourth tarsal bones. This ligament system, along
with the action of the fibularis and cranial tibial tendons, helps to limit tarsal extension.
A number of tendons insert on or (in the case of digital flexors and extensors) pass over the tarsal
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region. The major flexors of the tarsus include the cranial tibial tendon, which passes obliquely from
lateral to medial over the central tarsal bone to insert on the first and second metatarsal bones, and
the fibularis (peroneus) longus and brevis tendons, which insert on the fourth tarsal bone and plantar
surfaces of the metatarsals (longus) or the fifth metatarsal bone alone (brevis). The major extensor of
the tarsus is the common calcanean (Achilles) tendon, which is composed of three major compo-
nents: the gastrocnemius tendon (GT), which inserts on the tuber calcanei; the conjoined tendon,
formed from portions of the biceps femoris, semitendinosus, and gracilis tendons, which also inserts
on the tuber calcanei; and the superficial digital flexor tendon (SDFT), which passes over the tuber
calcanei on its way to the pes. The CCT will be discussed in greater depth later in Section 18.5.
Seven tendons have synovial sheaths as they pass the tarsus: the cranial tibial tendon and long
extensor of the first digit; the fibularis (peroneus) longus and brevis; the long and lateral digital
extensors; and the deep digital extensor tendon. The sheath of the deep digital extensor communi-
cates with the tarsocrural joint. The cranial tibial tendon, the fibularis longus and fibularis brevis
tendons, and the SDFT have bursae near their insertions in the tarsal region (Johnson 1985).
18.3 Fractures of the Tarsal Region
Pain in the tarsal region may originate from fractures of the metatarsi (discussed in Chapter 12),
fractures of the tarsal bones and fractures of the distal tibia and fibula (lateral malleolus). In imma-
ture animals, Type I and II Salter-Harris fractures (Chapter 13) are most commonly observed. In
mature animals, malleolar fractures or fractures of the distal tibial metaphysis are the most com-
mon types. Fractures of the malleoli may result in tarsocrural luxations because the collateral liga-
ments originate there.
Because the tarsal bones are held together so tightly by ligaments, these fractures often involve
more than one bone and may be accompanied by intertarsal luxations. Displaced fractures or luxa-
tions of the central tarsal bone, which acts a medial strut, cause angular deformity of the tarsus.
A wide variety of fractures of the specific tarsal bones have been described and treatment varies
based on the fracture specifics (Carmichael and Marshall 2018). Simple fractures and single-bone
luxations are generally treated with internal fixation, while partial tarsal arthrodesis (i.e. fusion of
joints distal to the tarsocrural joint) is used to treat injuries (including many calcaneal fractures) distal
to the tarsocrural joint. Pantarsal arthrodesis (i.e. fusion of all tarsal joints including the tarsocrural
joint) may be needed to treat articular fractures of the talus or tibia and other severe injuries.

As for any fracture, trauma is the main cause which can happen to dogs of any age/signalment.
Nevertheless, tarsal fractures and luxations are predominantly seen in medium-to-large, active
adult dogs. Bone fractures of the tarsal region are most commonly the result of a single traumatic
event. However, in racing Greyhounds, repetitive stress can cause fatigue fractures of the central
tarsal bone, and Dalmatians have been reported to suffer from atraumatic fractures of this bone
(Armstrong et al. 2019). Racing Greyhounds develop central tarsal bone fractures (and related
injuries, especially to the calcaneus and fourth tarsal bone) in the pelvic limb opposite to the direc-
tion of turn on an oval racetrack. Sighthounds and Dalmatians seem to be particularly susceptible
to central tarsal bone injuries (Armstrong et al. 2019). In most cases, there is a history of acute
onset of non-weight-bearing lameness. Avulsions of the tuber calcanei are occasionally seen in
immature dogs following falls or jumps.
18.3 Fractures of the Tarsal Regio 289

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When the injury is recent, the affected limb is usually carried. There may be an angular deformity
evident at or distal to the tarsocrural joint. Because of the acute nature of the injury, physical exam
findings usually show severe pain upon tarsal manipulation requiring sedation to perform a full
examination and diagnostics of the limb. Examination of the limb should include placing the tar-
sus through full range of motion, evaluation for joint effusion, and stress testing of the limb in
varus and valgus stress as well as applying dorsal and plantar stress (Figure 18.4). If the distal tibia
is held in position while the metatarsus is manipulated, excessive flexion, extension, or mediolat-
eral motion may be elicited.
(A) (C) (E)
(B) (D) (F)
Figure 18.4 Physical examination steps to detect tarsal joint pathology: (A) to fully flex the tarsal joint,
the hip and stifle joint also have to be flexed; (B) isolated tarsal hyperextension can be performed by
grasping the tibia below the stifle and extending the tarsus with the lower hand – this allows the observer
to differentiate stifle from tarsal pathology; joint effusion is palpable (C) caudal and (D) cranial to the
lateral malleolus; (E) applying upward pressure from plantar while flexing the stifle stresses the distal
tarsal joints and may show instability; (F) the common calcanean tendon can be stretched by holding the
stifle in extension from cranially while flexing the tarsus.
Fractures of the proximal aspect of the tuber calcanei are usually associated with lameness that
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features excessive tarsal flexion and sometimes the curled digits (crab-claw appearance), that is
more commonly associated with gastrocnemius insertion disruption (Figure 18.5).
Swelling is easy to detect, since there is very little soft tissue covering the bones of the tarsus. It
is usually limited to the site of the injury. Displacement of the central tarsal bone produces a pal-
pable and sometimes slightly mobile projection on the craniomedial aspect of the tarsus.
18.3.3 Diagnostics
Diagnosis of tarsal fractures (and associated luxations) is generally made on the basis of physical
and radiographic findings. Standard dorsoplantar and mediolateral projections are often sufficient,
(A) (C) (E)
(B) (D) (F)
Figure 18.5 Examples of traumatic tarsal joint injuries: Patient I (A–D) was diagnosed with proximal
intertarsal joint luxation due to disruption of the plantar ligaments. The patient shows (A) hyperflexion of the
tarsus with flexed digits, a similar appearance to patients presenting with Type IIc Achilles tendinopathy.
Standard (B) lateral views do not show obvious evidence of the (white arrow) fracture luxation; however, it can
be visualized on the (C) dorsoplantar view and the degree of disruption becomes obvious when performing (D)
flexed stress views; Patient II (E, F) was diagnosed with comminuted fractures of the central, second, third, and
fourth tarsal bones and proximal second metatarsal bones with associated (white arrow) soft tissue swelling.
18.4 Tarsal Joint Luxation 291
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(A) (D) (E) (G)
(B) (C) (F) (H)
Figure 18.6 Examples of traumatic tarsal joint injuries: Patient I (A–C) was diagnosed with a medial
collateral and talar ridge fracture; (A) lateral radiographs were nondiagnostic, (B) dorsoplantar radiographs
show (white arrow) soft tissue swelling on the medial side, (C) stress radiographs confirm disruption of the
medial collateral ligament as indicated by the (white arrow) opening of the joint and also illustrate the
talar ridge fracture. Stress views were performed by applying (blue arrows) medial pressure proximal to the
tarsus and lateral pressure distal to the tarsus (valgus stress view). Patient II (D–F) was diagnosed with a
central tarsal bone fracture that could be missed on the (D) standard lateral view since it only shows (white
arrow) mild displacement of the fracture; however, (E) with gentle flexion, the (white arrow) displacement
becomes more evident and (F) dorsoplantar views also clearly show the (white arrow) displaced fragment.
Radiographs of Patient III (G, H) show severely displaced (white arrows) fracture luxation of the proximal
intertarsal joint.
but oblique views can be useful. Images taken with the tarsus in flexion, extension, and mediolateral
stress (with a fulcrum placed on the tarsus to lever the metatarsus against; Figure 18.6) can help
define the level and direction of instability. CT is the most sensitive modality, but it is seldom needed
for detecting the presence of tarsal fractures; it can, however, help to define the nature of the frac-
ture and guide its repair (Butler et al. 2018).
18.4 Tarsal Joint Luxations
Tarsal joint luxations can occur at any level and may be due to ligament disruption or fractures of
the associated bones. Injuries to the collateral ligaments cause instability at the level of the tar-
socrural joint. The two other reasons for tarsocrural joint luxations are shearing injuries or frac-
tures of the medial and or lateral malleoli, which are the origins of the collateral ligaments. These
injuries result in medio-lateral instability. Luxations or instability of the distal tarsal joints may
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involve the plantar or dorsal intertarsal ligaments and the resulting instability may be dorso-
plantar and/or medio-lateral. The majority of these injuries are traumatic, but they may be due to
immune-mediated or (uncommonly) idiopathic disease. The proximal intertarsal joint (i.e. calca-
neoquartal and talocalcaneocentral joints) is the level most commonly involved but tarsometatar-
sal luxations are also encountered.
Treatment of these injuries may include nonsurgical approaches for mild injuries, but surgery is
generally recommended for complete (grade 3) sprains. Surgical treatment may include recon-
struction of the collateral ligaments, fracture fixation (e.g. for malleolar fractures), or partial and
pantarsal arthrodesis depending on the location and severity of the injury.

Dogs of all breeds and ages can be affected by traumatic tarsal luxations, although medium-to-
large, active dogs seem to be most often affected. Motor vehicle accidents are the most common
cause, but collateral injuries can also follow falls, running mishaps, and lower limb entrapment.
Collisions with vehicles can cause shearing injuries, which almost always happen on the medial
side of the tarsus. When the medial malleolus is ground away, medial collateral instability results.
Herding dogs can incur tarsometatarsal luxations when a foot is caught in the rungs of a gate dur-
ing a jump. When trauma is involved, the limb is initially carried. With time weight-bearing is
resumed, but severe (and apparently painful) lameness persists. With disruption of the dorsal liga-
ments, this lameness may be less severe compared to plantar ligament or collateral ligament
pathology. Please refer to Section 18.7.2 regarding idiopathic tarsal luxation and tarsal luxation
caused by immune-mediated disease.
Isolated rupture of one or both of the short lateral collateral ligaments has been reported in 6
young (3–40 month old) dogs, most of which were Retrievers (Sjöström and Håkanson 1994). This
injury was associated with fracture or fragmentation of the lateral trochlear ridge in three of these
dogs. It is not known if the talar injuries were strictly traumatic in origin or if osteochondrosis of
the lateral talar ridge was a predisposing factor.

Diagnosis is straightforward when both the short and long collateral ligaments of one side are
completely ruptured. The affected limb is usually carried right after the ligament has been injured,
but as time passes most dogs begin using it again. When the limb is bearing weight, medial collat-
eral insufficiency allows valgus angulation and lateral collateral insufficiency allows varus angula-
tion of the foot. There may be a wound present over the medial (most common) or lateral aspect of
the tarsus; sometimes this wound is small compared to the extent of the injury beneath. The tarsus
will be swollen, with the swelling usually centered on the tarsocrural joint and more severe on the
injured side. Crepitus and luxation may be felt when the joint is manipulated. Testing the collateral
ligament integrity is done with the tarsus both in extension and in moderate flexion. This allows
for testing of the short and long collateral ligaments. The distal tibia is held steady, and varus and
valgus stress is applied to the pes. If the lower limb deviates laterally with the tarsus in extension
and flexion, complete disruption of the medial collateral ligaments is present. Similarly, if medial
deviation of the pes happens in both tarsal positions, the lateral collateral ligaments are completely
torn. If deviation only happens with the tarsus in extension, just the long part of the collateral liga-
ment is torn; instability only in flexion suggests injury to the short collateral ligaments. Isolated
18.4 Tarsal Joint Luxation 293
damage to the short lateral collateral ligament can produce just a subtle rotational instability that
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can only be detected with the dog under heavy sedation. Testing is done with the tarsus in 60–90°
of flexion; the tibia is stabilized, and the foot is rotated in both directions. When the short lateral
collateral ligaments are torn, a click may be felt on the lateral side as the pes is supinated (Sjöström
and Håkanson 1994).
Dogs walk with the tarsocrural joint in some degree of flexion throughout the weight-bearing
phase of the gait. Below the tarsocrural joint, the rest of the tarsus resists this bending tendency and
normally remains straight, but disruption of the plantar tarsal ligaments or their attachments allows
flexion (and often subluxation) here. With acute distal tarsal joint injuries, the affected limb may be
held up throughout the gait, but most patients return to a severe but weight-bearing lameness. In
animals with proximal intertarsal luxation due to disruption of the plantar ligaments, the tarsus can
be seen to flex distal to the tarsocrural joint (i.e. at two levels rather than just at the tarsocrural joint),
when the dog is bearing weight (Video 18.1). There is usually some firm swelling on the plantar
aspect of the tarsus, at or distal to the base of the calcaneus. To demonstrate this instability, the exam-
iner holds the calcaneus in position and applies pressure on the pes through the metatarsal pad as a
dog would do while walking (Figure 18.4). Normally the distal pes will remain aligned with the long
axis of the calcaneus, but in dogs with tarsal injuries the pes will angle cranially. In contrast, disrup-
tion of the dorsal ligaments does not cause these obvious instabilities, since weight-bearing does not
stress the dorsal ligaments. Instability may be visible during liftoff/swing phase or during palpation,
which is performed by reversing the palpation performed for plantar ligament pathology. These inju-
ries are encountered less frequently and cause less severe signs and pain. Depending on the plane of
instability, dogs with tarsometatarsal luxations may show similar exam findings to dogs with proxi-
mal intertarsal luxation. If severe displacement is present (Figure 18.6), obvious instability, pain, and
deviation of the bones will be palpable, but with less severe injuries exam findings can be subtle.
Video 18.1
Achilles tendinopathy gaits.
18.4.3 Diagnostics
Orthogonal radiographs are part of the database, but diagnosis of the specific condition is usually
made through stress radiography. Stress radiographs can be done in any direction and are per-
formed in the same fashion as palpation during the physical exam. For example, for detection of
collateral ligament disruption, dorsoplantar radiographs should be taken both with the tarsus in
neutral position and with varus and valgus stress applied using a radiolucent fulcrum such as a
wooden spoon placed slightly above the tarsocrural level to lever against; the tarsocrural joint will
open up on the side of the collateral disruption (Mauragis and Berry 2012). There is also almost
always marked soft tissue swelling evident at the tarsocrural joint at the side of the collateral liga-
ment that is affected. With shearing injuries, the medial malleolus may be ground flat. Malleolar
fractures may be apparent, or small bone fragments may suggest avulsion of the origin of the col-
lateral ligament. Oblique views may show other injuries accompanying the ligament tear.
For detection of plantar ligament instability, a lateral view is made with the stifle held in
moderate extension while upward pressure is placed on the metatarsal pad and plantar aspect
of the metatarsus to stress the lower part of the tarsus in flexion (Figure 18.5). Dorsal angula-
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tion will be evident at the level of instability. And vice versa, for detection of dorsal ligament
instability, the pressure to the distal pes would be applied in a plantar fashion during extension
of the tarsal joint.
18.5 Pathology of the Common Calcanean Tendon
The CCT (also referred to as “Achilles tendon”) includes all structures that attach to the tuber cal-
canei. It is formed by the (i) GT, (ii) the SDFT, (iii) and the conjoined tendon (also referred to as
“accessory” or “combined” tendon) of the following three muscles: biceps femoris, gracilis, and
semitendinosus. The gastrocnemius muscle originates from the distal, caudal femur and forms the
GT approximately at the level of mid-tibia. This tendon is the main component of the CCT and the
major muscle responsible for tarsal extension. The superficial digital flexor (SDF) muscle origi-
nates together with the lateral head of the gastrocnemius muscle on the distal, caudal femur and
continues cranially to the gastrocnemius muscle proximally but then the SDFT wraps around the
GT medially to become the most caudal attachment to the tuber calcanei (Figure 18.7). This attach-
ment is accomplished by a broad, fibrocartilaginous “caplike”-structure attaching collaterally to
the calcaneus, which allows the SDFT to continue distally to its distal attachment at the plantar
surface of the proximal base of phalanges II–V, thereby providing stifle flexion, tarsal extension,
(A) (B) (C)
Figure 18.7 Type IIc Achilles tendinopathy: (A) the (a) gastrocnemius tendon is (red arrow) partially
disrupted, resulting in slight hyperflexion (plantigrade) stance. Since the (b) superficial digital flexor tendon
is (blue arrow) intact, the increased flexion angle forces the digits into (black arrow) flexion, which results in
the typical “crab-claw” stance. (B, C) The superficial digital flexor tendon wraps around the gastrocnemius
tendon medially to form a cap that attaches caudally to the tuber calcanei. When palpating the tendons
above the calcaneus, isolation of the tendons is possible if the tendons are not affected by pathology.
18.5 Pathology of the Common Calcanean Tendo 295
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Box 18.1 Grading of Pathology of the CCT (Meutstege 1993)

1) Type I = complete rupture
(a) Stance = plantigrade
2) Type II = partial rupture
(a) Stance = slightly increased hock flexion
i) Type IIa affects the musculotendinous junction
ii) Type IIb is similar to Type I but has an intact paratenon and therefore dogs are not
completely plantigrade
iii) Type IIc affects the GT only (with intact SDFT) resulting in increased flexor tension
on the digits (“crab claw”)
3) Type III = tendinosis only
(a) Stance = normal
and digit flexion. The conjoined tendon inserts medially on the tuber calcanei and plays a minor
role in tarsal extension.
A classification system (Box 18.1) that differentiates conditions causing structural changes of the
CCT based on location and severity of injury has been described (Meutstege 1993). An important
distinction should be made between acute, traumatic (e.g. Type I) rupture and a chronic, degenera-
tive (e.g. Type IIc) process, since the treatment differs substantially (Figure 18.8). Another rarely
encountered condition is luxation of the SDFT. Pathology affecting the origin of the gastrocnemius
muscle (e.g. avulsion and myotendinopathy) is also rare and discussed in Chapter 19.
18.5.1 Traumatic Rupture

Traumatic rupture may occur at any level of the CCT, with the musculotendinous junction and
insertion most commonly affected. Disruption may involve any of the five structures of the CCT but
most commonly affects all tendons (i.e. Type I or Type IIb injuries). Border Collies frequently sus-
tain these injuries (Corr et al. 2010), but obviously any dog may suffer from trauma. Lacerations may
be due to external trauma (e.g. sharp lacerations) or occur during exercising; the injury may be open
or closed. While open injuries simplify establishing a diagnosis based on the visible disruption of the
skin (and visibly disrupted tendon in some cases), closed injuries are diagnosed based on palpation
of the tendon and the associated plantigrade stance (i.e. the entire pes touching the ground;
Figure 18.8). However, recent literature (Corr et al. 2010; Gamble et al. 2017) has shown that plan-
tigrade stance (note that plantigrade stance was defined more loosely as an increased flexion angle
by these authors) does not always predict the specific tendons affected but is more likely to be pre-
sent in patients with injury at the musculotendinous junction. Palpation of a gap between the rup-
tured ends of the tendon is facilitated by stretching the CCT, which is accomplished by extending
the stifle and flexing the tarsus (Figure 18.4). The entire CCT should be palpated, since diffuse inju-
ries or injuries at multiple sites have been reported. Radiographs should be performed to rule out
any fractures or other osseous abnormalities. Ultrasonography can be utilized to determine the
exact location and extent of CCT disruption, and a grading system for this has been reported
(Gamble et al. 2017). As with palpation of the tendon, dynamic evaluation while the CCT is stretched
can help identify pathology. Treatment of acute injuries generally involves surgical apposition of the
tendon ends followed by some form of external or internal support while the tendon is healing.
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(A) (C) (E) (G)

(B) (D) (F) (H)
Figure 18.8 Examples of dogs with pathology of the Achilles tendon: (A) typical stance with Type IIc Achilles
tendinopathy caused by an intact SDF with a partially disrupted gastrocnemius muscle resulting in the typical
“crab-claw” stance with the (black arrow) digits flexed and the tarsus slightly hyperflexed; (B) typical (black
arrow) swelling associated with Type IIc Achilles tendinopathy; (C) early stages of Achilles tendinopathy as
illustrated by the (white arrow) soft tissue swelling of the tendon; (D–F) chronic Achilles tendinopathy is
frequently associated with (white arrows) calcification and (blue arrow) enthesopathy at the insertion at the
tuber calcanei; (G, H) typical stance and intra-operative appearance with acute, traumatic Type I Achilles injury.
18.5.2 Chronic Gastrocnemius Tendinopathy

Type IIc common calcanean tendinopathy (CCT2c) is a degenerative condition of the GT with an
intact SDFT (Meutstege 1993; Gamble et al. 2017). It is well recognized in medium- and large-
breed dogs and especially in middle-aged Doberman Pinschers and Labrador Retrievers (Corr et al.
2010; Gamble et al. 2017). The degeneration leads to elongation of the GT, thereby causing the
increased flexion of the tarsus. Since the SDF is not affected and the GT is only elongated, animals
are not presented with a completely plantigrade stance but rather with the typical “crab-claw”
appearance from increased tension on the SDF that results in flexion of the digits (Figure 18.7,
Video 18.1). This condition has also been described as an avulsion injury of the GT; however, this
is somewhat confusing since the soft tissue opacities visible on radiographs proximal to the calca-
neus likely represent dystrophic calcification rather than avulsion fragments. A chronic tendinitis
(Type III) has also been described in the literature. This condition may be a precursor to Type IIc
injuries, but little information about this is available.
The etiology of this condition is unclear, but a degenerative process is suspected given the atrau-
matic, chronic, and frequently bilateral presentation (Meutstege 1993; Gamble et al. 2017). As with
18.5 Pathology of the Common Calcanean Tendo 297
cruciate ligament pathology, once the tendon is weakened, minor trauma may cause acute exacer-
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bation of lameness, which may be the first time that owners notice the abnormality.
Palpation of the entire CCT should be performed as described for cases with traumatic rupture.
It is essential to evaluate the other pelvic limb, since approximately 50% of cases are bilaterally
affected (Gamble et al. 2017). Underlying conditions such as Cushing’s disease and long-term ster-
oid and perhaps enrofloxacin (Lim et al. 2008) administration should be excluded.
Radiographs may show soft tissue swelling of the affected region (most commonly at the inser-
tion at the tuber calcanei), avulsion fragments, enthesopathy, or dystrophic calcification of the
tendon (Figure 18.8). The latter can be difficult to differentiate from an avulsion fragment, but with
dystrophic calcification, the tuber calcanei does not show a defect, and multiple foci of calcifica-
tion are often present. Ultrasonography is more sensitive than palpation or radiography and facili-
tates the identification of the specific tendons involved as well as the severity of the disruption
(Gamble et al. 2017). Ultrasonography therefore provides a simple, noninvasive, and cost-effective
method to evaluate the CCT.
There is a lack of peer-reviewed literature comparing available treatment options for this disease.
Surgical repair is generally recommended (Corr et al. 2010), but treatment with orthotics com-
bined with surgery or as a sole treatment has also been reported (Wallace 2012; Mich 2014).
18.5.3 Luxation of the Superficial Digital Flexor Tendon

Luxation of the SDFT is an infrequent condition that results in pelvic limb lameness due to dis-
placement of the tendon at the level of the calcaneus. The tendon generally luxates laterally due to
disruption of the medial retinaculum. The condition may be triggered by mild trauma, although a
traumatic event is not always observed. While osseous abnormalities of the calcaneus have been
proposed as the underlying etiology (Reinke and Mughannam 1994), a weaker attachment on the
medial side has been suggested as the main cause by Kara (1998). Shetland Sheepdogs appear to be
predisposed (Solanti et al. 2002) but other breeds are also affected.
Patients show varying degrees of lameness depending on the acuity of the condition. Initially
dogs may be non-weight-bearing on the limb, but most dogs have a low-grade lameness at the
time of presentation. Some dogs show a skipping gait as is observed with patellar luxations.
Swelling will be palpable and sometimes visible over the tip of the calcaneus. In some cases,
bursitis is severe, causing the swelling to be fluctuant. In relatively acute cases, the diagnosis is
made by a popping sensation as the tendon displaces (Video 18.2). The SDF may become fixed in
its displaced condition when the condition is chronic. In this case, there is no palpable popping,
but the focal swelling remains. Radiographs should be taken to rule out other osseous pathology.
Luxation of the SDFT may be confused with Type IIc Achilles tendinopathy, and ultrasonogra-
phy can be used to confirm the integrity of the CCT, which differentiates this condition from all
other CCT pathologies. Ultrasonography is also useful for identifying chronic SDF luxations.
Surgical imbrication of the torn or stretched retinaculum usually gives good results, except in
some chronically affected dogs.
Video 18.2
Superficial digital flexor tendon luxation.


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Osteochondrosis/osteochondritis dissecans (OCD) of the tarsal joint is an uncommon disease of

young, mostly large-breed dogs that affects the talus. Either talar ridge can be affected, although
OCD is most common on the medial side. It is not unusual for both tarsi to be affected, so both tarsi
should be carefully assessed for pathology.
OCD fragments can damage adjacent cartilage surfaces, especially if they displace or break into
smaller pieces. If they migrate or are removed, the resultant defect causes joint incongruity.
Because of this, talar OCD reliably leads to OA of the tarsocrural joint. The osteochondrosis frag-
ments can contain a substantial amount of subchondral bone. Unsurprisingly, as fragment size
increases, prognosis for good limb use decreases. Reattachment of fragments can be difficult, and
healing is unpredictable. Surgical removal of talar ridge OCD remains controversial. Fragment
removal brings about clinical improvement in about half of treated dogs, but some degree of lame-
ness persists in most and OA progresses regardless of treatment (Van Der Peijl et al. 2012). Dogs
with significant lameness due to OA later in life may benefit from pantarsal arthrodesis. Migration
of osteochondrosis fragments into the synovial sheath surrounding the DDF tendon is a rare con-
sequence of OCD (Section 18.7.4).

Talar ridge OCD is generally a disease of young large-breed dogs and particularly of Labrador
Retrievers. Other predisposed breeds include Rottweilers, Pit Bulls, and Australian Cattle Dogs.
The majority of affected dogs are female.
Lameness develops during the first year of life and can be seen as early as 4½ months of age. However,
some dogs are presented for evaluation later in life, when tarsal OA begins to affect quality of life.

Talar OCD typically produces a weight-bearing lameness that is evident at both the walk and the trot.
A shorter stride is taken on the affected limb, and range of motion in the tarsus during each step is
reduced. The limb may be held abducted, especially when the dog rises from a sitting position. These
dogs may also display a positive “sit-test,” making talar OCD a differential diagnosis for cranial cruci-
ate ligament disease (Video 18.3). In the author’s experience, tarsal hyperextension may be present,
but in a recent study this was not found to be a common feature (Van Der Peijl et al. 2012).
Video 18.3
Typical gait with tarsal OCD.
Effusion is usually present on the cranial as well as on the plantaro-medial or plantaro-lateral

aspect of the tarsocrural joint, depending on the location of the osteochondral fragment. The degree
of swelling that is present gives an indication of the size of the fragment; larger fragments (and thus
poorer prognoses) tend to be associated with more impressive effusions. Crepitus may be felt on joint
manipulation, and the dog usually objects to joint flexion and full extension. Occasionally a displaced
osteochondral fragment can be felt just caudal to the malleolus and medial or lateral to the trochlear
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ridge, but palpation for such fragments is usually prompted by radiographic findings.
18.6.3 Diagnostics
Orthogonal radiographs can be diagnostic for OCD; however, smaller lesions are easily missed
due to the complexity of the joint. In normal tarsi, both talar ridges are circular on the lateral
radiographic view, but when OCD is present flattening of one of the ridges will be evident
(Figure 18.9). On the dorsoplantar projection, a gap between the talus and the tibia – normally a
close fit – can be seen, sometimes with osteochondral fragments visible within the defect. A dor-
soplantar skyline view of the caudal aspect of the talar trochlea taken with the tarsus in slightly
(A) (C) (E) (G)
(B) (D) (F) (H)
Figure 18.9 Examples of surgically confirmed tarsal OCD: Patient I (A, B) was diagnosed with OCD of the
lateral talar ridge. Radiographs show only subtle changes including (A) mild periarticular osteophytosis
(black arrow) on the lateral view mild, joint effusion (white arrow), and very subtle flattening of the
proximo-plantar aspect of the trochlea (red arrow). Patient II (C–H) showed more obvious changes including
the (C) extended lateral view shows flattening (white arrow) of the trochlea; (D) the dorsoplantar view
shows (white arrow) an increased joint space indicating a medial trochlear ridge defect; (E) the flexed
lateral view makes the (white arrow) trochlear ridge flattening more easily visible; (F) typical location for
(blue arrow) joint effusion in patients with OCD; (G, H) CT illustrating the (white arrow) OCD lesion and
(blue arrow) joint effusion.
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Figure 18.10 Radiographic positioning for dorsoplantar skyline radiographic evaluation of tarsal OCD in
canine patients is performed by placing the dog in dorsal recumbency. The legs should be elevated on a
foam pad and the tarsus should be angled slightly caudally to avoid superimposition. This skyline view
highlights the trochlear ridges and should be performed if a definitive diagnosis cannot be accomplished
with the standard views.
less than 90° flexion (to avoid superimposition) is occasionally helpful for highlighting ridge
defects (Mauragis and Berry 2012; Figure 18.10).
Small defects and fragments can be difficult to see on plain radiographs, especially on the lateral
side, where superimposition of the calcaneal shadow can obscure the trochlear ridge. CT is a more
sensitive modality (detecting 100% of OCD lesions in one study) and can be helpful in cementing
the diagnosis (Gielen et al. 2002).
18.7 Other Diseases Affecting the Tarsal Region
Although panosteitis more commonly affects the long bones of the thoracic limb, it can also affect
the femur and tibia and should therefore be considered a differential diagnosis in juvenile patients
with shifting limb lameness and pain on long bone palpation (Chapter 14).
Immune-mediated polyarthritis (IMPA) commonly affects the carpal and tarsal joints and is
therefore an important differential diagnosis when joint effusion and/or pain in the tarsal joint is
present. Affected dogs show a wide variation in clinical signs and examination findings, ranging
from crying in pain with palpable joint effusion to no apparent gait abnormality, pain, or palpable
18.7 Other Diseases Affecting the Tarsal Regio 301
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(A) (B) (D) (F)
(C) (E) (G)
Figure 18.11 Other diseases affecting the tarsal region: (A–C) pes varus deformity in a miniature
Dachshund; note the marked varus of the distal limb, (white arrow) shortening of the medial cortex of the
tibial diaphysis compared to the lateral cortex, and widening of the medial aspect of the tibiotarsal joint.
(D, E) Erosive immune-mediated polyarthritis in an adult dog that resulted in bilateral tarsal hyperflexion
and carpal hyperextension; note that the (white arrow) lytic changes are limited to the distal tarsal joints
resulting in instability at the tarsometatarsal joint. (F, G) Patient with chronic OCD and chronic
enthesopathy of the medial collateral ligament; (F) the dorsoplantar view shows (white arrow) flattening of
the medial trochlear ridge consistent with OCD; and (G) image of the patient illustrating (white arrow)
severe periarticular swelling.
joint effusion. Dogs with advanced erosive arthritis may experience joint luxations (Figure 18.11)
and walk plantigrade or have other joint deformities. Please refer to Chapters 9 and 13 for further
details regarding joint fluid analysis and the classification of IMPA, respectively.
Septic arthritis should also be considered as a differential diagnosis, but in the tarsus it is much
less frequent than immune-mediated disease.
18.7.1 Tarsal Deformities

Pes varus is a deformity of the distal tibia caused by premature closure of the medial distal tibial
physis (Radasch et al. 2008). The asymmetric closure results in varus angulation of the distal tibia.
It may be unilateral or bilateral. Since the majority of affected dogs are Dachshunds, the disease is
thought to have a genetic component, but it may be caused by trauma in other dogs. Affected dogs
have a “bow-legged” appearance (Figure 18.11) and variable clinical signs. The deformity may be
limited to the distal limb but may clinically affect. Depending on the severity of the deformity,
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surgical correction may be considered.
18.7.2 Idiopathic Tarsal Hyperflexion

Luxation or subluxation of the distal tarsal joints is usually of traumatic origin, but it can also
develop in the later stages of erosive immune-mediated arthropathies (Figure 18.11). Some dogs
(especially Shetland Sheepdogs and Collies) without history of trauma or evidence of immune
disease develop the instability gradually, and it may happen in both tarsi, sometimes in concert
with carpal hyperextension. If arthrocentesis and testing for antinuclear antibody and rheumatoid
factors speak against underlying immune-mediated disease, either inherent connective tissue
weakness or degeneration of the plantar support structures is suspected but not proven (Carmichael
and Marshall 2018). Dogs with this idiopathic, atraumatic presentation gradually develop a gait
abnormality that often appears to be more mechanical than painful in nature. Treatment is chal-
lenging due to the number of joints affected but generally involves partial tarsal arthrodesis,
although orthotic support can be considered.
18.7.3 Idiopathic Tarsal Hyperextension

Tarsal hyperextension can occur at multiple levels but most prominently involves the tarsocrural
joint. This condition may accompany talar OCD and is a feature of some myopathies (Marioni-
Henry et al. 2014). Additionally, tarsal hyperextension may be due to painful conditions more proxi-
mal in the limb, such as cranial cruciate ligament rupture, hip dysplasia, or lumbosacral stenosis. In
cases with more proximal pathology, tarsal hyperextension is thought to develop as a compensation
mechanism in which the associated weight shifting towards the thoracic limbs results in tarsal
hyperextension to gain pelvic limb length. Alternatively, pain in a more proximal joint may result in
a changed stance angle (i.e. a dog with stifle pathology may prefer to stand with increased flexion of
the stifle and therefore the tarsus is hyperextended to compensate). The presence of tarsal hyperex-
tension should therefore alert the diagnostician to the possibility of pathology located more proxi-
mally, even though the tarsal abnormality may be the most noticeable clinical sign.
In some cases, no other pathology can be identified. A congenital laxity of the fibularis musculo-
tendinous region has been implicated in calves (Kilic et al. 2015), but tarsal hyperextension is seldom
evident during the first few months of life in dogs. The hyperextension typically develops gradually,
usually during the first year of life. Dogs of any breed, age, or sex can be affected. The degree of hyper-
extension varies between cases and in some dogs, the abnormality may be intermittent. The tarsus
extends up to or beyond 180° by the end of the stance phase of the gait. The tarsocrural joint may
abruptly flip forward just before the foot is lifted. The affected tarsus may rock into and out of hyper-
extension when the dog is standing (Figure 18.12). Affected tarsi seldom appear to be painful on
manipulation. Range of motion in flexion is unaffected, but the abnormal tarsus can be extended at
least to 180°. Effusion or crepitus is usually absent unless there is concurrent talar OCD.
Radiographs of the tarsus are also usually normal unless talar OCD is present. If the tarsus is
stressed in extension, a lateral view will document the abnormally high tarsocrural angle without
other pathology (Figure 18.12). Degenerative changes may be seen, although they are observed
infrequently and may be secondary to other pathology in some cases. Radiography of the stifle and
the hip in the affected limb should be considered to evaluate for concurrent orthopedic abnormali-
ties. Since lumbosacral stenosis is occasionally associated with tarsal hyperextension, radiographs
and possibly MRI of this region may be indicated if lower back pain is evident.
18.7 Other Diseases Affecting the Tarsal Regio 303
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(A) (C) (E) (G)
(B) (D) (F) (H)
Figure 18.12 Other diseases affecting the tarsal region: (A, C, D) idiopathic tarsal hyperextension without
identifiable underlying pathology; (B) tarsal hyperextension secondary to severe stifle disease; (C) standard
lateral radiograph of patient depicted in image (A), note that there are (white arrows) degenerative changes
several joints of the tarsus; (D) stressed image illustrating the hyperextension visualized in image (A); (E, F)
calcification in the (white arrow) deep digital flexor tendon sheath likely representing a migrated OCD flap;
there is another (blue arrow) calcification in the dorsal joint space of unknown origin; and (G, H) tarsal
synovial cell sarcoma not the (white arrows) subtle lysis of the talus and distal tibia.
Tarsal hyperextension does not typically seem to be painful, so it is usually treated conservatively.
Orthoses that allow tarsal flexion while limiting extension may be considered. In calves, shortening
of the fibularis longus tendon seems to be effective in preventing hyperextension (Kilic et al. 2015),
but specific surgical therapy has not been reported for dogs. Once tarsal hyperextension has devel-
oped, it persists even if concurrent orthopedic conditions have been successfully addressed.
18.7.4 Osteochondrosis Fragment Migration into the DDF Tendon Sheath

An unusual manifestation of talar OCD is the migration of osteochondrosis fragments into the
synovial sheath surrounding the DDF tendon. This sheath communicates with the tarsocrural
joint just caudal to the medial malleolus and near the plantar aspect of the talus, making it possible
for free fragments from the medial (and occasionally lateral) talar ridge to become trapped around
the tendon.
These osteochondral fragments can irritate the DDF and restrict its motion within the sheath
(Post et al. 2008). Lameness is intermittent (resembling patellar luxation by causing a “skipping”
pelvic limb lameness) to continuous (particularly if severe arthritis is present due to the primary
OCD lesions), with decreased range of motion in the tarsus in both flexion and extension.
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Tarsocrural joint effusion is present. The DDF tendon sheath may be palpable as a distended and
painful vertical swelling on the plantaro-medial aspect of the tarsus and distal tibia.
Orthogonal radiographs may show swelling of the DDF tendon sheath and opacities in the region
of the tendon caudal to the tibia (Figure 18.12). Oblique views can be useful for highlighting
additional fragments. CT is the most sensitive test for showing all of the fragments within the
sheath, which is useful for guiding fragment removal surgery but generally not necessary for
diagnosis of this condition. Ultrasonography of the tendon sheath can also be used to localize
swelling to the DDF tendon sheath and find fragments.
Lameness attributed to irritation of the DDF can be treated with removal of the osteochondral frag-
ments from around the tendon. However, lameness due to the secondary degenerative changes
may persist following treatment.
18.7.5 Tarsal Region Neoplasia

Neoplasia is much less frequently observed in the tarsal region than in the carpal region, but
tumors of the synovium (Figure 18.12) and osteosarcoma should be considered as differential diag-
noses. Further details about neoplastic conditions are provided in Chapters 11 and 22.

While degenerative changes of the distal tarsal joints are frequently identified as an incidental
finding, lameness associated with centrodistal OA has been described in Greyhounds and Border
Collies (Guilliard 2005). Affected dogs show a pain response if the metatarsus is supinated while
the limb is extended behind the dog and the calcaneus is fixed in place.
The authors have diagnosed rupture of the tarsal extensor retinaculum as a cause of lameness,
but this has not been reported in the peer-reviewed literature.
Dee (2015) has reported lameness (often bilateral) in working German Shepherds associated
with thickening and presumed repetitive trauma to the cranial tibial tendon of insertion.
Fragmentation of the medial malleolus has been reported in a small number of young large-
breed (mostly Rottweiler) dogs; about half of the affected dogs had concurrent talar ridge OCD
(Newell et al. 1994). The association of this condition with lameness is unclear.
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Post, C., Guerrero, T., Ohlerth, S. et al. (2008). Joint mice migration into the deep digital flexor tendon
sheath in dogs: clinical cases and anatomical study. Vet Comp Orthop Traumatol 21 (5): 440–445.
Radasch, R.M., Lewis, D.F., Mcdonald, D.E. et al. (2008). Pes varus correction in Dachshunds using a
hybrid external fixator. Vet Surg 37 (1): 71–81.
Reinke, J.D. and Mughannam, A.J. (1994). Lateral luxation of the superficial digital flexor tendon in 12
dogs. J Am Anim Hosp Assoc 29: 303–309.
Sabanci, S.S. and Ocal, M.K. (2018). Categorization of the pelvic limb standing posture in nine breeds
of dogs. Anat Histol Embryol 47 (1): 58–63.
Sjöström, L. and Håkanson, N. (1994). Traumatic injuries associated with the short lateral collateral
ligaments of the talocrural joint of the dog. J Small Anim Pract 35 (3): 163–168.
Solanti, S., Laitinen, O., and Atroshi, F. (2002). Hereditary and clinical characteristics of lateral
luxation of the superficial digital flexor tendon in Shetland Sheepdogs. Vet Ther 3 (1): 97–103.
Thrall, D.E. and Robertson, I.D. (2016). Basic imaging principles and physeal closure time. In: Atlas of
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19
Stifle Region
Jennifer Warnock1 and Felix Michael Duerr 2
1
Carlson College of Veterinary Medicine, Oregon State University, Corvallis, OR, USA
2
STIFLE REGION
Pathology of the stifle joint is a common source of clinical pelvic limb lameness in dogs. While
many conditions affect the stifle region, cranial cruciate ligament disease (CCLD) and patellar
luxation are the two diseases responsible for the majority of clinical lameness seen in dogs.
Fortunately, both of these conditions can be tentatively diagnosed based on physical exam and
radiographs. Additional imaging modalities such as computed tomography (CT), ultrasound, mag-
netic resonance imaging (MRI), arthrocentesis, and arthroscopy can be used to confirm diagnoses,
detect additional and less common injuries affecting the region, and allow for surgical planning.
Osteoarthritis of the stifle joint most frequently is the consequence of cranial cruciate ligament
(CCL) deficiency. Other conditions such as patellar luxation and osteochondrosis dissecans (OCD)
are less common primary causes of osteoarthritis. The stifle is one of the joints reported to be
affected by immune-mediated as well as infectious arthritis and, therefore, arthrocentesis and syn-
ovial fluid evaluation should be considered in cases where establishing a diagnosis is difficult.
Figure 19.1 and Table 19.1 outline common differential diagnoses and diagnostic steps for the
stifle region.
19.2 Normal Anatomy
19.2.1 The Stifle Joint

The stifle joint is a large complex condylar joint. Articulating joint surfaces are found between the
femoral and tibial condyles (femorotibial joint), the patella and femur (femoropatellar joint), and
the fabellae (sesamoid bones of the gastrocnemius muscle) and the femur. The joint surfaces of the
tibial and femoral condyles are convex, and the plateau of the tibia is sloped, making the stifle a
relatively incongruent and unstable joint without its soft tissue supporting structures. This is one
of the main reasons, why injury to the stabilizing articular structures typically results in instability,
dysfunction, and pain.

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Table 19.1 Key features for selected diseases affecting the stifle region.
Common
Disease signalment Diagnostic test of choice Exam findings Treatment Clinical pearls Terminology
Fractures Any (physeal Radiographs Pain, crepitus, and Depends on Comparison to other Minimally displaced tibial
fractures in (orthogonal views non-weight-bearing location but (normal) limb can tuberosity avulsion
immature animals) needed, particularly for lameness frequently surgical help to diagnose fracture (MDTTAF)
minimally displaced fixation minimally displaced describes fractures of the
physeal fractures), may recommended physeal fractures tibial tuberosity with
require CT or stress secondary remodeling of
views the physis but minimal
displacement
Cranial cruciate Any breed but Palpation with See Box 19.1 Surgical treatment Early, partial tears do “Rupture” is obsolete
ligament disease middle-aged radiographs generally (TPLO) or not show drawer or terminology given the
(CCLD) medium-/ sufficient, may need nonsurgical thrust instability, but degenerative, slowly
large-breed dogs arthroscopy to confirm treatment radiographs easily progressive nature of the
predisposed partial tears detect joint effusion disease
Caudal cruciate Any breed, athletes Stress views, Caudal drawer Generally Difficult to
ligament rupture predisposed since arthroscopy, or MRI instability nonsurgical differentiate from
the trauma CCLD based on exam
requires caudal
blow to tibia
Stifle luxation Any breed since Radiographs, stress Severe pain and Surgical treatment Stifle radiographs lack Also known as “deranged”
traumatic views, and ultrasound obvious instability chronic, degenerative stifle
changes
Patellar luxation Small-breed dogs Palpation, radiographs, Patella instability Surgical and Small-breed dogs with
predisposed to or CT to determine graded 1–4 nonsurgical history of MPL and
MPL; large-breed degree of deformities (Box 19.2) treatment acute worsening of
dogs may have lameness may suffer
MPL or LPL from concomitant
CCLD
Osteochondrosis Large- and Radiographs but CT Pain on stifle Surgical removal Ideally diagnose and
dissecans (OCD) giant-breed may be required for manipulation or medical treat early, once
puppies subtle lesions without instability management arthritis is present
treatment is more
controversial
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Patellar ligament Any for traumatic; Radiographs and Obvious disruption Traumatic Common after TPLO Patellar tendinopathy
desmopathy athletic dogs for ultrasound to mild or no pain generally surgical, and TTA but does not
nontraumatic upon palpation nontraumatic cause lameness in
generally these patients
nonsurgical
Angular limb Large- and Radiographs (CT if Lameness and pain Surgical or Secondary patellar Tibial valgus and Genu
deformity giant-breed surgery is performed) variable nonsurgical luxation or CCLD varum/valgus
puppies management may be present
depending on
severity
Panosteitis Frequently seen in Radiographs (but may Pain on long bone Rest and pain Disease should be Other terms include
German Shepherd require CT during early palpation (more management self-limiting, if eosinophilic panosteitis,
Dogs between 5 stages) show common in clinical symptoms juvenile osteomyelitis, and
and 19 months of intramedullary thoracic limb), continue in the same enostosis or medullary
age radiodensities shifting leg leg, further imaging fibrosis
lameness should be considered
Septic arthritis Postsurgical dogs Joint fluid analysis, Moderate-to-severe Antibiotics and Dogs with preexisting
most common but culture, and physical pain on ROM, consider joint joint disease (such as
can happen in exam findings periarticular lavage; removal of arthritis) are
dogs with swelling, and implants once predisposed. A lack of
preexisting pitting limb edema bone healing fever or negative
arthritis complete culture results do not
rule out septic
arthritis
Gastrocnemius Athletic dogs but Radiographs may show Variable degree of Nonsurgical To stretch the muscle, Gastrocnemius avulsion is
myotendinopathy described in pets calcification, lameness and pain management extend the stifle and likely initial stage of the
as well enthesopathy, and upon palpation and unless acute, flex the tarsus more chronic
displacement; however, stretching of the traumatic avulsion myotendinopathy
ultrasound or MRI is muscle
needed if no
radiographic changes
are present
Long digital Athletic dogs but Palpation for luxation; Skipping lameness Nonsurgical most To stretch the muscle,
extensor described as radiographs may show with luxation, common flex the stifle, extend
tendinopathy complication after calcification asymptomatic with the tarsus, and flex
TPLO calcification the digits
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Septic
Stifle luxation arthritis
Visible
History of trauma
abnormality
Myotendino–
Fracture Stifle joint Consider to establish pathies
dislocation diagnosis
X-rays
Patellar Fracture/fissure normal/ Arthrocentesis
ligament X-rays Meniscal tears
line joint
desmopathy abnormal
effusion
only
Proximally displaced Collateral/
Cranial or caudal patella Ultrasound/MRI
patellar
cruciate ligament ligament injury
deficiency
Cranial or caudal
tibial displacement Caudal cruciate
Stress radiographs
Patellar luxation Pain in ligament
(Grade 2–4) stifle deficiency
Dislocated patella region
CT
CCLD, OCD, and OCD
patellar luxation Osteoarthritis
History of
Minimally
trauma
Osseous Angular limb Palpation
deformities/ Regional displaced
deformity (myo)tendinopathies:
premature fracture
physeal closure • Long digital extensor
• Gastrocnemius
Lytic lesion FNA Patellar luxation
Osseous (Grade 1–3)
neoplasia
Radiographically
visible calcification
Avulsion Soft tissue
fragment, neoplasia
Meniscal/LDE
calcification
Figure 19.1 Schematic of common diseases affecting the stifle region and the steps necessary to establish a diagnosis.
The joint capsule volume is large, extending proximally under the quadriceps femoris by approx-
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imately one patella’s length, laterally and medially to the margin of the femoral epicondyles, cau-
dally to the femoral articulation of the fabellae, and distally following the course of the long digital
extensor (LDE) tendon. There is a small joint sub-pouch extending around the tibial condyle and
fibular head, as well as the axial surface of the origin of the popliteus. The infrapatellar fat pad is
located just caudal to the patellar ligament but is extracapsular (i.e. located extra-articular). This
becomes important when evaluating lateral view radiographs of the stifle joint to diagnose effusion
of the joint. Understanding the location and volume of the stifle joint space also allows multiple
entry points for therapeutic joint injections and arthrocentesis and also prevents accidental injec-
tions into the infrapatellar fat pad.
The cruciate ligaments of the stifle joint are located intracapsular but are covered by a thin syno-
vial layer. The cranial cruciate ligament originates from the caudomedial aspect of the lateral femo-
ral condyle (i.e. intra-articularly from the caudal aspect of the lateral femoral condyle) and courses
diagonally, cranially, and medially to insert around the cranial intercondyloid area of the tibial
plateau. The CCL serves to limit craniocaudal translation, hyperextension, as well as excessive
internal rotation. The canine stifle joint is highly dependent on the CCL for stability during stand-
ing as well as the stance phase of weight-bearing; loss of this ligament causes profound instability
of the stifle joint (Korvick et al. 1994). The CCL has two functional bands: the craniomedial band
STIFLE REGION
and the caudolateral band (named based on their tibial attachment sites). The craniomedial band
is taut in extension and flexion, and the caudolateral band is taut in extension, but loose in flexion.
This is important to keep in mind when palpating for pathology that exclusively affects the cranio-
medial band, as it may be difficult to detect instability unless the stifle is placed in flexion.
The caudal cruciate ligament (CaCL) originates from the craniolateral aspect of the medial femo-
ral condyle (i.e. intra-articular from the cranial aspect of the medial femoral condyle), courses
caudodistally, and inserts on the caudal tibia (lateral edge of the popliteal notch). Its principle
function is to prevent caudal displacement of the tibia relative to the femur. It is larger than the
CCL and, as the name implies, crosses the CCL.
There are two intra-articular tendons in the stifle joint. The tendon of the long digital extensor
muscle originates in the extensor fossa of the femur and courses through the muscular groove of
the tibial plateau located just cranial to the lateral tibial condyle. Its origin on the proximal femoral
condyle can be confused for a stifle OCD lesion (Figure 19.2); this can be distinguished by the
proximal location away from the joint surface, as well as by the small semilunar shape of the exten-
sor fossa. The popliteal tendon is located in the caudal aspect of the joint, runs caudolaterally and
serves to limit external rotation of the stifle in flexion, and has a small attachment to the fibula
(Griffith et al. 2007).
The collateral ligaments serve to prevent varus/valgus joint instability, in addition to limiting
rotational instability. They are principally taut and especially important to joint stability when the
stifle is in extension. With increasing flexion of the stifle, the collateral ligaments, especially the
lateral collateral ligament (LCL), become more lax, and the CCL and CaCL take on additional
varus/valgus stabilization role (Vasseur and Arnoczky 1981).
The menisci (lateral and medial meniscus of the stifle joint) are concave, are semilunar-shaped
fibrocartilages, are wedge-shaped in cross section, and have a thin synovial intimal covering. These
meniscal fibrocartilages provide the majority of the weight-bearing surface of the stifle joint
between the incongruent, unstable, convex surface of the femoral and tibial condyles, making
them a crucial component of stifle joint stability. In the body of the meniscus, collagen bundles are
arranged in a circumferential orientation and bound by perpendicularly oriented radial fibers, an
arrangement that allows to mitigate compressive weight-bearing forces (Fithian et al. 1990). The
312 19 Stifle Region
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(A) (C) (E) (G)
(B) (D) (F)

STIFLE REGION
Figure 19.2 Normal radiographic anatomy of the stifle joint (Note: for images B, D lateral is on the left):
(A, B, E, F) lateral and craniocaudal views of the stifle of adult dogs; (C, D, G) lateral and craniocaudal
views of the stifle of immature dogs; (a) femur; (b) tibia; (c) patella; (d) fibula; (e) fabella(e), i.e. lateral/
medial gastrocnemius sesamoid bone; (f) popliteal sesamoid bone; (g) proximal tibial physis; (h) distal
femur physis; (i) apophysis of tibial tuberosity; (j) extensor fossa, i.e. fossa of origin of the long digital
extensor tendon; (k) medial and lateral supracondylar tuberosities (i.e. origin of the gastrocnemius
muscle) and superficial digital flexor (lateral tuberosity); (l) tibial tuberosity; (m) femorotibial joint; (n)
femoropatellar joint; (o) patellar ligament; (p) infrapatellar fat pad; and (q) cranial and caudal horn of the
menisci/joint fluid.
meniscal horns and attachments are nerve and blood vessel rich and, therefore, have important
sensory functions (O’Connor and Mcconnaughey 1978). Regionally, an individual meniscus con-
sists of a body and a cranial and caudal horn. The cranial and caudal horns of the medial meniscus
are attached to the tibial plateau via meniscotibial ligaments, which hold the meniscus in place
while weight-bearing (Pagnani et al. 1991). The transverse (formerly described as intermeniscal)
ligament connects the cranial menisco-tibial ligaments of the two menisci. The menisci are quite
mobile through range of motion (ROM) and move to match the position of the femur and tibia
through ROM (Park et al. 2018). However, there are two important differences between the attach-
ments of the medial and the lateral meniscus. The body of the medial meniscus has a close associa-
tion with the medial collateral ligament (MCL) and joint capsule, which tethers it more firmly to
the tibia. The lateral meniscus, on the other hand, has a strong association with the femoral con-
dyle via the menisco-femoral ligament that anchors the caudal meniscal horn to the femur (rather
than the tibia since the caudal menisco-tibial ligament of the lateral meniscus is infinitesimal).
This association allows the lateral meniscus to move with the femur, rather than being tethered to
the tibia, which is the main reason why the medial meniscus is injured more frequently than the
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lateral meniscus when CCL deficiency is present.

The patella is the articular sesamoid bone of the quadriceps complex. It is held in place by con-
gruent positioning within the trochlear groove and by its centralized attachment of the patellar
ligament on the tibial tuberosity and soft tissue support. Tension from the quadriceps group, patel-
lofemoral ligaments, joint capsule, and the alar fibrocartilages which glide over the trochlear ridges
through ROM is also a critical stabilizer of the patella. Derangement or injury of any of these
structures can predispose to patellar luxation.
19.2.2 Muscles of the Stifle Joint

The primary muscle stabilizers of the stifle joint are the quadriceps group, which perform stifle
extension, and the stifle flexors, the gastrocnemius and hamstring group (Hayes et al. 2013). The
quadriceps muscle is innervated by the femoral nerve and consists of the vastus medialis, vastus
intermedius, vastus lateralis, and the rectus femoris. The vastus lateralis and intermedius originate
on the vastus ridge of the proximal femur, while the vastus medialis originates on the craniomedial
aspect of the proximal femur on the cranial intertrochanteric crest. The rectus femoris is the only
member of the group to cross the hip joint, with its origin on the tuberosity of the rectus femoris
STIFLE REGION
and the iliopectineal eminence located on the ilium. These four muscles form the tendon of inser-
tion of the quadriceps muscle that includes the patella itself and the portion from the patella to the
tibial tuberosity, the patellar ligament (sometimes referred to as the patellar tendon). The patellar
ligament is the terminal insertion of the quadriceps mechanism and therefore contributes to stifle
extension. The dynamic tension of the quadriceps muscle helps to keep the patella tracking within
the trochlear groove.
The main muscles of the hamstring group are the semimembranosus, semitendinosus, and
biceps femoris muscles. The hamstrings originate from the ischial tuberosity and are innervated by
the sciatic nerve. The semitendinosus muscle branches, and part of it attaches to the proximal
medial tibial fascia as well as courses distally with the tendon of the gracilis muscle as part of the
common calcanean tendon. The semimembranosus inserts as a distinct but short tendon near the
origin of the gastrocnemius and just beneath the MCL on the medial tibial condyle. The biceps
femoris attaches via an aponeurosis of the fascia lata to the tibial tuberosity laterally, continuing
distally to become a part of the common calcanean tendon. The hamstring group works reflexively
via the cruciate ligament mechanoreceptors to limit cranial tibial translation, hyperextension, and
excessive internal rotation, hence protecting the CCL from damage during movements of the tibia
relative to the femur (Hayes et al. 2013).
The gastrocnemius has a medial and a lateral head, which originate from the caudal femur at the
supracondylar tuberosities and attach on the tuber calcanei. Each muscle head contains a sesa-
moid bone (fabella) just below its origin. The gastrocnemius is innervated by the tibial branch of
the sciatic nerve and its action is to flex the stifle and extend the hock. In contrast to the action of
the hamstrings, the pull of the gastrocnemius works to pull the femur caudal relative to the tibia
(Hayes et al. 2013).
The long digital extensor muscle originates intra-articularly in the extensor fossa of the lateral
femoral condyle and courses through the stifle joint and into the extensor groove of the tibia. The
tendon is located deep into the tibialis cranialis muscle and just cranial to a palpable prominence
on the lateral aspect of the tibia, called the Tubercle of Gerdy in humans. In most dogs, this protu-
berance is large enough to palpate. The muscle inserts on the dorsal surface of the distal phalanx
of digits II–V.
19.3 Fractures of the Stifle Region

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Fractures of the stifle joint region are common and include fractures of the distal femur, proximal
tibia/fibula, and patella. Mature animals most commonly sustain fractures of the diaphyseal area.
These fractures are easily identified radiographically, and treatment frequently requires surgical
intervention, particularly if substantial displacement is present. Fractures involving the articular
surface (Figure 19.3) are rare but are likely to result in osteoarthritis. These fractures also have the
potential to cause meniscal and cruciate ligament damage. As the stifle joint has a voluminous
outpouching at the distal femur, even distal femur fractures have the potential to affect the stifle
joint. Patellar fractures and fractures of the tibial tuberosity affect the quadriceps mechanism and
may make weight-bearing impossible. Inappropriate healing (e.g. malunion) of fractures affecting
the stifle region (in particular tibial tuberosity and distal femur fractures) can affect the
quadriceps-patellar mechanism and thereby may result in secondary patellar luxation. This should
be considered when making treatment decisions during initial presentation.
Fractures of the stifle region are frequently caused by severe trauma including vehicular collisions,
gunshot, kicks, etc. Therefore, careful evaluation of the entire patient for concomitant non-orthopedic
STIFLE REGION
(A) (C) (E) (G)
(B) (D) (F) (H)
Figure 19.3 Examples of stifle region fractures in four patients. Patient I (A, B) severely displaced SH Type I
fracture of the distal femur. Note the typical configuration of the distal femoral physis (white arrows).
Patient II (C, D) moderately displaced articular fracture of the proximal tibia in a mature patient. These
fractures are rare but require precise reconstruction since due to their disruption of the articular surface.
Patient III (E, F) comminuted fracture of the patella (white arrows). Patient IV (G, H) comminuted, SH Type IV
fracture of the distal femur. The white arrow indicates the articular component of the fracture, which is
important to recognize per-operatively.
19.3 Fractures of the Stifle Regio 315
injuries is imperative. The patient will typically exhibit non-weight-bearing lameness, with variable
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amounts of swelling and crepitus around the fractured region. Examination of the area usually shows
severe pain upon manipulation. Diagnosis of these fractures can generally be accomplished with
orthogonal radiographs, although the diagnosis can be missed if only a single view is taken (Figure 19.4).
CT may be beneficial for complex fractures, to identify intra-articular components, bone fissures,
and additional fragments that may be missed with radiographs.
19.3.1 Patellar Fractures

Traumatic patellar fractures are rarely encountered in dogs. They are the result of severe, direct
trauma to the patella and can be diagnosed with standard radiography (Figure 19.3). Because of
the extreme tension by the quadriceps muscle, treatment is challenging. Surgical fixation and par-
tial patellectomy are potential treatment options. These fractures may also be associated with dis-
ruption of the patellar ligament and other soft tissue pathologies (e.g. cruciate and collateral
ligaments, and menisci), which need to be carefully investigated (either at the time of surgery or
(A) (C) (E) (G)
STIFLE REGION
(B) (D) (F) (H)
Figure 19.4 Examples of physeal fractures in four patients. Patient I (A) severely displaced avulsion
fracture of the tibial tuberosity apophysis without disruption of the proximal tibial epiphysis. These
fractures generally require surgical reconstruction. Patient II (B) minimally displaced tibial tuberosity
avulsion fracture (MDTTAF). These patients are generally treated nonsurgically. Patient III (C–F) mildly
displaced fracture (C, D) of the proximal tibial apophysis and epiphysis. The small fragment (white arrow
image (C)) indicates that this is a Type II SH fracture. Note that the fracture is difficult to identify on the
craniocaudal view. The only abnormality is a (white arrow) slight widening of the lateral aspect of the
proximal tibial physis. Images (E, F) are of the normal leg and provided for comparison. Patient IV (G, H)
mildly displaced SH Type I fracture. Note the subtle (white arrows) widening of the medial and caudal
aspect of the proximal tibial physis.
with diagnostic imaging). Patellar fractures have also been reported to occur in up to 2% of dogs
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after tibial plateau leveling osteotomy (TPLO); however, these fractures generally do not require
surgical treatment (Rutherford et al. 2012).
19.3.2 Salter-Harris Fractures

Proximal tibia and distal femur fractures most frequently affect the physes and therefore are most
commonly observed in immature animals. Dogs of any breed with open physes may be affected.
Physes of domestic dogs are fragile and very little trauma can result in a Salter-Harris (SH) fracture.
Typical causes of these fractures include collision with humans or bigger dogs during play, falls off
furniture or down stairs, and jump-down injuries out of an owner’s arms, out of vehicles, or other
mild-to-moderate heights.
SH fractures of the proximal tibia and distal femur are most commonly Type I or II and therefore
do not involve the articular surface (see Chapter 13 for description of SH fractures). The proximal
tibial growth plate rarely fractures on its own and, more commonly, fractures in conjunction with
the tibial apophyseal growth plate (Figure 19.4C, D). The epiphysis generally rocks back (i.e.
caudolateral displacement) and failure to repair these fractures results in an excessive tibial pla-
teau which can cause CCL strain and tearing in the long term. The distal physis of the femur con-
STIFLE REGION
sists of four pyramidal grooves and corresponding pegs that result in the classis “W-shape” seen
radiographically (Figure 19.3). Similar to proximal tibial physeal fractures, the distal femoral epi-
physis commonly rocks back (i.e. caudolateral displacement) but failure to repair these fractures
results in excessive distal femoral procurvatum. Type III and IV fractures are rare and can be chal-
lenging to identify radiographically if displacement is minimal (Figure 19.4). Oblique radiographs
in addition to flexed and extended views can be used to identify minimal displacement.
Tibial tuberosity avulsion fractures may present in various degrees of severity ranging from a severely
displaced, palpable fracture with non-weight-bearing lameness to a minimally displaced fracture
with only mild clinical signs. Severely displaced fractures are best treated with surgical fixation that
ideally permits continued growth of the physis, if the patient has significant growth potential left.
Radiographs while fully flexing the stifle can exacerbate the displacement of these fractures and aid
in decision-making if displacement is minimal. It is important to note that the growth plate of the
tibial tuberosity apophysis (i.e. the site of the patellar ligament attachment) closes late during devel-
opment and the ossification may be irregular (von Pfeil et al. 2009). As such, interpretation of radio-
graphic changes to the area should be made with caution. Comparison to the non-affected limb is
advised before making a diagnosis. Based on these observations, a condition termed minimally dis-
placed tibial tuberosity avulsion fractures (MDTTAF) has been described (von Pfeil et al. 2012). Dogs
affected with MDTTAF show secondary remodeling of the physis with no or mild displacement of
the tibial tuberosity, while the most caudoproximal aspect of the tibial tuberosity always remains
attached to the proximal tibial epiphysis. Patients present with mild-moderate lameness and pain
when pressure is applied to the tibial tuberosity. Nonsurgical treatment is generally successful. In
people, a condition similar to MDTTAF is known as “Osgood-Schlatter disease”; however, since this
condition does not involve the physis, this terminology should not be used for dogs with MDTTAF.
19.4 Cranial Cruciate Ligament Disease
CCLD is the term used to describe any disruption of the CCL. This includes rare conditions such
as avulsion fractures and traumatic ruptures but generally CCLD refers to chronic degeneration of
the ligament. The latter is by far most commonly encountered and represents one of the most
19.4 Cranial Cruciate Ligament Diseas 317
f requent reasons for pelvic limb lameness in the dog. The condition has a complex multifactorial
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etiology that is still incompletely understood (Griffon 2010; Comerford et al. 2011). Many factors
have been shown to play a role including genetics, environmental (e.g. obesity, timing of steriliza-
tion, and poor physical condition), and conformational (e.g. tibial plateau angle [TPA]). Immune-
mediated disease has also been suggested as an underlying cause.
While more research is needed to understand the etiopathology of CCLD, the clinical progres-
sion is well described – degenerative CCLD results in osteoarthritis of the stifle joint, in many cases
bilaterally. The progressive inflammation and degradation of intra-articular structures eventually
lead to gross joint instability and patient disability. As the CCL degenerates and global joint inflam-
mation worsens, traumatic and degenerative meniscal tears occur secondarily.
Successful treatment of degenerative CCLD has been reported with both surgical and nonsurgi-
cal strategies (Wucherer et al. 2013). However, surgical treatment has been suggested to be supe-
rior and TPLO is the preferred surgical technique (Wucherer et al. 2013; Bergh et al. 2014; Beer
et al. 2018). Treatment decisions should be made on an individual basis considering owner and
patient factors including the severity of clinical symptoms, age, size, systemic health, and activity
level of the patient. Meniscal tears frequently lead to more severe clinical symptoms. These tears
can be successfully addressed surgically with partial meniscectomy. Avulsion fractures can be
treated by reattachment of the avulsed bone or with proximal tibial epiphysiodesis (Vezzoni et al.
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2008). The treatment of traumatic CCLD is similar to the treatment of degenerative CCLD.

Degenerative CCLD most frequently affects dogs of approximately 3–7 years of age (Baker and Muir
2018). Commonly affected breeds include large-breeds such as Labrador Retrievers, Pit Bulls,
Rottweilers, Golden Retrievers, Chesapeake Bay Retrievers, Queensland Heelers, Akitas, Australian
Shepherds, Doodles, Bernese Mountain Dogs, Boxers, German Shepherds, and giant-breed dogs,
such as English Mastiffs, Newfoundlands, Landseers, Great Pyrenees, and St. Bernards (Duval
et al. 1999; Witsberger et al. 2008). Avulsion fractures are only observed in immature animals. Since
the attachment of the ligament to the bone is stronger than the immature bone in these patients,
the bone rather than the ligament itself “gives.” Traumatic CCLD is not well described in adult
patients, although the authors have observed this condition in agility and other sporting dogs. This
condition has to be differentiated from more severe traumatic injuries (e.g. stifle luxations) that
also cause disruption of other soft tissue structures (e.g. collateral ligaments and CaCL).
Patient history varies widely, from acute onset of severe lameness to insidious progressive lame-
ness which worsens with exercise or activity. Dogs may experience difficulty in rising or morning
stiffness consistent with stifle osteoarthritis as reported by owners. In dogs with patellar luxation,
CCLD may cause sudden worsening of the preexisting lameness. Waxing and waning of the lame-
ness severity may also be reported. This can be due to an initial, partial ligament tear and hemar-
throsis, with further tearing of the ligament until the entire ligament is disrupted in addition to
meniscal tears later in the disease stage. The progression through the disease stages varies greatly
in timeline with some dogs having an insidious, slowly worsening lameness that can progress over
years. Many of these cases maintain a partially intact CCL and meniscus and symptoms are due to
the osteoarthritic changes, rather than instability. A recent study showed that Boxers have higher
osteoarthritis scores compared to other commonly affected breeds (Gilbert et al. 2019), indicating
that they may have a longer duration of joint inflammation before presentation for diagnosis.
Other dogs progress rapidly from partial tears to complete tears, at which time the lameness fre-
quently becomes non-weight-bearing. Owners often perceive the condition as an acute, traumatic
event associated with a bout of activity or event (such as a dog park collision, stepping into a hole,
etc.). However, as stated above, traumatic CCLD is extremely rare; therefore, the traumatic event
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perceived to coincide with the onset of injury is generally minor and only able to disrupt the liga-
ment because of previous weakening and degeneration. This is confirmed by the presence of radio-
graphic changes that indicate chronicity observed in these cases.

A tentative diagnosis of CCLD can be established based on the specific physical exam findings
associated with the progression of CCLD outlined in Box 19.1. Although early in the disease stage
only some of these features may be present (e.g. joint effusion and pain on hyperextension), with
complete ruptures all features can be observed solidifying the diagnosis.
19.4.2.1 Postural and Gait Changes

Observation can be used to identify postural and gait changes associated with CCLD. Patients will
show varying degrees of lameness resulting in the classic features associated with pelvic limb lame-
ness (Videos 1.1. and 1.3). The lameness can be a subtle weight-bearing lameness at the trot that
worsens with exercise in the case of early stable disease or partial tears. Alternatively, it can also be
a severe weight-bearing lameness easily observable at the walk and trot. The lameness typically is
caused by an unwillingness to completely extend the stifle, which can help differentiate it from hip,
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hock, or foot causes of lameness. Some dogs may avoid full ROM of the stifle by externally rotating
the stifle rather than flexing it. Dogs with meniscal tears or severe instability may be completely
non-weight-bearing.
Typically, patients will also offload the affected leg while standing, or offload the more acutely
painful side in bilaterally affected cases. This may be more obvious to observe than lameness dur-
ing motion in some cases (Video 1.1).
Lastly, several postural changes are observed with CCLD. The stifle may be kept flexed while
standing or during motion (Korvick et al. 1994) in an attempt to level the angle of the tibial plateau,
and the hock may be hyperextended to compensate for reduced stifle ROM and reduce the caudal
pull of the gastrocnemius muscle unit, which exacerbates tibial subluxation. Dogs with cranially
displaced meniscal tears may be unable to extend the stifle into a normal weight-bearing position.
When sitting, dogs with CCLD will sit with the affected stifle in extension due to the discomfort
Box 19.1 Progressive Physical Exam Findings Indicative of CCLD
1) Postural and gait changes

(a) Lameness and offloading of affected limb during stance
(b) Positive “Sit-test”
2) Palpation
(a) Stifle joint effusion
(b) Pain on hyperextension of the stifle joint
(c) Pain on flexion and loss of range of motion of the stifle joint
(d) Muscle atrophy
(e) Medial buttress
(f) Positive cranial drawer/tibial compression test
(g) Meniscal click
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(A) (B) (C)
Figure 19.5 A positive “sit-test” is one of the hallmark features indicative of CCLD (A) normal patient
illustrating a “square” sit with both stifles fully flexed; (B) bilaterally positive sit-test showing the limbs
placed on each side of the body; (C) unilaterally positive sit-test indicative of right-sided CCLD.
associated with full flexion of the stifle. This is known as the positive “sit test.” Dogs with unilateral
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CCLD may sit with only one stifle extended (and one stifle flexed and positioned normally under
their body); whereas, dogs with bilateral disease may extend both legs. Some dogs will extend both
legs by placing each leg on one side of their body, while others place the less affected limb under
their body (Figure 19.5 and Video 19.1). A positive sit test is not pathognomonic for CCLD and may
be observed in novrmal dogs (behavioral), or in dogs with hip or tarsal pathology.
Video 19.1
Positive “sit-test” examples in dogs with CCLD.
Bilaterally affected dogs will shift weight to the thoracic limbs by leaning forward and keeping
the thoracic limbs placed more caudally under the body. These dogs may develop a bodybuilder
appearance with hind end muscle atrophy and thoracic limb muscle hypertrophy. Bilateral dis-
ease severe enough to cause subluxation can result in a dog unable to get up and difficulty ambu-
lating. This may be confused with neurologic disease. Performing a neurologic exam and looking
for proprioception deficits will differentiate neurologic disease from severe bilateral CCLD.
19.4.2.2 Palpation
Degeneration of the CCL typically causes joint effusion, capsular and periarticular thickening, as
well as muscle atrophy. These pathologic changes can be identified on palpation of CCL-deficient
dogs. Standing behind the patient is the best way to detect asymmetries (Video 3.1). The examiner
may appreciate atrophy of the quadriceps, hamstring muscle group, biceps femoris, and cranial
tibialis muscle. In cases of severe stifle joint subluxation, careful palpation of the stifle may show
a cranially displaced tibial tuberosity relative to the patella. Many of the palpable abnormalities
can be identified in the awake patient; however, a sedated physical exam can be very helpful in
testing for joint instability, particularly in large, energetic, tense, or unruly patients. The resulting
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(A) (B) (C)
(D) (E) (F)

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Figure 19.6 Physical examination procedures to detect CCLD include (A) palpation of joint effusion is best
accomplished by palpating the indent just medial to the patellar ligament; (B) isolated hyperextension of
the stifle while maintaining a standing angle of the hip and tarsus can be accomplished by reaching in
between the dogs’ pelvic limbs and placing the upper hand cranial to the stifle, while extending the stifle
with the lower hand; (C) full stifle flexion can only be accomplished when simultaneously flexing the hip
and tarsus; the cranial drawer (D, E; see also Figure 19.7) and tibial compression (F; see also Figure 19.8)
tests can be performed while the patient is (D) standing or (E) in lateral recumbency.
muscle relaxation can allow for easier detection of subtle instability. Palpation of a meniscal click
may also be more accurate with sedation/anesthesia (Neal et al. 2015).
Palpable joint effusion is a consistent hallmark of CCLD at any stage and can be detected by feel-
ing for the medial and lateral borders of the patellar ligament. In the normal canine stifle, a divot
representing the joint space can be detected medial and lateral to the patellar ligament (Figure 19.6).
In the normal joint, the margins of the patellar ligament should be sharply apparent to the touch.
The pad of the index finger should fit into the space located about halfway between the insertion of
the patellar ligament at the tibial tuberosity (usually a distinct bony prominence) and the caudal
aspect of the patella. The earliest sign of CCLD will be subtle joint effusion which is consistent with
synovitis preceding ligament pathology. With joint effusion, this divot will fill in and the margins of
the patellar ligament will be less distinct. Joint effusion in combination with intermittent lameness
with exercise may be the only clinical signs detected in stable partial CCL tears. Initially this swelling
may feel soft or water balloon-like, and over time as the disease progresses, swelling can be detected
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laterally and attains a harder thickening representative of joint capsule thickening.

Over time, a knob of thickened tissue can be felt on the proximal medial aspect of the medial
tibial joint line, termed “medial buttress,” which represents a buildup of scar tissue to counteract
excessive internal tibial rotation with CCL deficiency. A challenge to the novice examiner is detec-
tion of CCL disease when present bilaterally, as the joint effusion and medial buttress can be fairly
symmetrical.
Pain or resistance to stifle ROM is a hallmark sign of the painful inflammation accompanying
CCL disease. Early on in the disease, pain on stifle hyperextension may be elicited, even when insta-
bility tests are negative. This is because the CCL counteracts hyperextension of the joint. Stifle
hyperextension needs to be tested without hyperextension of other joints (e.g. hip/tarsus) and
should therefore be performed with the hip and tarsus in a standing angle. The examiner can reach
in between the back legs to place one hand cranially to the stifle while using the other hand to
hyperextend the joint (Figure 19.6). As osteoarthritis and instability progress, the joint capsule
thickening and joint effusion can make full stifle flexion physically impossible and quite
uncomfortable.
In particular, patients with medial meniscal tears may have marked pain on flexion and in some
cases, upon internal rotation of the stifle, in fact dogs with pain specifically of stifle flexion are 4.3
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times more likely to have medial meniscal disease (Dillon et al. 2014). Meniscal tears most fre-
quently involve the caudal aspect of the medial meniscus with various types of tears having been
described (Kowaleski et al. 2018). Cranially displaced vertical (“bucket handle”) or flap meniscal
tears may make full stifle extension physically impossible. An additional finding on physical exam
that supports the presence of a meniscal tear is a “meniscal click” – the popping or clunking sound
emanating from torn or displaced meniscal tissue as the femur subluxates over the caudal medial
meniscal horn, snapping into a subluxated position (Video 19.2). The sound can also emanate from
a vertical longitudinal or flap meniscal tear as it displaces and reduces through ROM. When pre-
sent, a meniscal click has been reported to be 75–96% specific for actual meniscal damage
(McCready and Ness 2016). When combined with observation of pain on stifle flexion, the diagnos-
tic accuracy (i.e. correctly identifying the presence or absence of a disease) of detecting a meniscal
click is around 75% (Dillon et al. 2014; Neal et al. 2015). In other words, lack of a meniscal click
does not mean that meniscal injury is not present, and surgical examination, ultrasound, CT, or
MRI are necessary to definitively diagnose meniscal pathology. However, when a meniscal click
and pain on stifle flexion are observed, there is high likelihood that meniscal damage is present.
Performing ROM while placing the stifle in a stressed position (i.e. flexing the joint while perform-
ing tibial compression) can make it easier to detect a meniscal click in some patients. This test has
been described as the “modified tibial compression test” and was associated with a sensitivity of up
to 63% and specificity of up to 77% for detection of meniscal tears (Valen et al. 2017).
Video 19.2
Anatomy of meniscal tears.
Once osteoarthritis has developed, an additional noise that may be encountered during stifle
ROM is crepitus. Caused by the rubbing of the joint capsule on periarticular osteophytes, crepitus
has a higher pitched, light crackling sensation, that can be audible as well as palpable. Unlike a
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meniscal click which occurs only once during ROM, crepitus is most easily detected in the para-
patellar region around the trochlear ridges and is observable throughout the whole ROM of the
stifle joint.
The cranial drawer test elicits abnormal sagittal plane instability associated with CCLD and
is highly specific for rupture of the CCL, with a sensitivity of 86% and specificity of 98% (De
Rooster and Van Bree 1999c). The test can be performed with the patient standing or laying
down. Particularly larger dogs that are off-weighting the limb at a stance generally allow pal-
pation while standing. However, some dogs become tense, making it more difficult to assess
for instability. To perform the test, the examiner stabilizes the distal femur with one hand by
placing the tip of the index finger on the patella and the thumb on the lateral fabella. With the
opposite hand, the proximal tibia is grasped with the thumb placed in the region of the fibular
head and the tip of the index finger on the tibial tuberosity. The lower hand is used to first
push the tibia caudally (to reduce any present cranial tibial subluxation); the thumb is then
used to gently push the proximal tibia cranially (Figure 19.7). The lower hand also controls the
angle of the tibia relative to the femur. Ideally the trajectory of the movement of the tibia rela-
tive to the femur is parallel to the slope of the tibial plateau, to maximize the drawer motion
with minimal force or effort. If radiographs are unavailable (to estimate the tibial slope), the
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examiner can repeat the drawer test in flexion, increasing the angle of extension in 20° incre-
ments to find the position of maximal instability and elicit a positive test. The drawer test
should always be performed in both flexion and mild extension. Note that the collateral
(A) (B)
Figure 19.7 The cranial drawer test is performed by (A) placing the index finger on the patella and the
thumb on the lateral fabella, with the opposite hand, the proximal tibia is grasped with the thumb placed
caudal to the fibular head and the tip of the index finger on the tibial tuberosity. The lower hand is then
used to (B) gently push the proximal tibia cranially, which indicates CCLD deficiency.
l igaments are taut during full extension, providing some additional stifle stability, which mini-
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mizes the potential cranial drawer movement that can be elicited. Drawer testing should be per-
formed in flexion, because if only the craniomedial band is torn, drawer will be absent in
extension but present in flexion (since the caudolateral band is lax in flexion). When perform-
ing cranial drawer testing in a CCL-deficient stifle, the tibia will translate cranially relative to
the distal femur with a subjectively loose/sloppy end-feel (i.e. capsular end-feel) when maxi-
mum, cranial tibial displacement is reached. This is in contrast to puppies that frequently
display cranial drawer movement with a hard stop (distinct end-feel) once the maximum, cra-
nial displacement is reached (i.e. the intact CCL is engaged). This so-called “puppy drawer”
(Video 19.3) is normal and a similar finding can be observed in dogs with severe muscle atro-
phy. Dogs with tense pelvic limb muscles or chronic joint fibrosis on the other hand may have
diminished cranial drawer sign. The best way for the novice examiner to learn how to perform
the cranial drawer test is to learn on a dog under sedation. Technical pitfalls of this test include
eliciting normal tibial internal rotation and interpreting this as positive drawer.
Video 19.3
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Puppy drawer.
The cranial tibial compression (or thrust) test is another test for detecting CCL tears. The test
mimics the craniocaudal instability which occurs during weight-bearing. This test is subjectively
easier to perform on awake, energetic, or tense dogs than the cranial drawer test. However, the
tibial compression test can be difficult to interpret for the novice examiner. This test can also be
done with the patient standing or recumbent. The limb is placed with the hock in a standing posi-
tion and the stifle fully extended. One hand is placed over the cranial distal thigh with firm pres-
sure to keep the knee in full extension. The index finger of this hand is placed on the tibial tuberosity
to palpate for abnormal movement and to allow replacing the tibia in a caudal position (in case any
tibial subluxation is present). The other hand is used to flex the hock only, while the stifle is main-
tained in extension (Figure 19.8). In a normal stifle, no movement should be observed; in a stifle
that is CCL deficient, the tibial tuberosity will displace cranially. With a partial tear, this movement
may only consist of a few millimeters, which can be easily missed by the untrained or inexperi-
enced examiner. Visualizing the movement can be difficult in obese, or dogs with long coats, which
is why simultaneous palpation of tibial movement should be performed with the index finger. In
dogs with complete tears, the movement may be as obvious as a complete buckling of the stifle and
gross cranial movement of the tibial tuberosity. Performing this test while the dog is sedated is very
helpful for learning, especially for visualizing subtle thrust in partial CCL tears. A technical pitfall
of the technique is failure to keep firm enough pressure on the femur, which simply results in stifle
flexion and is not a true positive tibial compression test.
In a minority of patients, particularly those that have more acute (i.e. lacking chronic fibrous
tissue that provides some stability) CCLD, a very obvious positive tibial compression test can be
observed when the tibia is rotated internally. This finding has been termed “pivot shift” and is
defined as abrupt, cranial tibial displacement of the joint when the tibia is internally rotated (Video
19.4). While this condition has been described as a “jerking lateral movement of the stifle” while
weight-bearing (Gatineau et al. 2011; Knight et al. 2017), pivot shift can also be detected during
Figure 19.8 The cranial tibial compression test is

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performed by placing one hand over the cranial distal

thigh with the index finger placed on the tibial
tuberosity. The other hand is used to flex the tarsus,
while the upper hand maintains the knee in extension
(i.e. not allowing any flexion of the joint). Cranial tibial
movement indicates CCLD deficiency and may be
observed or detected with the index finger on the
tibial tuberosity.
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palpation. This is accomplished by internal rotation of the lower limb while performing the tibial
compression test. This test can be performed before surgery to determine appropriate treatment
strategies and after TPLO surgery, since pivot shift after this procedure may cause residual lame-
ness. A significant additional rotational instability may require therapeutic intervention (Knight
et al. 2017), most commonly with an anti-rotational suture. This rotation may be significant enough
to also induce a low-grade medial patellar luxation (MPL) in predisposed patients.
Video 19.4
Pivot shift.
19.4.3 Diagnostics
While exam findings (such as positive cranial drawer) have shown a high specificity to detect
CCLD, they are not pathognomonic for CCLD. Rare differential diagnoses (e.g. neoplasia such as
synovial cell sarcoma and osteosarcoma, immune-mediated arthritis) need to be considered when
establishing the diagnosis. Additional diagnostics, most often radiographs, are generally performed
to rule out these differential diagnoses and to further confirm the tentative diagnosis. Surgical
inspection (either via arthroscopy or arthrotomy) is most commonly used to confirm the diagnosis
and further characterize the sequelae of osteoarthritis and meniscal degeneration seen with this
disease. In case surgery is not performed, ultrasound or MRI can also be used to confirm the
diagnosis and to evaluate the meniscal status.
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(A) (C) (E) (G)
(B) (D) (F) (H)
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Figure 19.9 Cranial cruciate ligament disease (C–H) and normal radiographs for comparison (A, B):
radiographic changes consistent with (C, D) early CCLD include (white arrow) joint effusion and (black
arrows) early degenerative changes; (E, F) chronic CCLD include more (white arrows) advanced degenerative
changes; (G, H) patient with complete rupture of the CCL resulting in cranial tibial subluxation. Note that
although the craniocaudal view is frequently misinterpreted to show (white arrow) significant joint collapse,
this is due to the subluxation and radiographic beam positioning, and not a true finding.
Stifle radiographs are helpful to assess the osseous anatomy, rule out other pathology, and eval-
uate for key features associated with CCLD (Figure 19.9). Specific radiographic views (“TPLO-
views”; a craniocaudal view of the stifle including the entire tibia and hock joint, as well as a
90–90 flexed lateral view) are frequently performed if treatment with TPLO is considered as a
treatment option. This radiographic technique allows to measure the TPA required for surgical
planning (Figure 19.10). The degree of tibial sloping (i.e. TPA) may influence treatment decision-
making. Classic radiographic features of CCLD include joint effusion and osteoarthritic changes.
Joint effusion is easily identified with radiography because of the infrapatellar fat pad – effusion
causes cranial displacement of the fat pad and caudal displacement of the gastrocnemius fascia
(Figure 19.11). In the normal stifle, the cranial and caudal horns of the menisci can be seen as a
small triangular radiopaque density, located cranially and caudally between the femur and tibial
condyles (Figure 19.2). This should not be confused with early subtle joint effusion. Osteophytes
form at the junction of synovium and articular cartilage and are most commonly seen at the pro
distal pole of the patella, the joint capsule attachment on the femoral epicondyles, fabello-femoral
articulation, origin of the LDE tendon on the femur, the extensor groove on the tibia, suprapatel-
lar pouch, and the tibial condyles. In later stages of osteoarthritis, bone sclerosis can be seen in
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(A) (B) (C) (D)

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Figure 19.10 TPLO views of patients with varying degrees of tibial sloping: (A) red dots indicate
landmarks for measurement of identification of the tibial slope (red line; i.e. the cranial and caudal articular
margins of the tibial plateau); blue dots indicate landmarks for identification of the tibial axis (blue line; i.e.
from the center of the talus to the intercondylar eminence); the tibial plateau angle (TPA) is defined as the
angle formed by a line perpendicular to the tibial axis and the tibial plateau, in this case the TPA = 18°; (B)
TPA = 33°; (C) this dog suffered from a proximal tibial SH fracture that resulted in caudal displacement of
the proximal fragment resulting in a TPA = 43°, which is considered an “excessive TPA” requiring more
careful surgical planning; (D) TPA = 62°, this patient is also displaying caudal bowing of the proximal tibia.
the subchondral bone plate of the femur and tibial condyles. Radiographic osteoarthritis has been
shown to correlate with the degree of CrCL damage (Sample et al. 2017). If cranial tibial displace-
ment (also described as caudal femoral displacement by some authors; Rey et al. 2014) is evident,
disruption of the CCL can be confirmed radiographically. Several methods to objectively identify
displacement have been described (Plesman et al. 2012; Fujita et al. 2017). Two simple methods
that do not require any measurements include the evaluation of the intercondylar eminence in
relationship to the femoral condyles and the caudal aspect of the femur in relationship to the
caudal aspect of the tibia (Figure 19.12). In juvenile dogs, avulsion fractures may be visible
(Figure 19.13). Displacement of the popliteal sesamoid is a less commonly observed (Figure 19.13),
yet highly specific feature for diagnosis of CCLD with a reported accuracy of 99 and 100% speci-
ficity (De Rooster and Van Bree 1999a).
It should be noted that pathologic changes to the CCL and menisci will not necessarily induce
radiographically visible laxity of stifle joints in dogs (De Rooster and Van Bree 1999b). For dogs
with partial CCL tears, there may be minimal or no radiographic evidence of subluxation, but the
radiographic signs of osteoarthritis will help add evidence towards a clinical diagnosis. While
stress radiographs have been reported to have a 97% sensitivity and 100% specificity for CCL tears
when subluxation is present (De Rooster and Van Bree 1999c), they are rarely necessary to diagnose
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(A) (B)
(C)
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Figure 19.11 Frequent locations of (black arrows) degenerative changes associated with CCLD (A, B): (a)
infrapatellar fat pad; (b) joint effusion – outlined in image (C) in yellow; (c) patellar ligament – outlined in
image (C) in white; (d) degenerative changes at the distal tip of the patella.
(A) (B) (C) (D)
Figure 19.12 Cranial tibial displacement associated with CCLD (B–D) and normal radiographs for
comparison: (A) the (green asterisk) intercondylar eminence is located in close proximity to the (red
asterisk) center of the femoral condyles and a vertical line drawn tangential to the caudal aspect of the
femoral condyles falls within close proximity of the proximal tibial margin (Note that the radiographic
position will affect this measurement); (B) with mild and (C) moderate displacement, the distance between
the intercondylar eminence and center of the femoral condyles increases; (D) with severe displacement, the
line drawn from the condyles is distant from the proximal tibial margin.
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(A) (C) (E) (G)
(B) (D) (F) (H)

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Figure 19.13 Examples of uncommon presentations of CCL disruption in three patients. Patient I (A, B)
severe cranial tibial displacement in a dog with acute, traumatic rupture of the CCL. Note that the severe
displacements make it difficult to evaluate the craniocaudal radiographs and give the (false) impression of
a collateral ligament rupture. Patient II (C, D) avulsion fracture (white arrow) of the CCL in an immature
patient. Patient III (E–H) this patient was diagnosed with a (E) complete rupture of the CCL and (F) TPLO
surgery was performed. Postoperatively the tibia remained in cranial tibial displacement and “pivot shift”
was present. When externally rotated, the tibia (G) reduced into a normal position. Application of an (H)
anti-rotational suture was performed to eliminate internal rotation. Note the varying location of the (white
arrow) popliteal sesamoid with subluxation and reduction of the tibia as a feature indicating appropriate
position when located in a (G, H) normal position.
CCLD. These radiographs are performed by mimicking the cranial tibial compression test while
taking the X-ray (De Rooster and Van Bree 1999c). This radiographic technique can also be utilized
to demonstrate pivot shift instability after surgery (Figure 19.13).
Advanced imaging is rarely required to establish a diagnosis of CCLD. However, as outlined
above, a definitive diagnosis of meniscal injury cannot be established based on physical exam
and radiography. Ultrasound has been reported to diagnose meniscal tears with a correct clas-
sification rate of 84%, sensitivity of 86%, and specificity of 78%, while MRI has a correct clas-
sification rate of 77%, with a sensitivity of 68% and specificity 100% (Franklin et al. 2017). CT,
with and without intra-articular contrast application (i.e. CT-arthrography), and ultrasound
have also been reported for evaluation of the meniscus and parts of the CCL (Van Der Vekens
et al. 2019).
19.5 Patellar Luxatio 329
19.5 Patellar Luxation

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The patella is the largest sesamoid bone in the canine body. Its function is to redirect the forces of
the quadriceps muscle during stifle ROM (i.e. to allow the quadriceps to act as the major stifle
extensor). Patellar luxation is defined as dislocation of the patella outside (medial or lateral) of the
trochlear groove. Contraction of the quadriceps muscle results in pulling the patella onto a straight
line from the origin (proximal femur and ventral ilium for the rectus femoris muscle) to the inser-
tion (tibial tuberosity) of the quadriceps muscle. As such, the location of the origin and insertion
of this muscle determines whether the patella luxates.
Patellar luxation is one of the most commonly encountered orthopedic disease in dogs. It may be
of congenital origin (i.e. present at birth) but in most cases, it is a developmental disease (i.e. devel-
ops after birth) that has frequently been described as having a congenital etiology because it is
thought that abnormal skeletal development (with an underlying congenital etiology) results in
dislocation of the patella during development. Although several hypotheses have been suggested
(and been partially refuted), the etiology of patellar luxation remains somewhat unclear (Kowaleski
et al. 2018). A prominent explanation is that MPL originates from primary hip skeletal abnormali-
ties, including coxa vara (decreased femoral neck inclination) and relative retroversion of the fem-
oral neck (i.e. a decreased anteversion angle). The resultant genu varus (i.e. bow-legged deformity,
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where the knees are too far apart while the hocks are too close together) may be accompanied by
femoral deformities including distal external femoral torsion and femoral varus, hypoplastic or
absent medial trochlear ridges, and a hypoplastic trochlear sulcus. Displacement of the patella
medially draws the tibial apophysis medially, resulting in medial rotation of the entire joint, medial
torsion of the proximal tibia, and medialization of the tibial apophysis. In the severest cases, the
articular surfaces of the femoral and tibial condyles may be deformed and hypoplastic medially.
The quadriceps muscle’s resting tension causes it to follow the shortest possible path along the
thigh, whereby acting like a bow string, it pulls the patella further out of the trochlear groove,
exacerbating skeletal abnormalities in the growing dog. The joint capsule becomes adhered and
contracted medially and stretched laterally, adding an overarching internal rotation of the entire
stifle joint. Dogs with MPL may have a patella that rides proximally in the trochlear groove, termed
“patella alta” (Mostafa et al. 2008).
Lateral patellar luxation (LPL) is associated with an opposing suite of skeletal abnormalities,
including coxa valga, genu valgus (i.e. knock-knee deformity, where the knees are too close together
while the hocks are too far apart), femoral valgus, an undersized lateral trochlear ridge, a laterally
rotated joint, lateral tibial tuberosity torsion, lateral bowing of the proximal tibia, and medial tor-
sion of the distal tibia. Dogs with LPL may have a patella that rides distally in the trochlear groove,
termed “patella baja” (Mostafa et al. 2008).
Patellar luxation may occur concomitantly with CCLD in up to 25% of dogs with MPL (Campbell
et al. 2010). It is of great importance to determine whether the CCL is also affected since dogs with
the combination of CCLD and patellar luxation generally respond less favorably to nonsurgical
treatment. The determination of patella alta or baja and the degree of skeletal deformities are par-
ticularly important to decide if surgical treatment should be considered. Various treatment options,
including surgical and nonsurgical treatment options have been described (Di Dona et al. 2018).
Most commonly employed surgical treatments include soft tissue reconstruction (e.g. release of
the retinaculum on the side of luxation and imbrication of the opposing side), tibial tuberosity
transposition (to realign the extensor mechanism), trochleoplasty (deepening of the trochlear
groove), and corrective osteotomy of the distal femur (to correct underlying femoral varus or valgus
for MPL or LPL, respectively). The decision on whether or not to pursue surgery is made on a case-
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by-case basis taking into consideration the age, breed, and clinical symptoms of the patient, the
severity of luxation, as well as owner expectations. In general, lower-grade luxations in small-
breed dogs are often treated nonsurgically, while large-breed dogs more frequently require surgical
corrections including corrective osteotomies.

Since patellar luxation is a developmental disease, the majority of dogs are diagnosed by
3 years of age. Neutered dogs are predisposed and by far the majority of patellar luxations are
diagnosed in small-breed dogs (O’Neill et al. 2016). While previously thought that MPL is seen
predominantly in small-breeds and LPL in large-breeds, this has been shown to be incor-
rect – medial luxation is by far the most common type of luxation, in both small- and large-
breed dogs (Bosio et al. 2017). However, LPL is by far more common in large-breed dogs (Kalff
et al. 2014; Di Dona et al. 2018) and rarely seen in small-breed dogs. MPL is commonly seen in
toy and small-breed dogs such as Pomeranian and Yorkshire Terrier (O’Neill et al. 2016).
Large-breed dogs commonly affected include Labrador and Golden Retrievers, Pit Bulls,
Huskies, and Bull Dogs.
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Dogs affected with patellar luxation may present with varying degrees of clinical symptoms
ranging from nonclinical, to the typical symptoms of “skipping” pelvic limb lameness, to severe
skeletal deformities and abnormal posture (Video 19.5). The symptoms depend on the severity of
the deformities and degree of patellar luxation. Dogs with high-grade (Box 19.2) luxations are
more likely to have angular limb deformities (ALDs), severe gait abnormalities, and postural dis-
abilities. These severe abnormalities generally become apparent early in puppyhood. Dogs with
Grade 2 luxations will show an intermittent non-weight-bearing lameness when the patella luxates
and therefore are more likely to be presented to the veterinarian then dogs with Grade 3 luxations.
The latter show a more consistent lameness that, particularly if bilaterally present, may not be
recognized as an abnormality by owners. Dogs with Grade 1 luxations will generally not show any
clinical signs. Similarly, they may present as puppies (when deformities are severe) or the diagno-
sis may be an incidental finding during routine examination.
Video 19.5
Patellar luxation gait.
Traumatic patellar luxation is poorly described in the veterinary literature. This condition is
generally described as traumatic rupture of the retinaculum without any skeletal deformities.
Onset of lameness is acute and moderate-severe pain is associated with the inciting cause.

Patellar luxation is generally diagnosed based on physical exam findings and the degree of deform-
ity is evaluated radiographically. The disease may affect both limbs, requiring careful examination
of both stifles. However, most often one side is more severely affected clinically.
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Box 19.2 Grading of Patellar Luxation

Grading of patellar luxation based on location of the patella with typical clinical symptoms
and degree of skeletal deformities (italicized) known to occur:
Grade 1: “In-In” (i.e. the patella is always located in the trochlear groove unless manually
forced and held outside the groove):
●● Patella does not spontaneously luxate, but it can be manually luxated, however, it returns
into the groove upon release of pressure
●● No clinical symptoms and no skeletal deformities
Grade 2: “In-Out” (i.e. the patella is typically located in the trochlear groove but remains outside
the groove at times even without manipulation):
●● Patella spontaneously luxates and reduces (which causes the typical “skipping” pelvic limb
lameness)
●● Patella will readily luxate with manual pressure, but reduces on its own (i.e. returns back into the trochlear
groove)
●● Only mild skeletal deformities that may not be readily visible
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Grade 3: “Out-In” (i.e. the patella is typically located outside of the trochlear groove but can be
manually reduced back into the trochlear groove):
●● Patella is most often in a luxated position (which causes more consistent low-grade lameness, but
rare “skipping” pelvic limb lameness may be observed)
●● Patella can be reduced with manual pressure, but it will reluxate spontaneously upon release of manual
pressure
●● Moderate skeletal deformities that may result in abnormal posture
Grade 4: “Out-Out” (i.e. the patella is always located outside of the trochlear groove and cannot
be manually reduced):
●● Patella is always luxated (which causes a consistent lameness of varying severity)
●● Severe, obvious skeletal deformities resulting in abnormal posture
As noted above, the degree of lameness can vary but skipping pelvic limb lameness raises suspi-
cion of a Grade 2 patellar luxation. There are other differential diagnoses for skipping pelvic limb
lameness including luxation of the LDE tendon, superficial digital flexor, neurologic disease (e.g.
lateralized disc), and “Happy Jack Skip.” Patient conformation can indicate a propensity for patel-
lar luxation. Dogs with genu varus may be more likely to have MPL; whereas, dogs with genu val-
gus may be more likely to have LPL.
Patellar luxation is graded 1–4 based on physical exam findings (Box 19.2). This categorization is
important as it aids decision-making regarding the course of treatment and the need for surgical
intervention. Some authors have also included the degree of skeletal deformities into this grading
system (Kowaleski et al. 2018); however, this system is more difficult to apply if the degree of
deformity does not match the palpation. Therefore, the grading should be primarily based on the
location and ability to reduce the patella. However, higher-grade luxations are generally associated
with more severe skeletal deformities, more severe clinical symptoms, and more obvious postural
abnormalities. To assess the patella for luxation, the patella needs to be identified and the stifle
should be moved through ROM. The direction of location should be noted, realizing that bidirectional
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luxation is possible. In normal dogs, identification of the patella is straight-forward, but in cases
with substantial periarticular swelling or high-grade luxations it can be difficult. In these cases, the
examiner should identify the tibial tuberosity and follow the patellar ligament proximally.
Some dogs will spontaneously luxate the patella as the stifle flexes and the quadriceps pulls the
patella out of the trochlear groove. Luxation is generally associated with a popping sensation
particularly in low-grade luxations. If the patella does not spontaneously luxate, the examiner
must check to see if it can be manually luxated. Since dogs with MPL tend to have patella alta, the
patella may luxate more easily when the stifle is in full extension (Mostafa et al. 2008). To luxate
the patella medially, the examiner extends the stifle, rotates the distal limb internally, and pushes
the patella medially. It is generally easiest to place the patella between the thumb and index finger
of one hand while using the other hand to manipulate the distal limb. The opposite is performed
for lateral luxation – partial flexion of the stifle, external rotation of the distal limb, and pushing
the patella laterally. Applying pressure through ROM should be performed if the diagnosis is not
obvious. Most animals will display patellar luxation in both standing and recumbent positions;
however, in some patients, the muscle tension will mask a patellar luxation when standing.
Therefore, evaluation should be performed in both positions if there is doubt about the diagnosis.
Similarly, very tense animals may need to be sedated to diagnose mild patellar luxation. Placing
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the sedated dog in lateral recumbency with the affected leg down and “pulling” the patella medi-
ally can also be helpful for diagnosis. Depending on the degree and direction of dynamic patellar
instability, removing the tension of the quadriceps may make patellar luxation easier, or more
difficult. Therefore, in some animals, sedation or general anesthesia may make it actually more
difficult to palpate the luxation. As noted above, the patella should be reduced (if possible) and
the stifle evaluated for signs of CCLD (including drawer sign). In dogs with Grade 4 luxation, it
can be difficult to differentiate whether mild drawer instability results from the abnormal anat-
omy or from CCLD.
19.5.3 Diagnostics
Radiographs are critical for surgical planning but are also helpful to document osseous anatomy,
document secondary osteoarthritis, and evaluate for concomitant CCLD. However, they cannot be
used to rule out patellar luxation since with Grade 2 and 3 luxations the patella may temporarily
be located within the trochlear groove. In this capacity, radiographs can only be used to determine
that a patient does not have radiographic evidence of patellar luxation (i.e. “not a Grade 4”) or that
there is radiographic evidence of patellar luxation (i.e. “not a Grade 1”).
Standard orthogonal radiographs of the stifle should be obtained. The craniocaudal views are
used to evaluate the position of the patella. A lateral, flexed radiograph is used to assess for evi-
dence of joint effusion and degenerative changes. While both features are observed with patellar
luxation, they are generally mild and substantial changes indicate CCLD (Figure 19.14). The lat-
eral view can also be used to evaluate for patella alta or baja. This is accomplished by measuring
the patellar length (“PL”) and the distance from the distal apex of the patella to the tibial tuberosity
(i.e. the length of the patellar ligament, “PLL”). Ratios of the PLL:PL that are greater than 2.06
indicate patella alta (Mostafa et al. 2008), predisposing the patient to MPL. Similarly, values lesser
than 1.97 indicated patella baja, predisposing the patient to LPL.
If surgical correction is deliberated, particularly in large-breed dogs, additional radiographs of
the femur should be considered. Craniocaudal radiographs of the femur should be performed to
assess whether the degree of femoral varus (for MPL) or valgus (for LPL) requires surgical
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(A) (C) (E)
(B) (D) (F)
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Figure 19.14 Examples of patients with MPL in two patients. Patient I (A–D) presented with bilateral
Grade 2 MPL. Images (A, B) show a displaced patella, minimal joint effusion, and degenerative changes
commonly seen with patellar luxation. Note that there is no radiographic evidence of MPL in images (C, D)
since the patella was located within the trochlear groove at the time of the radiographs. The patient also
had a chronic injury to the (white arrow) lateral head of the gastrocnemius muscle as indicated by
degeneration of the lateral fabella. Patient II (E, F) was diagnosed with CCLD and MPL as indicated by the
more advanced (white arrows) degenerative changes and (black arrow) moderate-severe amount of joint
effusion. These features can be used to raise the index of suspicion for concurrent CCLD but are not
diagnostic. The cranial tibial subluxation on the other hand (note the location of the femoral condyles in
relation to the intercondylar eminence) indicates disruption of the CCL.
c orrection. Several techniques have been described to measure the femoral varus angle (FVA)
(Dudley et al. 2006; Miles et al. 2015) and precise radiographic positioning is crucial to obtain accu-
rate measurements. Several features have been suggested to determine appropriate positioning,
namely that the patella should be centered within the trochlear groove, the fabellae should be
bisected by the femoral cortices, the lesser trochanter should be partially visible, the proximal
nutrient foramen should be visible in the center of the diaphysis, and the vertical walls of the inter-
condylar fossa should be visible as parallel lines (Jackson and Wendelburg 2012; Kowaleski et al.
2018). To accomplish a true craniocaudal view, the femur needs to be perpendicular to the radio-
graphic beam and parallel to the detector. With modern X-ray equipment, this can be accomplished
by angling the radiographic beam so that it is perpendicular to the femur or taking the radiograph
in lateral recumbency with the beam horizontally. Alternatively, the patient’s body may be elevated
(Figure 19.15). Attempting to obtain a true craniocaudal view via traditional extended femur views
will result in femoral foreshortening and inaccurate femoral varus measurements (Jackson and
Figure 19.15 Illustration of technique

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used to obtain adequate positioned

craniocaudal radiographs of the femur
used to measure the degree of femoral
varus. The patient’s body is elevated of
the table to allow parallel positioning
of the femur to the detector.
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Wendelburg 2012). If the limb is rotated, the normal anatomy of the femur (mild varus and procur-
vatum) will give the (false) appearance of excessive varus deformity (Figure 19.16). Alternatively,
CT can be used to determine femoral varus and torsion (Dudley et al. 2006), as well to assess troch-
lear groove depth (Petazzoni et al. 2018). Therefore, in complex cases or for surgical planning, CT
may be quicker and more accurate than radiographs.
19.6 Stifle Luxation
Stifle luxation, also known as “deranged stifle,” happens secondary to severe trauma, especially
trauma that involves traction or torsion of the joint. Stifle luxation results in injuries to the soft
tissue stabilizers of the joint and can include disruption of one or both cruciate ligaments, one or
both collateral ligaments, and the meniscotibial ligaments/menisci. Unlike the cruciate ligaments,
the collateral ligaments of the stifle are very rarely individually injured in the dog. Therefore, any
collateral ligament instability should raise the index of suspicion for additional injuries. Treatment
of stifle luxation generally requires surgical reconstruction since the injuries are severe and result
in substantial stifle instability in multiple planes.

Any dog can suffer from stifle luxation since it is caused by trauma. However, the condition is more
commonly seen in active medium- to large-breed dogs. Dogs that are free roaming or have the abil-
ity to escape to roam have an increased risk of vehicular trauma, a common cause of stifle luxa-
tions. Likewise, working dogs and hunting dogs are vulnerable to complex stifle injury from
interaction with livestock or due to rough terrain.
19.6 Stifle Luxatio 335
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(A) (B) (C) (D)
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Figure 19.16 Measurement of the femoral varus angle (FVA) is performed on (A) accurately positioned
craniocaudal radiographs of the entire femur. The (B) FVA is the angle formed between the (red line)
proximal and (black line) distal femoral axis. The distal femoral axis is a line perpendicular to the (blue
line) transcondylar axis, which is the line connecting the distal aspects of the lateral and medial femoral
condyles. Note that inaccurate positioning can result in false measurements as illustrated by images (C, D)
which are of the same patient that underwent surgical correction of MPL. Note that the femur appears
straight in image (C), while image (D) gives the (false) impression of femoral varus.

The patient with stifle luxation will likely be non-weight-bearing with swelling and joint effusion
of the stifle. The source of lameness is generally obvious to identify. Palpation of the stifle typically
shows severe pain and therefore should be done after pain medications are administered.
Evaluation of the cruciate ligaments is performed by testing cranial and caudal drawer motion.
The collateral ligaments are tested by applying varus and valgus stress to the stifle (Video 3.1). For
testing the MCL, the examiner places one hand over the distal femur and one hand over the proxi-
mal tibia with the thumbs facing toward each other. Bracing the thumbs against the estimated
position of the MCL, the examiner applies valgus (i.e. levering distal limb laterally) stress to the
joint. If the joint opens up into valgus stress, the MCL has been compromised. The same is repeated
with the thumbs aligned over the lateral collateral ligament. If the joint opens up into varus insta-
bility, the lateral collateral ligament has been compromised.
19.6.3 Diagnostics
Standard, orthogonal stifle radiographs in addition to stress radiographs are helpful to further
define the extent of injuries and rule out any fractures. Radiographs will also show visible joint
effusion, soft tissue swelling, and joint subluxation or complete luxation (Figure 19.17), as well as
intra- or extra-articular avulsion fragments at ligamentous insertion sites.
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(A) (C) (E) (G)
(B) (D) (F) (H)

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Figure 19.17 Examples of (A–F) stifle luxation and (G, H) caudal cruciate ligament rupture: (A) lateral view
of a patient with stifle luxation. Note the multiple (white arrow) avulsion fragments indicative of severe
trauma; (B) stress radiograph of patient with disruption of both, the medial collateral ligament (MCL) and
lateral collateral ligament (LCL). Note the gapping of the lateral side and displacement that indicates
disruption of both ligaments; (C–E) patient with disruption of the CCL and LCL. Note the (white arrow)
avulsion fragment on the lateral view without evidence of displacement while the (D) varus-stress view
shows disruption of the LCL as identified by the (white arrow) gapping of the lateral joint; the valgus-stress
view shows that the MCL is functionally intact despite showing (white arrow) avulsion fragments indicating
that a partial disruption of the MCL is present; (F) valgus-stress view showing gapping of the medial joint
compartment indicating disruption of the MCL; (G, H) isolated caudal cruciate ligament rupture in an adult
patient. Note that the standard lateral view does not show evidence of osteoarthritis; mild joint effusion is
present. The stress view indicates caudal displacement of the tibia and also note the cranially displaced
(white arrow) popliteal sesamoid bone.
A fractured fibular head or avulsed fibular head indicates lateral collateral ligament instability.
On frontal view stress radiographs, the joint will gap open on the side with the torn collateral liga-
ment. Although advanced imaging can be performed to further classify the injury, it is rarely
needed.
19.7 Isolated Caudal Cruciate Ligament Rupture
Most CaCL injuries occur in conjunction with degeneration of the CCL. In fact, up to 88% of dogs
with degenerative CCLD also have damage to the CaCL via the degenerative effects of synovitis
and global joint inflammation (Sumner et al. 2010). The second most common cause of CaCL
injury is due to stifle luxation, as part of multiple ligamentous injury or rupture. The CaCL is rarely
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injured on its own (Johnson and Olmstead 1987) but generally results from trauma such as a blow
to the proximal tibia that stresses the integrity of the CaCL. However, since isolated CaCL disrup-
tion is easily mistaken for CCLD, it is important to be aware of this differential diagnosis. Since
CaCL injury frequently does not require surgical intervention, preoperative identification is imper-
ative to establish an appropriate treatment plan.
Isolated CaCL injury can be challenging to differentiate from CCL disruption. The mainstay of
diagnosis involves physical examination and stress radiographs. To evaluate the integrity of the
CaCL, the examiner performs the caudal tibial drawer test. This test is performed in the same fash-
ion as the cranial drawer test; however, a positive test shows a tibia that translates caudally relative
to the femur (rather than cranially as with CCLD). It is important to evaluate the end-feel when
moving the tibia cranially and caudally – the intact CCL will create a hard stop (distinct end-feel)
once the maximum, cranial displacement is reached (i.e. the intact CCL is engaged). When trans-
lating the tibia caudally relative to the distal femur, a subjectively loose/sloppy end-feel (i.e. capsu-
lar end-feel) will be encountered when maximum, caudal tibial displacement is reached (i.e. where
in a normal dog the CaCL would be engaged). Unfortunately, even experienced evaluators are
unable to reliably differentiate caudal, cranial, and combined injuries of the cruciate ligament(s)
based on drawer testing (Might et al. 2013).
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Stress radiographs can be used to confirm disruption of the CaCL. To perform these views, the
observer levers the tibia caudally, requiring manipulation of the proximal tibia close to the joint;
therefore, appropriate collimation is necessary. Caudal displacement of the tibia can be identified
by evaluating the position of the intercondylar eminence in relation to the femoral condyles.
Cranial displacement of the popliteal sesamoid may also be observed (Figure 19.17). Arthroscopy
or advanced imaging can be used to definitely confirm the diagnosis.
Osteochondrosis/osteochondritis dissecans (OCD) is a rare disease of the canine stifle and overall
the stifle joint is the least common joint to be affected by OCD (i.e. the shoulder, elbow, and tarsus
are more common joints to be affected). It typically strikes large- or giant-breed puppies including
Great Danes, Labrador Retrievers, Golden Retrievers, Newfoundlands, German Shepherds,
Mastiffs, and Wolfhounds (Denny and Gibbs 1980; Fitzpatrick et al. 2012; Kowaleski et al. 2018).
Male, rapidly growing puppies fed nutritionally inappropriate diets (e.g. excessive consumption or
over supplementation of protein or calcium) are at greatest risk; clinical signs appear between 5
and 10 months of age. Stifle OCD can be bilateral or unilateral and is most commonly seen on the
axial (medial) aspect of the lateral femoral condyle but can also be seen on the axial (lateral) aspect
of the medial femoral condyle. Stifle OCD in the juvenile dog is treated similarly to other OCD
lesions with simple removal of the flap or resurfacing techniques (Fitzpatrick et al. 2012). If OCD
is diagnosed in older animals, secondary osteoarthritis is likely to be present. Additionally, con-
comitant CCLD needs to carefully be ruled out (and treated if present). In these cases, accomplish-
ing a diagnosis can be challenging if there is only partial disruption of the CCL.
On physical exam, a mild-to-severe weight-bearing lameness can be observed unilaterally or
bilaterally. In dogs with bilateral disease, there is generally one side more severely affected than the
other. The dogs may stand with the stifles in extension, and in bilateral cases, may be shifting
weight to the thoracic limbs. Patients may show significant pain and disability from this disease
due to loss of a major weight-bearing surface of the stifle. Later in life, symptoms may be due to
secondary osteoarthritis. Moderate to marked joint effusion without joint instability is a key fea-
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ture of OCD yet does not allow differentiation from partial CCLD. OCD may also occur in combi-
nation with CCLD, particularly if OCD lesions are mild and not detected until later in life.
Standard orthogonal radiographs of the stifle joint are a reasonable first-line of diagnostics.
However, identification of OCD of the stifle joint can be difficult since the femoral condyles nor-
mally display varying degrees of flattening radiographically. Therefore, advanced imaging may be
preferable if the index of suspicion is high based on the patient’s signalment and exam finding.
Radiographic abnormalities range from subtle subchondral bone sclerosis, flattening of the con-
dyles to easily visible cartilage flaps (Figure 19.18). Oblique views of the femoral condyles can help
further visualize potential lesions. CT is more sensitive than radiography at detecting the location,
size, and extent of OCD lesions. It is also more sensitive in detection of small osteochondrosis
lesions or small displaced mineralized free bodies. Ultrasound has also been used to detect OCD
(A) (C) (E) (G)

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(B) (D) (F) (H)
Figure 19.18 Examples of surgically confirmed stifle OCD in four patients. Patient I (A, B) adult patient
with lateral femoral OCD lesion (white arrows) that was also diagnosed with partial CCLD at the time of
surgery. Flattening and irregularity of the (black arrow) lateral condyle on the craniocaudal view indicate
OCD; however, the lesion is not detectable on the lateral view and the diagnosis may therefore be missed/
confused with isolated CCLD. Patient II (C, D) OCD-lesion of the lateral femoral condyle in a juvenile patient
that is visible as a (black arrow) flap on the lateral view and lucency in the condyle on the craniocaudal
view. Patient III (E, F) juvenile patient with an OCD lesion of the medial femoral condyle, the fragment (black
arrow) was found to be a displaced OCD fragment at the time of surgery. Note that neither view clearly
establishes the diagnosis of OCD. Patient IV (G, H) adult patient with CCLD and chronic OCD of the lateral
femoral condyle. Note the more severe osteoarthritis and the (black arrow) flap visible on the lateral view.
However, the craniocaudal view does not show clear evidence of OCD.
19.9 Patellar Ligament Patholog 339
lesions (Marino and Loughin 2010) and may offer a less costly and invasive method to establish a
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diagnosis. Arthroscopy allows direct assessment of cartilage health in the joint and may also be
used to diagnose and immediately treat OCD.
19.9 Patellar Ligament Pathology
Pathology of the patellar ligament can be categorized into traumatic and nontraumatic etiolo-
gies. Nontraumatic patellar ligament desmopathy most commonly occurs in patients with a
history of corrective osteotomies for CCLD (Figure 19.19) and generally does not require surgi-
cal intervention. Traumatic injury may be iatrogenic or due to sharp trauma and generally
requires surgical apposition and external support. Patellar ligament rupture secondary to
administration of steroids (Smith et al. 2000) and fluoroquinolones (Cabassu et al. 2001) have
also been reported.
(A) (C) (E)
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(B) (D) (F)
Figure 19.19 Examples of patellar desmopathies in five patients. Patient I (A, B) adult patient that
sustained patellar ligament rupture after surgical correction of patellar luxation. Note the (white arrow)
calcified and thickened patellar ligament. Patient II (C) typical (white arrow) patellar ligament thickening
after TPLO surgery. Patient III (D) traumatic fracture of the distal patella resulting in disruption of the
extensor mechanism. Patient IV (E) nontraumatic patellar desmopathy without a history of surgery. Note the
(white arrow) thickening and enthesopathy. Patient V (F) nontraumatic patellar desmopathy without a
history of surgery. Note the (white arrow) thickening and calcification of the patellar ligament.
19.9.1 Nontraumatic Patellar (Ligament) Desmopathy

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Patellar ligament thickening and desmopathy has been described following tibial tuberosity
advancement (TTA) and TPLO in up to 80% of the cases (Dan et al. 2019). This is thought to occur
due to increased stress placed on the ligament. In most cases, it does not result in clinical lameness
and appears to be self-limiting.
A similar condition may be observed in patients that have not undergone surgical treatment. As
with people (Dan et al. 2019), it may be caused by chronic overuse and intense athletic activities.
The authors have observed it in large-breed, athletic dogs. Lameness is typically progressive and
intermittent, with worsening of pain during exercise and jumping.
Physical exam may reveal varying but typically mild degrees of pelvic limb lameness. Tenderness
or pain may be elicited with direct palpation of the ligament and flexion of the stifle. Some cases
have visually evident or palpable patellar ligament thickening.
Thickening of the patellar ligament (or surrounding region) is easily recognized radiographically
but it may be difficult to differentiate patellar ligament from abnormal peritendinous soft tissues.
To assess the structural integrity of the ligament, ultrasound or MRI can be used. Using a combina-
tion of physical exam findings of a thickened, painful patellar ligament, plus soft tissue specific
imaging allows the best assessments for therapeutic intervention.
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19.9.2 Patellar Ligament Laceration/Rupture

Traumatic patellar ligament desmopathy is an uncommon injury in dogs (Das et al. 2014) and is
associated with high leaps and falls, bites, lacerations, and other traumas. Any breed of dog is sus-
ceptible to sharp trauma. However, puppies are more likely to avulse the tibial apophysis rather
than rupture the tendon from falls and other trauma. Iatrogenic laceration has been described as a
complication of stifle surgery (Das et al. 2014).
On physical exam, rupture of the patellar ligament prevents active stifle extension and causes
involuntary stifle collapse during the stance phase. If sharp trauma is suspected, the stifle should
be examined for lacerations or wounds. A chronically ruptured tendon may be thickened. In cases
of complete tears, the patella will be displaced proximally throughout flexion and extension ROM.
The stifle may be painful especially if other tissue trauma is present.
A lateral radiograph in the flexed and extended position can document a proximally displaced
patella, particularly in stifle flexion, as well as thickened tendon and any avulsion fragments when
present. With complete rupture, the patella is located proximal to the trochlear groove due to the
contraction of the quadriceps. Imaging of the tendon itself with ultrasound or MRI allows visuali-
zation of integrity of the remaining tendinous soft tissue.
19.10 Other Diseases Affecting the Stifle Region
19.10.1 Angular Limb Deformity

The most common types of stifle joint ALD are an excessive TPA (i.e. a TPA of 35° or greater) and
frontal and transverse plane deformities of the femur. The latter is a common cause of patellar
luxation in dogs. The former generally presents in combination with (and because of symptoms
associated with) CCLD and has been reported to be associated with early neutering in large-breed
dogs (Duerr et al. 2007). It can also be the result of undetected or untreated proximal tibial physeal
injury/fracture. As sagittal plane deformity is generally well tolerated in dogs, observation of this
19.10 Other Diseases Affecting the Stifle Regio 341
deformity is difficult on physical exam, although some patients may show a compensatory gait of
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stifle flexion to keep the tibial joint surface parallel with the ground.
ALD due to trauma, nutritional deficiencies, hypertrophic osteodystrophy, retained cartilagi-
nous cores, and other genetic/congenital skeletal dysplasias can result in various complex deformi-
ties. These deformities may result in secondary patellar luxation or hip pathology. Pure, isolated
frontal plane deformity of the proximal tibia is rare, but spontaneous proximal tibial valgus deform-
ity has been described in large- or giant-breed dogs (Olsen et al. 2016).
19.10.2 Gastrocnemius Injury

Injury to the origin of the Gastrocnemius muscle is a rare injury in dogs that may be caused by
acute trauma or chronic overuse. Gastrocnemius myotendinopathy has been described in both pet
or athletic, medium- to large-breed dogs and presents most commonly as none to mild, chronic
pelvic limb lameness (Kaiser et al. 2016). The lateral head of the muscle is typically affected.
Physical exam findings include pain upon palpation of the muscle origin at the medial supracon-
dylar tuberosity, stifle pain, and effusion, but with no stifle instability. Since the gastrocnemius
muscle is a stifle flexor and tarsal extensor, simultaneous stifle extension and tarsal flexion while
palpating the origin of the muscle may exacerbate pain. Radiographs may reveal chronic changes
STIFLE REGION
(enthesopathy and mineralization) at the origin of the muscle and fabella (Figure 19.14) and mild
joint effusion. However, advanced imaging (MRI or ultrasound) is necessary to establish the diag-
nosis if radiographs are normal.
Acute, traumatic, and atraumatic avulsion of the muscle has also been reported. Likely this con-
dition describes the precursor of the above-described chronic myotendinopathy. However, clinical
symptoms can be more severe and result in non-weight-bearing lameness and a slightly dropped
hock, or even mild plantigrade stance. Radiographs may show distal displacement of one
(Figure 19.20) or both fabellae, fracture or fragmentation of the fabellae.
19.10.3 Long Digital Extensor Tendon Injury

LDE tendon injuries include rupture, luxation, and chronic tendinopathies. The LDE tendon can
be traumatically injured in dogs of any age, although avulsion fractures of the origin of the tendon
typically happen in juvenile animals (Fitch et al. 1997). Dogs with traumatic luxation, tears, or
avulsion fracture will have stifle joint effusion, pain with flexion of the stifle, and crepitus if the
injury is chronic. Iatrogenic laceration during the lateral approach to the stifle joint can also occur.
Luxation is a rare cause of lameness in dogs and can either be nontraumatic or traumatic. This
condition should be considered a differential diagnosis for “popping” sounds originating from the
stifle. The diagnosis can be made by placing a finger over the tubercle of Gerdy (located on the
lateral, proximal tibia) while placing the stifle joint through ROM. Clinical signs vary but may
include intermittent lameness or skipping gait making it a differential diagnosis for patellar luxa-
tion. Luxation of the LDE has also been reported as a complication after TPLO (Haaland and
Sjöström 2007). Calcification of the LDE tendon (Figure 19.20) has been reported in a dog that also
suffered from CCLD (Kennedy et al. 2014).
Radiographs may be normal or show cranial displacement of the fat pad with joint effusion. In
dogs with an avulsion fracture, a bony fragment may be seen in the craniolateral aspect of the
joint. The LDE itself can be imaged via MRI, CT, ultrasound, and arthroscopy. On ultrasound, the
LDE can be seen as a hypoechogenic linear structure just cranial to the lateral meniscus (Soler
et al. 2007).
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(A) (C) (E) (G)
(B) (D) (F) (H)

STIFLE REGION
Figure 19.20 Other diseases affecting the stifle region: (A–D) patient with proximal tibial valgus resulting
in visible (C) angular limb deformity – note that the (A) lateral view shows (white arrow) both condyles
(rather than the condyles being superimposed) indicating the deformity. The extent of the deformity can
further be classified based on the (B) craniocaudal view and (D) CT; (E, F) patient with traumatic avulsion of
the medial head of the gastrocnemius muscle – note the (white arrow) distally displaced medial fabella. The
stifle is otherwise normal indicating that this is an isolated injury; (G, H) patient with (black arrows)
calcification of the LDE tendon and changes indicative of CCLD (which was confirmed at the time of surgery).
19.10.4 Stifle Region Neoplasia

Neoplasia of the stifle region is a common differential diagnosis because of the predilection site for
osteosarcoma (Figure 22.1). Histiocytic sarcoma, villonodular synovitis, and lymphoma have all
been reported in the stifle. Radiography as a first-line diagnostic and additional imaging and/or
diagnostics should be considered if neoplasia is suspected. Further details about neoplastic condi-
tions affecting the region are provided in Chapters 11 and 22.

Although Panosteitis more commonly affects the long bones of the thoracic limb, it can also affect
the femur and tibia and should therefore be considered a differential diagnosis in juvenile patients
with shifting limb lameness and pain on long bone palpation (Chapter 14).
Septic arthritis is an important differential diagnosis particularly if the patient has a history of
recent stifle surgery. However, hematogenous or local spread as well as spontaneous septic
arthritis (Chapter 14) have all been described in the stifle.
Reference 343
Quadriceps contracture can result secondary to femoral fractures (i.e. quadriceps “tie down” or
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“fracture disease”) or because of infectious disease (i.e. “parasitic” quadriceps contracture).

Please refer to Chapter 20 for further details.
Happy Jack Skip (also referred to as “Jack Russell Tick”) is a condition that has not been
described in the peer-reviewed veterinary literature but anecdotally is described as intermit-
tent, non-weight-bearing lameness without an identifiable cause. The condition presents
similarly to a Grade 2 MPL (i.e. a “skipping” pelvic limb lameness); however, the patella is
stable during palpation. It is seen in Jack Russell Terriers but the authors have observed it in
other terriers and small-breed dogs. Proposed reasons for the skipping include dynamic
patellar luxation (e.g. the luxation only occurs during certain maneuvers/muscle contrac-
tures), neurologic disorders (e.g. nerve impingement that may be dynamic), hip pathology, or
a behavioral condition.
Other rare causes of lameness associated with pathology in the stifle region include epiphyseal
dysplasia (Chapter 20 and Figure 20.16), ganglion and synovial cysts (Franklin et al. 2011;
Murata et al. 2014), osteochondromatosis (Smith et al. 2012), synovial hemangioma (Arias et al.
2009), and avulsion of the popliteal muscle (Tanno et al. 1996).
STIFLE REGION
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avulsion in a dog. Vet Radiol Ultrasound 38 (3): 177–181.

Fithian, D.C., Kelly, M.A., and Mow, V.C. (1990). Material properties and structure-function
relationships in the menisci. Clin Orthop Relat Res (252): 19–31.
Fitzpatrick, N., Yeadon, R., Van Terheijden, C., and Smith, T.J. (2012). Osteochondral autograft transfer
for the treatment of osteochondritis dissecans of the medial femoral condyle in dogs. Vet Comp
Franklin, A.D., Havlicek, M., and Krockenberger, M.B. (2011). Stifle synovial cyst in a Labrador
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157–160.
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resonance imaging to arthroscopy for diagnosing medial meniscal lesions in dogs with cranial
cruciate ligament deficiency. J Am Vet Med Assoc 251 (1): 71–79.
Fujita, Y., Sawa, S., and Muto, M. (2017). Radiographic measurement of the angle of the tibial
translation in the Beagle dog. Vet Rec 180 (10): 252–252.
Gatineau, M., Dupuis, J., Plante, J., and Moreau, M. (2011). Retrospective study of 476 tibial plateau
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Gilbert, S., Langenbach, A., Marcellin-Little, D.J. et al. (2019). Stifle joint osteoarthritis at the time of
diagnosis of cranial cruciate ligament injury is higher in Boxers and in dogs weighing more than
35 kilograms. Vet Radiol Ultrasound 60 (3): 280–288.
Griffith, C.J., Laprade, R.F., Coobs, B.R., and Olson, E.J. (2007). Anatomy and biomechanics of the
posterolateral aspect of the canine knee. J Orthop Res 25 (9): 1231–1242.
Griffon, D.J. (2010). A review of the pathogenesis of canine cranial cruciate ligament disease as a basis
for future preventive strategies. Vet Surg 39 (4): 399–409.
Haaland, P.J. and Sjöström, L. (2007). Luxation of the long digital extensor tendon as a complication to
tibial plateau levelling osteotomy. Vet Comp Orthop Traumatol 20 (3): 224–226.
Hayes, G.M., Granger, N., Langley-Hobbs, S.J., and Jeffery, N.D. (2013). Abnormal reflex activation of
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Jackson, G.M. and Wendelburg, K.L. (2012). Evaluation of the effect of distal femoral elevation on
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Kaiser, S.M., Harms, O., Konar, M. et al. (2016). Clinical, radiographic, and magnetic resonance
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mineralization and cranial cruciate ligament rupture in a dog. Vet Surg 43 (5): 593–597.
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20
Hip Region
Nina R. Kieves
Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, OH, USA
Lameness of the pelvic limb in the canine is often attributable to pathology associated with the
coxofemoral joint and surrounding structures. These can include osseous conditions affecting the
surrounding skeletal structures (pelvis and proximal femur) or the joint itself including, luxation,
developmental disease (hip dysplasia [HD]), and avascular necrosis of the femoral head. Muscle
conditions should also be included as differential diagnoses when investigating discomfort of the
hip region, including quadriceps contracture, gracilis and semitendinosus/semimembranosus
myopathy, and iliopsoas tendinopathy. The most commonly utilized tests include radiographs and
ultrasound. Figure 20.1 and Table 20.1 outline common differential diagnoses and diagnostic steps
for the hip region.
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20.2 Normal Anatomy
The femoral head and acetabulum form the hip joint (Figure 20.2). Like the shoulder joint, its ball
and socket configuration allow it to function with a large range of motion – with the ability for signifi-
cant flexion, extension, as well as abduction and adduction. The primary joint stabilizers are com-
prised of the ligament of the head of the femur and the joint capsule. Secondary stabilizers include
the acetabular labrum, a fibrocartilaginous band that extends laterally from the dorsal acetabular rim
(DAR) and ventrally across the acetabular notch (i.e. the transverse acetabular ligament). Finally,
hydrostatic pressure is created by joint fluid and the periarticular muscles of the joint.
Periarticular muscles of the hip include the gluteal muscles (deep, middle, and superficial),
iliopsoas, quadratus femoris, gemelli, and the internal and external obturator muscles. The gluteal
muscles function to extend the hip joint, as well as internally rotate and abduct the femur. The
deep gluteal originates on the body of the ilium and the ischiatic spine extending caudally to insert
on the cranial aspect of the greater trochanter. It functions to extend, and abduct the hip, while also
medially rotating the femur. The largest of the gluteals, the middle, originates on the ilium and
inserts on the dorsal greater trochanter. The piriformis also contributes to hip extension with its
origin on the lateral surface of S3 and Cd1, inserting on the dorsal aspect of the greater trochanter

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Table 20.1 Key features for diseases affecting the hip region.
Disease Common signalment Diagnostic test of choice Exam findings Treatment Clinical pearls Terminology
Fractures Any breed or age Radiographs Pain, crepitus, non- Depends on location Acetabular and
(orthogonal views), weight-bearing lameness severely displaced
may need additional fractures of the
views or fluoroscopy to ilium are generally
diagnose slipped treated surgically
capital femoral physis
Coxofemoral Any breed or age; intact, Radiographs Pain, crepitus, Closed or open Anesthetize for Hip Luxation
luxation male dogs predisposed (orthogonal views) non-weight-bearing; reduction closed reduction
(higher risk of trauma) craniodorsal luxation: attempts to relax
appearance of shorter muscles
limb, held with the thigh
adducted rotating the
stifle outward; ventral
luxation: appearance of
longer limb longer,
abducted position with
internal rotation
Juvenile hip Any breed but more Radiographs Pain with range of JPS if diagnosed Normal
dysplasia common in large- and (orthogonal views) and motion, positive before 5 months of Radiographs do not
giant-breeds (German PennHIP; Ortolani Ortolani, muscle atrophy age; Medical r/o disease
Shepherd Dogs, maneuver management for
Newfoundland, osteoarthritis and
Retriever breeds, and pain; total hip
Rottweilers), arthroplasty or
5–12 months of age femoral head and
neck ostectomy
Adult hip Same breeds as juvenile, Radiographs Pain, crepitus, decreased Medical management Most cases respond
dysplasia mature age (orthogonal views) ROM, and muscle for OA; total hip well to medications
atrophy arthroplasty or and rehabilitation;
femoral head and if medical
neck ostectomy management fails,
surgery should be
considered
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Avascular Small-breed dogs, Radiographs Pain, crepitus, variable Surgical: total hip Can be bilateral Legg-Perthes,
necrosis of the 4–11 months of age; (orthogonal views), CT lameness, can be arthroplasty or and frequently Calve-Perthes,
femoral head genetic in Miniature for early presentation non-weight-bearing femoral head and patients also have Legg-Calve-
Poodle and West neck ostectomy patellar luxation Perthes, aseptic
Highland White Terrier necrosis of the
femoral head,
osteochondritis
juvenilis, and
coxa plana
Gracilis German Shepherd Dog, Palpation of muscle; Distinctive gait: Medical Can be bilateral;
contracture males 3–7 years of age biopsy for definitive shortened stride with management; surgery dogs non-painful
diagnosis reduced stifle extension unrewarding
jerking motion of the
limb
Quadriceps Young, often after femur Physical exam; muscle Unable to flex stifle If secondary to Differentiate Fracture
contracture fracture biopsy trauma – prevention etiopathogenesis disease;
is the best treatment; (d/t fracture quadriceps “tie
if secondary to orparasitic) based down;”
Neospora and caught on history. Perform parasitic
early medical titers for Neospora quadriceps
management may and toxoplasmosis contracture
avoid progression if bilateral and no
history of trauma
Iliopsoas Any breed or age; Ultrasound, MRI Variable lameness; pain Rest, pain relief; Ultrasound is
myotendinopathy however, working dogs with hip extension and rarely surgery operator dependent
may be more prone internal rotation modality; Diagnosis
based on palpation
may result in
overdiagnosis
Neoplasia Any breed or age Radiographs, CT; Pain, crepitus, variable Based upon tumor Can be difficult to
biopsy for definitive lameness type: surgery, differentiate
diagnosis radiation, neoplasia from
±chemotherapy severe
osteoarthritis and
sepsis
r/o = rule out and dt/ = due to.
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History of trauma
Fracture
Visible Septic
abnormality arthritis
diagnosis
Hip
luxation Fracture line
Soft tissue
Arthrocentesis injury
X-rays X-rays
abnormal normal
Sl-joint Hip joint dislocation
luxation Muscle
Ultrasound/MRI contracture
Hip Sl-joint separation

dysplasia/
Soft tissue
OA Muscle biopsy neoplasia
Joint laxity/ Pain in hip

Septic osteoarthritis region
arthritis Juvenile hip
FNA dysplasia
Juvenile
dog
Lytic lesion
Osseous
neoplasia Early Legg-
PennHIP/Ortolani Perthes
Soft tissue
calcification
Myopathy Sl-joint
CT disease
Degenerative changes
of Sl-joint
History of
Minimally
trauma
Sl-joint
dysfunction displaced
fracture
Figure 20.1 Schematic of common diseases affecting the hip region and the steps necessary to establish a diagnosis.
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(A) (C)
(B) (D)
Figure 20.2 Normal anatomy of the hip region: (A) ventrodorsal and (B) lateral radiographic views of a
normal immature dog; (C) ventrodorsal and (D) lateral radiographic views of a normal adult dog. The arrows
indicate the (white arrow) physis of greater trochanter; (black arrow) capital physis; (red arrow) pubic
symphysis; (a) pelvis; (b) femur; (c) obturator foramen; (d) ilial body; (e) L7; (f) sacrum; (g) pubis; (h) ischium;
(i) ischiatic tuberosity; (j) acetabulum; (k) sacroiliac joint; (l) greater trochanter; (m) femoral head; (n) lesser
HIP REGION
trochanter; (o) tuber coxae; and (p) tuber sacrale.
with the middle gluteal tendon. The superficial gluteal extends the pelvic limb as well as
contributing to abduction; its origin is the lateral border of the sacrum and Cd1 and the sacrotuber-
ous ligament extending distal to insert on the third trochanter. The sacrotuberous ligament runs
from the transverse process of S3 and Cd1 to the lateral angle of the ischiatic tuberosity. As a group,
the gluteal muscles are innervated by the cranial and caudal branches of the gluteal nerve.
The quadratus femoris, gemelli, and the internal and external obturator muscles make up the
caudal hip muscles. This group of muscles is innervated by the sciatic nerve and primarily allows
rotation of the femur as the stifle turns outward (creating a supination-like effect). They also
antagonize the middle gluteal muscle, which tends to pronate the femur (i.e. moves the stifle
inward).
The adductor muscle is the primary adductor of the pelvic limb originating on the entire pelvic
symphysis, ischiatic arch, and ventral pubis and ischium. It also has a large insertion area covering
the entire lateral lip of the caudal surface of the femur. Also originating from the pubis at the
iliopubic eminence of the pubic tubercle is the pectineus, inserting on the distal end of the medial
lip of the caudal face of the femur. Along with the adductor, the pectineus contributes to hip
adduction. They are both innervated by the obturator nerve.
The iliopsoas muscle is comprised of the psoas major and iliacus muscle and is innervated by the
femoral nerve. The psoas major originates from the transverse processes of L2 and L3 and the bod-
ies of L4 through L7. The iliacus originates on the ventral surface of the ilium. They combine to
352 20 Hip Region
have a common insertion on the lesser trochanter of the femur. The function of the iliopsoas is
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primarily hip flexion, but it also contributes to external rotation of the femur as well as lumbar
flexion.
Hip extension, thigh adduction, stifle flexion, and tarsal extension are controlled by the following
group of muscles found superficially on the caudal portion of the medial thigh: the semitendino-
sus, semimembranosus, and gracilis muscles. The semitendinosus muscle originates on the
ischiatic tuberosity and inserts at the cranial border of the tibia. It has an aponeurosis that spreads
onto the crural fascia. A well-developed fibrous band extends from its caudal border and joins the
calcanean tendon, inserting on the tuber calcaneus giving it the ability to extend the tarsus in addi-
tion to flexing the stifle and extending the hip. The semimembranosus originates on the ischiatic
tuberosity and inserts on the distal mid-femur, as well as on the proximal end of the tibia. Its pri-
mary function is hip extension, with the ability to flex or extend the stifle depending upon the
position of the limb. Extension of the hip is also aided by the gracilis that originates on the pubic
symphysis and inserts on the cranial border of the tibia with the semitendinosus. In addition to hip
extension, it contributes to adduction of the pelvic limb as well as flexion of the stifle. The semiten-
dinosus and semimembranosus muscles are innervated by the sciatic nerve, while the gracilis is
innervated by the obturator nerve.
The sartorius is made up of a cranial and caudal head, with the cranial head originating on the
medial crest of the ilium and inserting on the patella with the quadriceps, and the caudal head
originating on the cranial ventral iliac spine, inserting on the cranial medial border of the tibia with
the gracilis muscle. While both heads contribute to flexion of the hip joint, the cranial belly extends
the stifle, and the caudal head flexes the stifle. The sartorius is innervated by the femoral nerve.
The last muscle to contribute to hip extension is the large biceps femoris. It originates on the
sacrotuberous ligament and ischiatic tuberosity, and inserts via the fascia lata to the patella, patel-
lar tendon, and cranial border of the tibia, and via the crural fascia to the tuber calcanei. In this
respect, it can contribute to stifle extension, and tarsal extension. Uniquely, the caudal portion of
the muscle will flex the stifle. The biceps femoris is innervated by the sciatic nerve.
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The sacroiliac (SI) joint is both a synovial and cartilaginous joint. Biomechanically, the SI joint
functions to support the weight of the caudal portion of the body and to transfer propulsion forces
from the pelvic limbs to the spine. The apposed crescent-shaped surfaces of the medial wing of the
ilium and sacrum are covered by cartilage, with a thin joint capsule uniting their margins. This
allows for some rotation and translational movement of the ilium relative to the sacrum. Dorsal to
the auricular surfaces, the wing of the sacrum and the wing of the ilium are rough and possess
irregular projections and depressions that tend to interlock. Fibrocartilage fills this space between
the bony projections of both bones that unites the two wings. Through the medium of this fibro-
cartilage, the ilium and sacrum are firmly united in adulthood, forming the SI synchondrosis (syn-
chondrosis sacroiliaca). The SI synchondrosis is located craniodorsal to the synovial portion of the
joint.
The SI joint does have a small amount of normal motion, though it is very slight (Gregory et al.
1986). How much motion is not fully known, one study estimated ~7 degrees of rotation and likely
a small amount of craniocaudal and dorsoventral motion, while an in vivo CT imaging study found
only ~2 degrees of motion (Saunders et al. 2013). The SI joint is primarily stabilized by the dorsal
and ventral SI ligaments and the sacrotuberous ligament, and is innervated by S1–S3/4 with
sensory input from L1–S3.
The SI joint is connected to the wings of the ilium and sacrum via four soft tissue structures: a
craniodorsal synchondrosis component, a caudoventral synovial component, the dorsal SI
ligaments, and the ventral SI ligaments. The dorsal SI ligaments are divided into a short and a long
20.3 Fractures of the Hip Regio 353
part and are more extensive than the ventral SI ligaments, which are composed of many short,
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fibrous fascicles that are arranged in two groups. Those of the cranial ventral group run medially
and caudally from the ilium to the sacrum. Those of the shorter caudal ventral group run medially
and cranially. The thin joint capsule appears between them.
20.3 Fractures of the Hip Region
Fractures of the pelvis occur commonly with motor vehicle trauma or other high energy traumas
such as falling from a height. Fractures can occur to the pelvic bones, SI joint, or the coxofemoral
joint itself – fractures of the femoral head, femoral neck, and acetabulum.
Dogs will typically present non-weight-bearing on the affected limb, or possibly laterally recum-
bent depending upon concurrent injuries. Patient stabilization is the primary objective before any
orthopedic issues are addressed, as many dogs with such trauma will have concurrent injuries (e.g.
pneumothorax, pulmonary contusions, and urogenital injury).
Orthogonal radiographs should be obtained under heavy sedation or general anesthesia to con-
firm the presence of fracture(s) and to assess the fracture anatomy. The pelvis can be considered a
rigid box-like structure, with fractures commonly occurring in specific locations and patterns.
Because of this box-like structure, for there to be displacement the pelvis must fracture in at least
three places. However, because SI luxation may also act like a fracture, displacement can occur
under that scenario (e.g. pubic and ischial fracture in combination with SI luxation would also
allow for displacement; Figure 20.3). CT may be indicated in cases of acetabular factures or more
complex cases and may be combined to assess for comorbidities.
20.3.1 SI Joint Luxation and Sacral fractures
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Sacroiliac luxation-fracture (SIL/F) denotes traumatic separation of the ilial wing from the sacrum
(Figure 20.4). As with fractures of the pelvis, for displacement to occur several other fractures or
luxations must be present, unless bilateral luxation is present with an intact pelvis. The iliac wing
will typically displace cranially and dorsal to the sacrum due to the pull of attached musculature.
While SIL/F can involve a small portion of the sacral wing fracturing, this should be differentiated
from a true sacral fracture (Figure 20.5), where the sacral bone is significantly involved. Cases of
sacral fracture are typically more painful than SIL/F, and dogs will commonly have neurologic
deficits unlike those with simple SIL/F. If such signs are noted on physical exam, sacral fracture
should be considered. CT imaging elucidates the extent of damage more readily than survey radio-
graphs. SIL/F can be treated surgically or nonsurgically (Fauron and Déjardin 2018). Considerations
to include in selection of treatment include patient level of pain, degree of instability of the pelvis,
and amount of narrowing of the pelvic canal.
20.3.2 Fractures of the Ilium

Fractures of the ilium are most commonly long oblique fractures oriented from cranioventral to
caudodorsal (Figure 20.3). While most are midbody, they can also extend cranially involving a
portion of the SI joint, or caudally over the dorsal aspect of the acetabulum (not involving the
joint). Ilial fractures are generally accompanied by fractures of the ischium and pubis, which are
generally not treated surgically. Treatment can be surgical or nonsurgical and usually depends on
displacement.
354 20 Hip Region
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(A) (B)
(C) (D)
Figure 20.3 The pelvis can be considered a rigid box-like structure and for any substantial displacement
to occur, at least three fractures have to be present (unless an SI luxation is also present). (A) Typical
appearance of a dog with multiple fractures of (red arrows) pubis and ischium and an (black arrow) SI
luxation; the green arrow illustrates the distal aspect of the sacrum, the location where the articular
HIP REGION
surface of the ilium should be located. This allows for (white arrow) displacement of the ilium (i.e. it is
located further cranial than the tip of the ilium of the contralateral side). (B) Example of an iliac fracture
illustrating the concept of the “pelvic box.” Note that while the (white arrow) wing of the ilium itself is not
displaced, the fractured (black arrow) body of the ilium can be seen cranial to the tip of the wing of the
ilium. Also note the location of the obturator foramina indicating the displacement. (C) The fracture itself is
best visualized on the lateral radiograph (white arrow); (D) note restoration of the structural integrity of the
pelvis, including the symmetric location of the obturator foramina and tips of the ilial wings, after surgical
repair of the fracture illustrated in (B, C).
20.3.3 Fractures of the Coxofemoral Joint

With fracture of the coxofemoral joint there will be pain and crepitus with range of motion of the
joint. This can sometimes be difficult to assess given the patients generalized discomfort, or with
fractures of the ilium near the coxofemoral joint. These are intra-articular fractures and surgical inter-
vention is generally recommended to achieve the best outcome for the patient. Even with surgical
intervention, such injury predisposes the patient to develop osteoarthritis (OA) in the joint over time.
20.3.3.1 Fractures of the Acetabulum

In cases of possible acetabular involvement, a CT scan can be useful to determine exact loca-
tion and extent of the fracture. If CT is not available for imaging, oblique lateral views can be
useful to remove some of the superimposition of the pelvis aiding in assessment for acetabular
involvement and comminution. Caudal acetabular fractures may not necessarily require
20.3 Fractures of the Hip Regio 355
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(A) (C) (E)
(B) (D) (F)
Figure 20.4 Pelvic fractures I: (A, B) multiple pelvic fractures including SI luxation (illustrated by black
arrow in image (A) and the cranially located tip of the ilial wing) and comminuted ilial and acetabular
fractures of the opposing side. The lack of bone dorsal to the femoral head, (illustrated by black arrow in
image (B) clearly indicates that the fractures seen on the ventrodorsal view includes an acetabular fracture.
HIP REGION
(C, D) Minimally displaced, long-oblique acetabular fracture (black arrow, image (D) that cannot be identified
on the ventrodorsal view; however, a fracture of the ischium (black arrow, image (C) can be visualized. (E, F)
CT and ventrodorsal radiographs of a dog with multiple pelvic fractures. CT aided in establishing the
diagnosis of SI luxation (white arrow) in this case, which was difficult to visualize radiographically.
s urgical fixation; however, this has been disputed and some recommend fixation of all acetabu-
lar fractures (Boudrieau and Kleine 1988).
20.3.3.2 Slipped Capital Femoral Physis and Femoral Neck Fractures

In young dogs, Salter-Harris Type I or II fractures of the capital femoral physis most commonly
occur secondary to trauma, with Type I being the most common (see Chapter 13 for review of the
classification system). These fractures can be challenging to diagnose, as they are often reduced
when a standard hip extended radiograph is evaluated. If there is pain on manipulation of the cox-
ofemoral joint in a young dog and a capital physeal fracture is suspected, a frog leg view of the pelvis
can help delineate such a fracture. Additionally, placing the hip through range of motion while
taking fluoroscopic (or serial digital) images can help reveal such a fracture (Figure 20.5). In some
cases, no trauma is noted, and the onset of lameness is gradual. Such atraumatic separation has
been previously reported, but is rare (Moores et al. 2004) and is sometimes referred to as a slipped
capital femoral physis based on a similar condition described in children (Dupuis et al. 1997). In
children, it is broken down further into a pre-slip, acute, chronic, and acute-on-chronic stage.
356 20 Hip Region
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(A) (C) (E)
(B) (D) (F)
Figure 20.5 Pelvic fractures II: (A, B) sacral fracture (black arrow) and multiple fractures of the ischium
and pubis in a dog; (C, D) severely displaced slipped capital physeal fracture that is easily identified on
radiographs; (E, F) minimally displaced (black arrow) slipped capital physeal fracture and (white arrow)
acetabular fracture. Note that the physeal fracture is difficult to identify on radiographs. (F) Fluoroscopy
HIP REGION
aided in establishing the diagnosis of (black arrow) mild displacement of the fracture.
Fractures of the femoral neck can occur in patients of any age and can be classified as intracap-
sular or extracapsular. These fractures can also be challenging to diagnose, particularly if they are
minimally displaced, and may require additional imaging (e.g. CT or fluoroscopy) to accomplish a
diagnosis. For both fractures (capital physeal and femoral neck fractures), surgical repair is gener-
ally recommended, or if not possible salvage with a femoral head and neck ostectomy or total hip
arthroplasty.
20.4 Coxofemoral Luxation
Coxofemoral luxation (CFL) accounts for 90% of all luxations seen in dogs (Wardlaw and
McLaughlin 2018). For the coxofemoral joint to luxate, two or more of the primary stabilizers
must be disrupted. The amount of soft tissue injury that occurs allowing for CFL varies; how-
ever, at minimum a portion of the ligament of the head of femur and the joint capsule must be
disrupted. In addition, surrounding musculature including the gluteal muscles may be dis-
rupted, partially or fully. In some cases, avulsion of a portion of the head of the femur occurs
with disruption to the ligament of the head of the femur. Damage to the acetabulum may also
occur but is rare.
20.4 Coxofemoral Luxatio 357
The most common type of CFLs is craniodorsal, comprising approximately 80% of all luxations.
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Typically, luxation occurs when a supraphysiologic force is applied to the femur. This causes the
distal femur to be adducted, stretching/tearing the joint capsule and the ligament of the head of
the femur. Then, the femoral head slides over the dorsal rim of the acetabulum completing the
tearing of the ligament and the capsule. The gluteal and iliopsoas muscles act upon their insertion
at the greater and lesser trochanters causing the head of the femur to move craniodorsally. Ventral
luxation and caudodorsal luxation are rare. Ventral luxation most commonly occurs with a fall or
slip where the stifle is abducted rapidly. The femoral head may luxate into the obturator foramen
if the limb is rotated internally when it is luxating, or it may be adjacent to the pubis if the limb was
undergoing simultaneous external rotation of the limb when the luxation occurs.
Nonsurgical (closed reduction) and numerous surgical techniques (open reduction) have been
described for the treatment of CFL. Closed reduction is often attempted first in patients with nor-
mal anatomic configuration of the hip joint; however, this is associated with an approximately 50%
failure rate for single attempts at reduction. Historically, after closed reduction, it is recommended
that the limb be placed in an Ehmer sling for 10–14 days to prevent reluxation (McLaughlin 1995).
When a closed reduction fails, or there are concurrent orthopedic injuries (HD, pelvic fractures,
intra-articular fractures), open reduction with stabilization, total hip arthroplasty, or femoral head
and neck ostectomy is warranted.

The majority of CFLs in dogs are the result of external trauma, with vehicular trauma composing
59–83% of cases (Bone et al. 1984; Basher et al. 1986; McLaughlin 1995). Trauma may happen to
any age or breed of dog; however, young intact male dogs are more likely to undergo vehicular
trauma. Dogs with HD are predisposed to both craniodorsal and ventral hip luxation compared to
dogs with normal hip coxofemoral joint conformation. Spontaneous luxations have been reported
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in a series of dogs with minimal to no evidence of HD and no trauma (Trostel et al. 2000).

CFL is often suspected based upon physical examination of the patient. Dogs will often present
non-weight-bearing on the affected limb, or non-ambulatory in the rear if they have sustained
bilateral CFL, which occurs in approximately 6% of cases (Basher et al. 1986). If any trauma was
associated with the injury, the entire patient should be assessed for stability prior to addressing any
luxation. Dogs may be intermittently weight-bearing if the luxation occurred sometime ago. In all
cases, severe discomfort and crepitus are present with range of motion of the hip.
With a craniodorsal luxation, the affected limb typically appears shorter than the contralateral
limb and is held with the thigh adducted rotating the stifle outward (externally) and the hock
inward (Video 20.1). On palpation of the hip region, the greater trochanter will be elevated com-
pared to the normal limb and there will be increased space between the greater trochanter and the
tuber ischii. In a normal non-luxated coxofemoral joint, palpation of the greater trochanter, the
Video 20.1:
Hip luxation gait.

358 20 Hip Region
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(A) (B)
Figure 20.6 Coxofemoral luxation palpation: (A) lateral radiograph of a patient with craniodorsal coxofemoral
luxation; the location of the greater trochanter (yellow star) is on a “line” between the cranial dorsal iliac spine
(red star) and ischiatic tuberosity (blue star) while in a (B) normal dog it is located below this line.
cranial dorsal border of the wing of the ilium, and the ischiatic tuberosity will form a triangle with
the greater trochanter positioned distal to a line between the cranial dorsal iliac spine and the
ischiatic tuberosity. This normal triangle becomes a line when the coxofemoral joint is luxated in a
craniodorsal direction with the greater trochanter being easily palpated between the two other
landmarks (Figure 20.6). Additionally, the clinician’s thumb may be placed between the greater
trochanter and ischiatic tuberosity in the ischiatic notch and the femur externally rotated to palpate
for a luxation. If the hip is luxated the clinician’s thumb will be pinched with this motion, but if it
is not luxated the thumb will be displaced with this motion.
Conversely, with ventral hip luxation the affected limb appears longer than the contralateral
normal limb, and the limb is held in an abducted position with internal rotation. The greater tro-
HIP REGION
chanter will be in a more medial location than expected, and the femoral head may be entrapped
within the obturator foramen, inhibiting internal rotation and adduction of the femur.
20.4.3 Diagnostics
Diagnosis of CFL is confirmed via orthogonal radiographs (standard ventrodorsal and lateral
views; Figure 20.7). These should be thoroughly evaluated for concurrent trauma such as acetabu-
lar or pelvic fractures, slipped capital physeal fractures and fractures of the greater trochanter in
young patients, femoral head or femoral neck fractures, and SI luxation. Evidence of HD should
also be noted, as this affects treatment recommendations. At least, thoracic radiographs should be
considered in all cases of known trauma.
20.5 Hip Dysplasia
HD is a developmental disease where there is joint laxity and inadequate coverage of the femoral
head by the acetabulum. It is the most common orthopedic disease seen in dogs (King 2017). The
exact etiology is unknown; however, several studies have shown it to be a genetic disease with a
complex inheritance pattern (numerous genes), which is likely influenced by environmental
factors that influence its expression (Ginja et al. 2015; King 2017). Initially, there is laxity of the
20.5 Hip Dysplasi 359
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(A) (C) (E)
(B) (D) (F)
Figure 20.7 Coxofemoral luxation: (A, B) traumatic cranio-dorsal luxation; (C, D) traumatic caudo-ventral
luxation; and (E, F) luxation secondary to hip dysplasia. (A) Note the avulsion fragment of the femoral head
(white arrow) – a contraindication for closed reduction. (E) The bilateral nature in combination with the
degenerative changes (the white arrow indicates femoral neck thickening) suggests that this dog is not
HIP REGION
suffering from traumatic coxofemoral luxation, but rather severe laxity due to hip dysplasia.
coxofemoral joint without evidence of OA. This laxity allows subluxation of the hip joint to occur,
eventually giving rise to a shallow acetabulum, flattening of the femoral head from wear on the
DAR, and eventually the development of OA of the joint. Treatment for HD most commonly con-
sists of medical management; however, numerous surgical options are available. Early diagnosis of
HD is key since some treatment options, such as juvenile pubic symphysiodesis (JPS), are only
effective if performed before 5 months of age (Schachner and Lopez 2015).

HD is most commonly seen in large-breed dogs, but can be seen in most breeds, with Sighthounds
being a protected group of dogs. Some more commonly affected breeds include German Shepherd
Dogs, Newfoundlands, Retriever breeds, and Rottweilers with a reported prevalence of up to 17%
(Witsberger et al. 2008). Early gonadectomy (<5 months of age) has been associated with a higher
risk of developing HD (Spain et al. 2004). One study found castrated male dogs to be significantly
more likely to be affected by the disease (Witsberger et al. 2008).
A clinical bimodal presentation – dogs presenting as juveniles (juvenile form) or as middle-aged
dogs (chronic form) – is seen in dogs affected by HD (Demko and McLaughlin 2005; Witsberger
et al. 2008; Smith et al. 2018). However, radiographic progression has been reported to be linear
(Smith et al. 2006). Dogs presenting at a young age generally are more severely affected and have
360 20 Hip Region
pain associated with their coxofemoral laxity and resulting inflammatory changes (e.g. synovitis).
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These dogs will present with a history of exercise intolerance compared to other puppies, reluctance
to climb stairs and jump onto things/into the car, generalized muscle atrophy of the pelvic limbs,
a bunny hopping and short-strided gait (Video 20.2), narrow stance, and occasionally vocalization
with petting of the hip region or manipulation of the hip joint. Later in life, presentation is associ-
ated with OA of the hip joint and a history of decrease in activity, stiffness when rising, worsening
lameness with heavy activity, reluctance to jump, muscle atrophy of the pelvic limbs, and possible
change in behavior associated with pain being reported by owners.
Video 20.2:
Hip dysplasia gait examples.

Diagnosis is most commonly made based on physical exam findings and orthogonal radiographs.
Dogs with HD experience pain particularly during hip extension. Differential diagnosis for pain on
extension of the coxofemoral joint include any other coxofemoral joint disease (e.g. aseptic necro-
sis of the femoral head in young patients, femoral head and neck fracture, sepsis, and neoplasia),
neurological disease affecting the lower back (e.g. lumbosacral disease), stifle pathology (most
notably cranial cruciate ligament rupture), or pathology of any muscle stretched during hip exten-
sion (e.g. sartorius, iliopsoas muscle). Therefore, further manipulation of the hip joint (flexion and
abduction) should be performed as the next diagnostic step. If pain is elicited during these latter
two maneuvers, true pathology of the hip joint is more likely. If no pain is elicited, further evalua-
tion of the differential diagnoses should be pursued (Figure 20.8 and Video 3.1).
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In young dogs, examination will reveal generalized pelvic limb muscle atrophy, pain with
manipulation of the coxofemoral joint, and joint laxity. Hip laxity can be assessed with specific
tests such as the Ortolani maneuver (Figure 20.9 and Video 20.3), whereby the hip is subluxated
and subsequently reduced (Syrcle 2017). The Ortolani test is typically performed with the dog in
lateral recumbency, but can also be done with the dog in dorsal recumbency. The clinician places
one hand on the dorsal aspect of the pelvis and spine to stabilize it, the second hand is placed on
the stifle to maneuver the hip joint. Initially, the hip is subluxated by adducting the stifle and plac-
ing gentle pressure proximally to allow the femoral head to subluxate/luxate above the dorsal rim.
This aspect of the Ortolani test is also known as the Barlow test. Next, gentle proximal pressure is
maintained along the axis of the femur while the limb is abducted. A clunk or click may be heard,
and palpated when the hip is reduced, this is considered a positive test. The Barden’s test, which is
less frequently used, also assesses for laxity of the hip joint. This is done by placing a lateral force
on the femur with one had while the dog is in lateral recumbency without abducting the limb. The
other hand is placed on the greater trochanter to assess for motion. If there is more than ½″ of
Video 20.3:
How to perform the Ortolani maneuver.

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Pain on HIP EXTENSION
Pain on hip
abduction and YES
flexion?
NO
Pain on lumbosacral Pain on stifle Pain on stretching of

palpation hyperextension individual hip flexors
Indicates
Indicates STIFLE Indicates MUSCLE Indicates HIP
NEUROLOGIC
pathology pathology pathology
pathology
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Perform further palpation Perform further palpation Perform further palpation
Perform further palpation
and diagnostics of L4-S2 and diagnostics of stifle (e.g. and diagnostics of hip flexors
and diagnostics of hip joint
region (e.g. neuro exam, drawer, thrust testing, and (e.g. stretching, ultrasound,
(e.g. radiographs)
radiographs, and MRI) radiographs) and MRI)
Common DD: Common DD: Common DD: Common DD:

Lumbosacral disease Cruciate disease Iliopsoas myopathy Hip osteoarthritis
Figure 20.8 Algorithm to differentiate the four differential diagnoses for pain on hip extension: hip, stifle,
neurologic, or muscular pathology.
motion, it is suggestive of laxity of the joint. The Ortolani test may be inaccurate in dogs <4 months
of age; however, Gatineau et al. (2012) found that dogs with evidence of hip OA at 2 years of age all
had a positive Ortolani test at 6 months of age. On the other hand, only 50% of dogs with a positive
Ortolani test at 6 months of age went on to develop radiographic hip OA at 2 years of age. Thus, a
positive Ortolani test has a strong sensitivity, but poor specificity at 6 months of age for predicting
the development of radiographic OA at 2 years of age (Gatineau et al. 2012).
In comparison to younger dogs suffering mainly from laxity, older dogs will present primarily
with signs of OA including a weight-bearing lameness that is typically bilateral, though one limb
may be worse. They will have generalized pelvic limb muscle atrophy, decreased range of motion
(particularly in extension and abduction) possibly with palpable crepitus, and in cases with severe
362 20 Hip Region
Figure 20.9 When performing the

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(A)
(B) Ortolani maneuver (A) gentle dorsal
pressure during adduction of the hip is
applied. If laxity is present, this (B)
results in subluxation of the hip joint.
The (C) limb is then abducted, which (D)
results in reduction of the joint, which
can be palpated or heard as a “clunk,”
defined as a positive Ortolani sign.
(C) (D)
subluxation the greater trochanter may be palpated more dorsally than expected due to subluxa-
tion of the hip joint (similarly to CFL). Ortolani testing is not indicated in these patients as there is
HIP REGION
no laxity in the progressive stages of the disease.
20.5.3 Diagnostics
Radiographs should be performed to confirm the diagnosis of HD and rule out the presence of
other pathology such as septic arthritis and neoplasia, or fractures of the femoral head/neck.
Radiographic positioning is imperative for accurate evaluation of laxity of the coxofemoral joint.
Standard films include a lateral pelvis, and a ventrodorsal view with the hips extended. For the
lateral view the ilial wings should be superimposed with one pelvic limb pulled in front of the
other. The ventrodorsal view should be performed so that the pelvis is straight, and the limbs are
extended and parallel to the imaging table. A straight pelvis will have symmetrical obturator
foramens, and the width of the wings of the ilium will be equal. If one side is wider than the other,
the patient is crooked (with the thinner side being elevated further from the table). Additionally,
the vertebrae should be assessed for alignment; with straight alignment, symmetrical transverse
processes and a spinous process centered on the body of the vertebrae will be observed. The femurs
should be parallel to the table or they will appear foreshortened. A portion of the lesser trochanter
should be visible and the patella should be within the trochlear groove with the fabellae bisecting
the cortices (Figure 20.10).
In young dogs, minimal to no OA may be noted, although evidence of subluxation or full
luxation may be present (which is generally assessed on the ventrodorsal leg extended view,
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(A) (C) (E)
(B) (D) (F)
Figure 20.10 Radiographic views of three patients diagnosed with coxofemoral osteoarthritis secondary
to hip dysplasia displaying the radiographic progression: (A, B) juvenile patient displaying (black arrow)
severe subluxation without arthritic changes; (C, D) adult patient displaying (white arrow) arthritic changes
namely a thickened femoral head and (black arrow) subluxation; (E, F) adult patient displaying severe
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osteoarthritic changes of the hip joint. Note that this patient is the only patient that displays obvious
changes on the lateral view.
unless luxation is present). It is important to note that in some dogs with juvenile HD, conven-
tional radiographs may not show any pathology, including a lack of subluxation/decreased cover-
age of the femoral head by the acetabulum on the ventrodorsal view. This is because maximum
hip laxity occurs in a neutral position (similar to weight-bearing standing position) and when
performing the standard leg extended radiographs, the joint capsule is twisted and forces the
femoral head into the acetabulum (also called “windup mechanism”; Figure 20.11; Heyman et al.
1993). However, as the disease progresses with age, evidence of OA will develop including periar-
ticular osteophyte formation on the femur (caudolateral curvilinear osteophyte), osteophytes on
the cranial and caudal acetabular rim, joint remodeling including flattening of the femoral head
and subchondral sclerosis of the craniodorsal aspect of the acetabulum. Often, the acetabulum
will also be shallow compared to a normal coxofemoral joint. The lateral projection may show
complete dorsal luxation of the hip joint, or loss of normal joint space, but these changes are only
observed with more severe disease.
Numerous specific radiographic assessments have been developed for evaluating dogs for HD
with two common methods including the Orthopedic Foundation for Animals (OFA) evaluation
and PennHIP (the University of Pennsylvania Hip Improvement Program) to help try and deter-
mine which dogs may develop clinical HD over time. OFA radiographic evaluation consists of
364 20 Hip Region
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(A) (C) (D)
(B)
Figure 20.11 Windup mechanism: juvenile animals with mild-moderate hip laxity (i.e. hip dysplasia)
may have (A) normal appearing standard radiographs with normal femoral head coverage (white arrow).
(B) PennHIP radiographs can be used to demonstrate pathologic laxity (white arrow). (C) This is explained
by the so-called “windup mechanism,” when standard leg extended ventrodorsal hip radiographs are
performed the joint capsule is twisted which forces the femoral head into the acetabulum artificially
improving the radiographic appearance of the hip joint. While (D) degenerative changes (black arrow) and
subluxation (white arrow) will become more obvious as the animal grows and the disease progresses, early
intervention (e.g. juvenile pubic symphysiodesis) may prevent such progression. As such, early diagnosis
(i.e. by 20 weeks of age) is crucial.
subjective evaluation of a ventrodorsal hip extended view for evaluation of hip conformation asso-
ciated with joint subluxation, joint congruity, and evidence of OA. A grade of excellent, good, fair
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(all considered within normal limits), borderline, and mild, moderate, or severe (considered dys-
plastic) is assigned based on these secondary changes. Dogs must be 2 years of age or older to have
an official score given.
If subluxation is not obvious, PennHIP (Figure 20.12) may be performed as soon as 16 weeks of
age to more objectively evaluate laxity (Butler and Gambino 2017). PennHIP requires a certification
process, mandatory submission of the radiographs to a for-profit company (that will also evaluate
the radiographs and provide a report) and the use of a fulcrum device. The PennHIP report includes
a reported distraction index (DI) that is given relative to other dogs of the same breed. The report
also stratifies risk as low, mild, moderate, or high for developing OA based on the laxity of the indi-
vidual. The DI measures the maximal femoral head displacement from the center of the acetabu-
lum when a custom fulcrum device is used to place lateral stress to the proximal femur. It is
calculated by dividing the distance between the geometric center of the femoral head and geometric
center of the acetabulum by the radius of the femoral head. As the DI increases, so does the risk of
developing OA with age; dogs with a DI 0.3 are more at risk. PennHIP radiographs should always
be performed prior to testing for a positive Ortolani to avoid cavitation (Figure 20.12).
While the PennHIP distraction method appears to be highly predictive for the development of
OA, not all clinicians have access to the equipment and certified personnel required to perform this
series of radiographs. One method for performing distraction-stress radiography without the use of
a specific device was described by Flückiger et al. (1999). In dorsal recumbency femoral heads are
displaced manually in a craniodorsal direction and a subluxation index is calculated by comparing
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(A) (C) (G)
(D)
(B) (E) (F)
Figure 20.12 Coxofemoral osteoarthritis in patients with (A–F) mild and (G) severe juvenile hip dysplasia:
images (A–F) are from the patient with juvenile hip dysplasia that did not show (A) evidence of pathology
on routine ventrodorsal radiographic views. Based on clinical suspicion, the (B) PennHIP distraction
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technique was used to establish the diagnosis. Please note that the image is for the purpose of illustration
of the distraction device and its position only; appropriate protective equipment should be worn when
performing the procedure. PennHIP radiographs consist of a (C) distraction view that allows for measuring
of the distraction index (DI). This is performed by (D) placing a circle over the acetabulum (indicated by blue
circle) and the femoral head (indicated by red circle). The distance (d) between these two is then divided by
the radius (r) of the femoral head circle. When performing PennHIP, it is important to avoid cavitation
(see white arrow in image (E) indicating gas bubbles from excessive distraction) since this does not allow
for accurate readings. As such, Ortolani testing should not be performed until after the procedure. Image
(F) illustrates the frog leg view also requested by PennHIP that is used to evaluate acetabular filling. Image
(G) is of a juvenile patient of the same age that is displaying obvious subluxation (white arrow). In this case,
further evaluation with PennHIP is not necessarily due to the severity of the disease.
the distraction films to conventional hip extended pelvic radiographs (Flückiger et al. 1999).
The dorsolateral subluxation test is another method that evaluates joint subluxation with dogs
positioned in a weight-bearing position and can be performed between 4 and 8 months of age
(Farese et al. 1998).
Other specific radiographic techniques to evaluate for evidence of HD include the DAR radio-
graphic projection (Meomartino et al. 2002), and the Norberg angle (NA). The DAR projection is
used to evaluate and measure the dorsal acetabular slope (DAS). In a normal dog, the DAR is
sharply pointed; whereas, with the development of HD, the rim progresses from being slightly
blunted and rounded to eroded. The DAS slope increases with worsening (more laxity) of HD.
366 20 Hip Region
Gatineau et al. (2012) found an increased DAS to be correlated to an increased risk of developing
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OA. Though it should be noted, the DAS was most predictive when the DI was >0.7.
Another measurement used to quantitatively evaluate HD is the NA. To make this measurement
a hip extended ventrodorsal view is used. First, a line is drawn connecting the centers of the femo-
ral heads, then a line is drawn from the center of the femoral head to the ipsilateral craniolateral
acetabular rim. If the NA 105°, it is considered normal. However, Gaspar et al. (2016) compared
NA to DI and dorsolateral subluxation score and found that a cutoff of 105° was not highly predic-
tive for HD suggesting that a much higher angle should be used, such as 112° in order to predict
laxity in dogs with a DI of 0.3.
Distraction radiography appears to hold more promise to screen animals for HD compared to
hip-extended radiographs (Verhoeven et al. 2012). Evidence of hip laxity remains the most predica-
tive risk factor for the development of OA in dysplastic hips (Smith et al. 2001). In the future, blood
sample testing may simplify screening for HD, though a DNA test that recently became available
was found to be of low diagnostic value (Ginja et al. 2015; Manz et al. 2017).
In older dogs with OA who have sudden worsening of one side, or present with toe touching to
non-weight-bearing lameness, cranial cruciate ligament rupture, sepsis, or neoplasia should be con-
sidered as a differential diagnosis. Radiographs of dogs with severe OA can be difficult to differentiate
from infection and/or neoplasia (Figure 20.16). In these cases, arthrocentesis may assist in making a
definitive diagnosis. Additional imaging with CT scan may also be useful. If warranted, arthroscopy,
ultrasound or CT guided biopsy can be performed as well (Butler and Gambino 2017).
20.6 Avascular Necrosis of the Femoral Head
Avascular necrosis of the femoral head is known by many names: Legg-Perthes, Calve-Perthes,
Legg-Calvé-Perthes, aseptic necrosis of the femoral head, osteochondritis juvenilis, and coxa
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plana (Demko and McLaughlin 2005). It is a disease affecting the vascularity of the femoral
head and neck of small-breed dogs, causing a noninflammatory aseptic necrosis. The definitive
etiology of the disease is not known; however, several theories have been proposed including
anatomic conformation, deficiency in blood clotting factors, hereditary factors, hormonal
imbalances, infection, infarction and obstruction of the venous drainage of the femoral head
and neck, and trauma.
Regardless of the exact etiology, the progression of the disease is well delineated. Initially, the
compromise to the blood supply leads to ischemia and necrosis of the femoral head. This is fol-
lowed by an attempt at repair with fibrovascular tissue. Due to the underlying compromise to the
bone, subsequent repeated forces on the bone cause fissures and clefts to develop in the articular
cartilage of the femoral head, leading to collapse of the subchondral bone and flattening of the
femoral head. The damage to the joint surface will eventually lead to the development of OA.
Conservative treatment with pain management is only reported to be adequate in 25% of cases,
thus surgical intervention with femoral head and neck ostectomy or total hip arthroplasty is typi-
cally recommended.

Numerous breeds have been reported as being afflicted with the disease, with toy breeds and
terriers being predisposed to developing avascular necrosis of the femoral head. It has been deter-
mined to be an autosomal recessive trait in the miniature poodle and the West Highland white
20.7 Muscle Contracture 367
terrier (Robinson 1992; Demko and McLaughlin 2005). Males and females are equally affected,
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with most dogs presenting between 4 and 11 months of age. Approximately 12–16% of cases are
affected bilaterally. Dogs will present with unilateral or bilateral pelvic limb lameness (Demko and
McLaughlin 2005).

Dogs will have pain and crepitus with range of motion of the affected hip joint(s). They may have
accompanying atrophy of the limb from disuse. Given the prevalent signalment of toy-breed dogs,
concurrent patella luxation may be present. This may confuse the veterinary exam; however, if both
are present the hip pathology generally causes more pain than the stifle pathology in these cases.
20.6.3 Diagnostics
Diagnosis of avascular necrosis of the femoral head is suspected based on signalment, history, and
physical exam findings. It is confirmed via orthogonal radiographs of the pelvis (Figure 20.13). In
the early stages of the disease, there may be an increased joint space. Once vascular necrosis has
occurred, radiographic changes will be seen within the femoral head and neck as areas of lucency.
Ultimately, there may be flattening of the femoral head, collapse of the joint space, and progressive
degeneration of the joint. CT scan may also be performed if radiographs are unequivocal (during
early stages of the disease). Differential diagnosis include fracture (slipped capital physeal fracture,
femoral neck fracture), infection, and neoplasia.
20.7 Muscle Contractures
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Muscle contraction describes the normal, physiologic process of muscle shortening during activa-
tion. Muscle contracture, on the other hand, is a pathologic process that results in permanent
shortening of the muscle leaving it unable to stretch. The normal muscle fibers are replaced by
fibrous connecting tissue, which will shorten the affected muscle. Muscle contracture is also
referred to as “fibrotic myopathy” or “fibrotic contracture” in the literature (Taylor and Tangner
2007; Adrega Da Silva et al. 2009; Cabon and Bolliger 2013). Muscle contractures are different from
acute strain injuries because of their chronicity. However, it is possible that muscle strains trigger
muscle contractures (Section 20.9.3; Nielsen and Pluhar 2005).
20.7.1 Gracilis Contracture

A syndrome known as gracilis contracture (also referred to as gracilis myopathy), can affect not
only the gracilis muscle, but also the semitendinosus and semimembranosus, and rarely the
biceps femoris muscles, individually, or concurrently (Lewis et al. 1997; Steiss 2002; Spadari et al.
2008).
The exact etiology of gracilis contracture is not known. It has been theorized to develop
secondary to acute trauma, chronic repetitive trauma, infection, autoimmune disease, neuro-
genic disorders, vascular abnormalities and even drug reactions, though none have been proven
(Taylor and Tangner 2007). Affected dogs frequently participate in tracking-obedience-protection
work from a young age (Steiss 2002), giving some credence to repetitive stress/trauma as a cause
368 20 Hip Region
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(A) (B)
(C) (D)
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Figure 20.13 Images of different disease stages of avascular necrosis of the femoral head: (A) very early
changes showing a mild irregularity of the femoral neck (white arrow); (B) progression of the same changes
as noted in image A; (C) similar changes in a different patient affecting the femoral neck and head; (D)
severe changes associated with chronic avascular necrosis of the femoral head (white arrow), note that the
animal is also showing degenerative changes of the contralateral limb that are more consistent with
coxofemoral osteoarthritis.
of the contracture. Histologic evaluation shows normal muscle being replaced by a dense network
of collagenous connective tissue.
Unfortunately, to date no treatment for gracilis myopathy has been proven to be successful.
Various surgical methods of treatment have been attempted, but none have been shown to be suc-
cessful long term: Surgical resection of the muscle results in resolution of clinical signs for two to
three months, when symptoms recur (Lewis et al. 1997). Although gracilis myopathy may affect a
dog’s overall performance and the pathognomonic gait abnormality remains for the life of the
patient, it is not thought to be painful by their owners to the extent that patients can function well
enough to have good daily quality of life.
20.7.1.1 Signalment and History

This disease most commonly affects male German Shepherd Dogs between the ages of 3–7 years
but has been reported in Rottweilers and Doberman Pinchers as well (Steiss 2002). Dogs will pre-
sent with a unique and consistent gait abnormality. The gait comprises a shortened stride in the
20.7 Muscle Contracture 369
affected limb with reduced stifle extension and a quick, almost elastic jerking motion of the limb
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with internal/medial rotation of the foot with external rotation of the calcaneus and concurrent
internal rotation of the stifle during the mid and late swing phase (Video 20.4). In the early stages
of the disease, these changes in gait can be subtle. However, the disease typically progresses until
it becomes pathognomonic for gracilis contracture.
Video 20.4:
Gracilis contracture gait.
20.7.1.2 Physical Exam

Physical exam will reveal a taught fibrous band palpable along the caudomedial aspect of the thigh
(Figure 20.14). If the gracilis and semitendinosus muscle complex is stretched, there may be some
muscle spasming. This is done by concurrently flexing the hip, extending the stifle, and abducting
the limb. In later stages of the disease, the stifle is often unable to be fully extended. Generally, the
(A) (D)
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(B) (C)
(E)
Figure 20.14 Muscle contractures: (A) gracilis contracture; (B–E) quadriceps contracture: (A) note the
fibrotic gracilis muscle (white arrow); (B–E) two dogs suffering from quadriceps contracture due to (B, C)
Neospora infection and (D, E) fracture disease. (B) ventrodorsal radiographs showing luxation of the hip
joint due to (C) severe stifle and hock extension. (D, E) Note the classic straight limb and non-weight-
bearing position with stifle and hock extension due to inability to flex these joints seen with quadriceps
contracture.
370 20 Hip Region
fibrosis affects the more distal myotendinous region and not the origin of the muscle. While the
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disease can be unilateral, it often progresses to affect the dog bilaterally.
20.7.1.3 Diagnostics
Definitive diagnosis is made via muscle biopsy; however, the characteristic gait and physical exam
findings generally suffice to make a clinical diagnosis of the disease. Ultrasound may also be used
to confirm muscle pathology. Differential diagnosis for gracilis myopathy includes acute injury to
the gracilis muscle (Section 20.9.3).
20.7.2 Quadriceps Contracture

Quadriceps contracture, sometimes referred to in the literature as tie down, or stiff stifle disease, is
significantly more common than gracilis myopathy. It most commonly occurs following femur
fracture in puppies, or prolonged fixation of the stifle with external coaptation at a young age.
Unlike gracilis contracture, it is a significantly debilitating process as it causes the dog to be unable
to flex the femur or the hock (Bardet 1987).
In addition to contracture occurring following femoral fracture, quadriceps contracture can
occur secondary to parasitic muscle diseases such as Neospora caninum and toxoplasmosis. These
dogs are frequently puppies and are often affected bilaterally. They will initially have weakness and
muscle atrophy in the rear limbs as inflammation secondary to the infection affects the muscles
and nerve roots of the pelvic limb. With progression of the disease they lose their patellar reflex as
lower motor neuron damage progresses, ultimately leading to further muscle atrophy and fibrosis
leading to rigid hyperextension of the pelvic limbs (Crookshanks et al. 2007; Reichel et al. 2007).
Given the two different etiologies and treatment considerations it is important to differentiate
between fracture disease (i.e. quadriceps “tie down” after femur fracture) and parasitic quadriceps
contracture (i.e. due to infectious myositis). Prognosis is considered to be guarded once the disease
has advanced; however, successful surgical management has been reported in cases with fracture
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disease (Moores and Sutton 2009). Therefore, early treatment with appropriate antibiotics
(for parasitic quadriceps contracture) and/or rehabilitation is indicated to prevent development of
irreversible changes.
20.7.2.1 Signalment and History

Quadriceps tie down most commonly occurs following femur fracture repair in puppies, but it can
occur in adult animals as well. The risk for development of contracture increases if repair of the
fracture is not appropriate, leading to poor limb use, or if there is a prolonged period of immobili-
zation. Dogs with parasitic quadriceps contracture are also frequently puppies and may have a
history of traveling from or being located in areas exposed to the known pathogens.
20.7.2.2 Physical Exam

On palpation, the quadriceps muscle will feel like a tight band, similar to gracilis contracture. With
fracture disease, there are adhesions between the muscle and femur as well as periarticular fibrosis.
Dogs may initially only show atrophy of the quadriceps with poor limb use. As the muscle fibrosis
progresses, function will decrease significantly, and the dog will have difficulty ambulating. In
severe cases, since dogs cannot flex their stifle or hock, they will walk with a straight limb, often
scraping the dorsum of the foot leading to open wounds (Figure 20.14). The stifle and tarsocrural
joints are unable to be flexed, even under heavy sedation. There may be pain associated with
palpation of the muscle belly. In extreme cases, there may be genu recurvatum (i.e. stifle bent
20.8 Iliopsoas Tendinopath 371
ackwards) and secondary hip pathology (subluxation), patellar luxation, and eventually ankylosis
b
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of the stifle joint (Vaughan 1979).
20.7.2.3 Diagnostics
Young dogs with no known traumatic injury should have N. caninum and toxoplasmosis titer levels
checked and/or muscle biopsy taken for histopathology which reveals multifocal lymphohistio-
cytic myositis (Crookshanks et al. 2007). Histologically, the muscle fibers are replaced by fibrous
connective tissue in fracture disease.
Radiographs are used to evaluate fracture healing or to evaluate for secondary changes such as
hip luxation and patellar luxation as well as genu recurvatum (Figure 20.16).
20.8 Iliopsoas Tendinopathy
The iliopsoas muscle is comprised of the psoas major and iliacus muscles, whose primary function
is flexion of the coxofemoral joint along with adduction and external rotation of the femur. It also
contributes to core stabilization and flexion of the lumbar spine.
Iliopsoas injuries can present as isolated, acute injuries or as chronic overuse injuries. It has also
been suggested that iliopsoas injury may occur as a secondary, compensatory problem due to a
primary disease (Cabon and Bolliger 2013; Cullen et al. 2017). Since pain upon palpation of the
muscle is often found in conjunction with concurrent orthopedic or neurologic conditions, a thor-
ough evaluation of the patient is essential to ensure a primary injury/pathology is not missed
(Nielsen and Pluhar 2005).
Treatment most frequently is nonsurgical; however, tenotomy of the iliopsoas tendon can be
performed in refractory or severe cases (Stepnik et al. 2006; Ragetly et al. 2009; Cabon and
Bolliger 2013).
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In acute cases, strains most commonly occur when there is a sudden abduction of the limb (Breur
and Blevins 1997). Common history includes slipping while walking, jumping out of a vehicle, or
rough play. During such motions, eccentric contraction is occurring – the muscle is contracted
while being stretched (Nielsen and Pluhar 2005). Chronic injury is thought to be secondary to
microtrauma to the muscle fibers from repetitive use. Sporting and working dogs may be at
increased risk for both forms (Cabon and Bolliger 2013; Cullen et al. 2017).

Iliopsoas tendinopathy can cause varying degrees of pelvic limb lameness. Degree of lameness var-
ies depending upon severity of the strain. If there is current inflammation of the muscle or there is
significant fibrosis, the femoral nerve may be entrapped causing toe touching to non-weight-
bearing lameness (Stepnik et al. 2006; Adrega Da Silva et al. 2009).
Dogs can present with unilateral or bilateral injury. On gait evaluation, dogs will often have a
shortened stride as they do not fully extend their pelvic limbs. There may be pain with extension of
the hip joint, exacerbated by internal rotation of the limb. Hip extension is often decreased due to
pain or in some cases fibrosis of the muscle. This may occur with primary or secondary compensa-
tory injury.
372 20 Hip Region
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(A) (C)
(B) (D)
Figure 20.15 Iliopsoas palpation: the Iliopsoas muscle can be palpated (A, B) in standing or (C, D)
recumbent position. Pain during (A) hip extension may be caused by the iliopsoas muscle or stifle, hip or
neurologic pathology (Figure 20.8). As such, further palpation of the muscle is required to evaluate whether
the source of pain is originating from the iliopsoas muscle: (B) palpation of the abdominal portion of the
muscle below the vertebral column can be performed while the animal is standing or (C) while in lateral
recumbency. Stretching of the muscle is performed by (D) hyperextending the spine, while simultaneously
extending the hip joint and internally rotating the limb.
Direct palpation of the iliopsoas can cause pain, which is often most pronounced at the insertion
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near the lesser trochanter. Palpation is performed either in lateral recumbency or with the dog
standing (Figure 20.15). Muscle strain can occur at any portion of the muscle. While generally
muscle strains are thought to occur frequently at the myotendinous junction, the most frequent
site of injury in a recent report was the tendon of insertion (Cullen et al. 2017). Both the insertion
at the lesser trochanter and the more proximal muscle belly should be assessed. The muscle belly
can be palpated by cupping the hands and gently placing dorsal and medial pressure along the
body of the psoas muscle cranioventral to the wing of the ilium. When truly injured and sore, sig-
nificant pressure is rarely required to elicit a pronounced reaction.
Because the groin region is generally a sensitive area even in normal dogs, caution in overinter-
preting a response from the dog while palpating the area is needed. If there is pain on coxofemoral
extension, but no exacerbation of discomfort with internal rotation of the femur, or direct palpa-
tion of the iliopsoas muscle, primary coxofemoral joint pathology is most likely. To help differenti-
ate lumbosacral pain from primary coxofemoral pathology the author prefers to lay the dog in
lateral recumbency and ensure the pelvis is stable when performing hip extension to avoid any
flexion or hyperextension of the lumbosacral joint and lumbar spine while extending the hip
(as often occurs when extending the hip from a standing position).
Other muscle groups near the iliopsoas should also be assessed for discomfort including the
gracilis, semitendinosus, sartorius, and pectineus muscles. In a small case series of 22 dogs, the
iliopsoas was the most common muscle strained in cases of pelvic limb muscle strains. However,
isolated pectineus muscle strains occurred 23% of the time, and concurrent iliopsoas and pectineus
muscle strain was found in 25% of cases (Nielsen and Pluhar 2005).
20.9 Other Diseases Affecting the Hip Regio 373
20.8.3 Diagnostics
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As mentioned above, muscle palpation is a subjective assessment and therefore confirming a

tentative diagnosis based upon palpation with objective imaging is ideal. Establishing a definitive
diagnosis should include ruling out comorbidities or alternate diseases including lumbosacral
pathology, pathology of the coxofemoral joint, and stifle pathology. Radiographs may show dys-
trophic mineralization or avulsion fractures (Vidoni et al. 2005), but in general they appear normal
(unless comorbidities are detected) and cannot assess muscle fiber pattern for evidence of strain.
Imaging of the iliopsoas muscle typically consists of ultrasonography or MRI. Ultrasonographic
features of the muscle have been described (Cannon and Puchalski 2008) and many dogs that
showed pain upon palpation of the muscle had ultrasonographic changes in one study (Cullen
et al. 2017). Several grading systems (stage/grade I–III with I = mild and III = severe) have
been proposed (Cabon and Bolliger 2013; Cullen et al. 2017). However, these grading systems
have been challenged recently (Mueller-Wohlfahrt et al. 2013).
20.9 Other Diseases Affecting the Hip Region
20.9.1 Sacroiliac Joint

Pain in or around the SI joint is commonly recognized in human medicine secondary to misalign-
ment of the joint, abnormal movement, or insufficient stabilization of the joint. To date, it has
received little attention in veterinary medicine. The SI joint serves to transmit the propulsive forces
from the pelvic limbs to the vertebral column. It also supports the weight of the torso and may help
buffer ground impact forces (Saunders et al. 2013). SI pain is recognized in horses (Jeffcott et al.
1985), but not well documented in dogs. However, given its innervation and similar anatomy, it can
be postulated that disease at the SI joint could cause pain in dogs. A retrospective study evaluating
canine survey radiographs found over 60% of radiographs to have calcification of the interosseous SI
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ligaments, and 44% to have calcification of the dorsal and/or ventral SI ligaments (Knaus et al. 2004).
The clinical significance of such radiographic lesions has yet to be correlated with discomfort and
performance issues.
As it is not a well-defined syndrome in dogs, a definitive diagnosis of SI joint pain is difficult to
make. In humans, SI joint disease can cause sciatic pain secondary to compression from piriformis
tension (piriformis syndrome) manifesting as buttock pain, without radiation of pain down the
limb (Foster 2002). In dogs, it has been hypothesized that piriformis tension and muscle spasm
may also occur with SI joint dysfunction and pain (Edge-Hughes 2007). Diagnosis of SI joint dys-
function has been proposed to be based upon movement, and stress testing, as well as evaluation
of anatomic landmarks for asymmetry. Similar methods have been proposed for use in dogs as
well. However, assessing pain of the SI joint specifically in dogs is difficult and subjective and
while any of the below mentioned techniques have been proposed (Edge-Hughes 2007), they have
not been validated and caution must be used when interpreting them.
Yet, evaluating symmetry of the ischial tuberosities, and the iliac crests can be useful. This is
done by standing the dog in a square, equally balanced position, and palpating along the most
caudal portion of the ischial tuberosities for ventral or dorsal rotation of the ilia. The iliac crests
are also palpated for cranial or caudal slip by running the hands along the sides of the back until
the wings of the ilia are found. Additional palpation may include strumming the piriformis
muscle from caudal to cranial while assessing for pain, as well as evaluating the sacrotuberous
ligament for asymmetry of its positioning and for pain on palpation. A pain provocation stress
test based on a human thigh thrust technique has also been proposed: the dog is placed in lateral
374 20 Hip Region
recumbency and slow, deliberate force is placed by holding the stifle and pushing the femur
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dorsally while the other hand stabilizes the sacrum. The hip is at neutral range of motion and
held in slight abduction to differentiate hip pain from SI pain. Pain is thought to be elicited by
stressing the dorsal SI ligaments. Movement testing is done in humans to evaluate amount and
quality of movement of the SI joint with voluntary flexion of the limb and trunk. While not vol-
untary motion, a dog’s hip can be flexed and extended and quality and amount of motion of the
iliac spine can be assessed for symmetry (Edge-Hughes 2007). Muscles used for stabilization of
the pelvis can be assessed for strength including the gluteals, latissimus dorsi, multifidus,
abdominals, and epaxials. Caution must be used in making such assessments, however, as these
can be weak with other orthopedic and neurologic disease such as HD, and lumbosacral or
thoracolumbar disease. Along with muscle strength, flexibility testing can be performed,
particularly of the hamstrings, piriformis, sartorius, iliopsoas, adductors, tensor fasciae, and
latissimus dorsi. The abdominal obliques may show asymmetry. Finally, evaluating for hyper-
and hypomobility of the SI joint via direct palpation while stressing the joint in a craniocaudal
direction and dorsal-ventral direction can be performed.
As the diagnosis of SI joint dysfunction is in its infancy, no definitive treatment currently exists.
Case reports of rehabilitation have been reported and a method of injecting the SI joint with ultra-
sound guidance was described in a cadaveric model (Jones et al. 2012), as this is commonly per-
formed in humans and horses for pain non-responsive to physical therapy. Accuracy of injecting
the SI synovial joint space was deemed fair to poor, although accuracy of injecting the synchondro-
sis and ventral and dorsal ligaments was deemed good. This modality needs further investigation
to evaluate its potential for widespread clinical use.
20.9.2 Septic Arthritis

Septic arthritis (Figure 20.16) of the hip joint has been described and is generally seen in dogs with
preexisting OA (Benzioni et al. 2008). Please refer to Chapter 14 for further information.
HIP REGION
20.9.3 Muscle Strains and Tears

Muscle strains represent a common reason for pain and orthopedic dysfunction in people. Because
these injuries are frequently self-limiting and diagnosis involves advanced imaging, only limited
information exists in veterinary medicine. However, one study of canines reported that the adductor,
pectineus, and iliopsoas may be prone to acute, stretch-induced injury (Nielsen and Pluhar 2005).
Acute gracilis muscle rupture, also termed “dropped back muscle,” has been described in the
racing greyhound (Eaton-Wells 1992). With such acute injury there is often significant soft tissue
swelling and bruising, unlike with gracilis contracture. Repair of the muscle tear generally allows
the dog to return to racing.
20.9.4 Hip Region Neoplasia

The most common neoplasia of the hip is proximal femoral osteosarcoma that may be difficult to
differentiate radiographically from OA in some cases. OA and osteosarcoma may also occur simul-
taneously, making establishing a diagnosis even more challenging. Well positioned radiographs
and additional views (e.g. frog leg) can help to detect subtle lucencies and pathologic fractures
(Figure 20.16), but advanced imaging (e.g. CT/MRI) may be necessary. Further details about
neoplastic conditions affecting the region are provided in Chapters 11 and 22.
20.9 Other Diseases Affecting the Hip Regio 375

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Sorjonen et al. (1990) described compression of the sciatic nerve between the sacrotuberous ligament
and secondary changes from severe hip OA.
Calcification of the gluteal muscles has been described and may indicate chronic trauma or overuse
(Liu and Dorfman 1976).
MacInnes et al. reported a benign unicameral bone cyst of the hip joint causing mild lameness in
an 11 year old dog (MacInnes et al. 2005).
Epiphyseal dysplasia, also known as multiple epiphyseal dysplasia, is a rare osteochondrodysplasia
that causes a growth disturbance of bone and cartilage (Rorvik et al. 2008). It results in defects
of ossification of the epiphyses and most commonly affects the shoulder, stifle and hip joint
(Figure 20.16).
(A) (B) (C)
(D) (E)
HIP REGION
Figure 20.16 Other diseases of the hip region: (A–C) proximal femoral osteosarcoma; (D) septic arthritis;
(E) epiphyseal dysplasia. (A, B) Images of a dog diagnosed with coxofemoral osteoarthritis and osteosarcoma;
(A) note that the osteolytic changes are fairly subtle on the conventional X-ray; however, (B) they are more
obvious on a frog leg, oblique view (white arrows). (C) This dog suffered from a pathologic fracture secondary
due to osteosarcoma, note that the lytic changes are again very subtle and displacement of the fracture
(white arrow) is minimal and therefore can easily be missed. (D) Septic arthritis in a dog previously
diagnosed with coxofemoral osteoarthritis. Note that the osteoarthritic changes are very similar to the
changes associated with sepsis (white arrow). (E) Epiphyseal dysplasia affecting the stifle and hip joint of a
juvenile dog. Note failure of normal ossification (white arrows), which is more obvious in the stifles.
376 20 Hip Region
References
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Adrega Da Silva, C., Bernard, F., Bardet, J.F. et al. (2009). Fibrotic myopathy of the iliopsoas muscle in
a dog. Vet. Comp. Orthop. Traumatol. 22 (3): 238–242.
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Boudrieau, R.J. and Kleine, L.J. (1988). Nonsurgically managed caudal acetabular fractures in dogs: 15
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Cullen, R., Canapp, D., Dycus, D. et al. (2017). Clinical evaluation of iliopsoas strain with findings
from diagnostic musculoskeletal ultrasound in agility performance canines: 73 cases. Vet. Evid. 2 (2)
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Anim. Pract. 35 (5): 1111–1135.
Dupuis, J., Breton, L., and Drolet, R. (1997). Bilateral epiphysiolysis of the femoral heads in two dogs.
J. Am. Vet. Med. Assoc. 210 (8): 1162–1165.
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Comp. Orthop. Traumatol. 5 (1): 18–21.
Edge-Hughes, L. (2007). Hip and sacroiliac disease: selected disorders and their management with
physical therapy. Clin. Tech. Small Anim. Pract. 22 (4): 183–194.
Farese, J.P., Todhunter, R.J., Lust, G. et al. (1998). Dorsolateral subluxation of hip joints in dogs
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of coxofemoral joint laxity in dogs. Vet. Surg. 28 (1): 1–9.
Foster, M.R. (2002). Piriformis syndrome. Orthopedics 25 (8): 821–825.
Gaspar, A.R., Hayes, G., Ginja, C. et al. (2016). The Norberg angle is not an accurate predictor of
canine hip conformation based on the distraction index and the dorsolateral subluxation score.
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projection for early detection of canine hip dysplasia: a prospective study. Vet. Surg. 41 (1): 42–53.
Ginja, M., Gaspar, A.R., and Ginja, C. (2015). Emerging insights into the genetic basis of canine hip
dysplasia. Vet. Med. (Auckl) 6: 193–202.
Gregory, C.R., Cullen, J.M., Pool, R., and Vasseur, P.B. (1986). The canine sacroiliac joint. Preliminary
study of anatomy, histopathology, and biomechanics. Spine 11 (10): 1044–1048.
Heyman, S.J., Smith, G.K., and Cofone, M.A. (1993). Biomechanical study of the effect of coxofemoral
positioning on passive hip joint laxity in dogs. Am. J. Vet. Res. 54 (2): 210–215.
Jeffcott, L.B., Dalin, G., Ekman, S., and Olsson, S.E. (1985). Sacroiliac lesions as a cause of chronic
poor performance in competitive horses. Equine Vet. J. 17 (2): 111–118.
Jones, J.C., Gonzalez, L.M., Larson, M.M. et al. (2012). Feasibility and accuracy of ultrasound-guided
sacroiliac joint injection in dogs. Vet. Radiol. Ultrasound 53 (4): 446–454.
King, M.D. (2017). Etiopathogenesis of canine hip dysplasia, prevalence, and genetics. Vet. Clin. North
Am. Small Anim. Pract. 47 (4): 753–767.
Knaus, I., Breit, S., Kunzel, W., and Mayrhofer, E. (2004). Appearance and incidence of sacroiliac joint
disease in ventrodorsal radiographs of the canine pelvis. Vet. Radiol. Ultrasound 45 (1): 1–9.
Lewis, D.D., Shelton, G.D., Piras, A. et al. (1997). Gracilis or semitendinosus myopathy in 18 dogs.
J. Am. Anim. Hosp. Assoc. 33 (2): 177–188.
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two dogs. J. Small Anim. Pract. 17 (6): 371–377.
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canine hip dysplasia (CHD). PLoS One 12 (8): e0182093.
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(5): 1175–1196.
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Meomartino, L., Fatone, G., Potena, A., and Brunetti, A. (2002). Morphometric assessment of the canine hip
joint using the dorsal acetabular rim view and the centre-edge angle. J. Small Anim. Pract. 43 (1): 2–6.
Moores, A.P., Owen, M.R., Fews, D. et al. (2004). Slipped capital femoral epiphysis in dogs. J. Small
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Nielsen, C. and Pluhar, G.E. (2005). Diagnosis and treatment of hind limb muscle strain injuries in 22
dogs. Vet. Comp. Orthop. Traumatol. 18 (4): 247–253.
Ragetly, G.R., Griffon, D.J., Johnson, A.L. et al. (2009). Bilateral iliopsoas muscle contracture and
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21
Neurological Disease of the Pelvic Limb

Lisa Bartner
21.1 Introduction
Dogs with monoparesis and/or neurogenic lameness are frequently presented to the veterinary
practitioner, although less commonly so than those with spinal cord conditions. It is important to
recognize and differentiate these neurologic deficits from orthopedic lameness since the causes,
treatment, and prognosis often differ greatly. Clinical signs of neurologic gait abnormalities can be
challenging to differentiate from lameness derived from orthopedic origin and therefore are the
focus of this chapter. Table 21.1 outlines common differential diagnoses and diagnostic steps for
neurological disease affecting the pelvic limb.
21.2 Relevant Anatomy
Similar to the thoracic limb, the anatomic structures of the nervous system that can be implemented
in causing a pelvic limb lameness or monoparesis include the intumescence of the spinal cord and
the efferent neuron (i.e. motor nerve) and all its constituents. The lumbosacral intumescence is
located within the central nervous system (CNS) and is composed of spinal cord segments L4–S3,
with small contributions from L3. The cell body of the efferent neurons is within the intumescence,
while the remaining aspects are located in the peripheral nervous system (PNS).
There are seven pairs of lumbar nerves exiting the spinal cord bilaterally, through a similarly
numbered intervertebral foramen and caudal to the same numbered vertebra. As the spinal cord
courses caudally, each segment is shorter than the vertebral segment and as a result the spinal cord
ends around the fifth or sixth vertebral bodies (Figure 4.2). In large dog breeds, this may be more
cranially positioned (fifth lumbar vertebra) and in small dogs, this can be located more caudally
(e.g. sixth lumbar vertebra). Thus, the entirety of the lumbosacral intumescence lies within the
spinal canal between the third and fifth lumbar vertebral bodies (Figure 4.2). For this reason, the
last several pairs of spinal nerves extend longer distances within the vertebral canal before exiting
their respective intervertebral foramen.
The dorsal nerve root branches exit the foramina and innervate epaxial muscles while the last
four or five ventral branches of the lumbar nerves and the ventral rootlets of all sacral nerves join

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Table 21.1 Key features of select neurologic diseases causing monoparesis or neurogenic lameness of the pelvic limb.
Clinical
Diagnostic test of presentation Distinguishing exam
Disease Common signalment choice and course findings Treatment Clinical pearls
Intervertebral disc Young‐ to middle‐aged History and Acute, Depends on severity Depends on clinical Common cause of
(IVD) extrusion adults; examination progressive, or and location; spinal signs; conservative lameness or monoparesis;
(Hansen Type I) chondrodystrophic MRI wax/wane hyperesthesia or surgical frequently lateralized and
common acute
IVD protrusion Older History and Chronic and Mild to no Depends on clinical Often occurs in DLSS at
(Hansen Type II) dogs; examination usually hyperesthesia signs; conservative L7–S1 and at this location
non‐ MRI progressive or surgical commonly causes
chondrodystrophic lameness or monoparesis;
otherwise rarely causes
unilateral signs
Fibrocartilaginous Young to middle‐aged, History and Peracute, Usually non‐painful Conservative Common cause of
Embolism (FCE) large- and giant-breed examination non‐progressive and asymmetric lameness or monoparesis
MRI after 24 hours signs
Degenerative Older, large‐breed History and Usually chronic Can be vague; Depends on clinical Common cause of
Lumbosacral dogs (e.g. GSD); males examination urinary/fecal signs, conservative, monoparesis or lameness
Stenosis (DLSS) MRI incontinence or surgical especially at L7–S1;
CT foraminal stenosis and
Type II IVDH commonly
Radiographs present
Discospondylitis Medium- to large- History and Acute, wax/ Hyperesthesia; Conservative Lameness or monoparesis
breed; male dogs examination wane, or generally, no or (>12 months can be encountered,
overrepresented Radiographs chronic, minimal neurologic antibiotics); surgery especially with foraminal
MRI generally deficits only warranted with stenosis
progressive compression (IVDH,
CT subluxation)
Neoplasia of the Older but any age History and Acute or Sensory exam Conservative, Common cause of
spinal nerve or examination chronic and (cutaneous testing) surgical, and monoparesis or lameness
spinal cord Radiographs progressive and muscle atrophy radiation therapy
MRI, CT
Electrodiagnostics
Peracute = several hours; acute = several days; chronic = weeks or longer.

CSF, cerebrospinal fluid; CT, computed tomography; GSD, German Shepherd Dog; MRI, magnetic resonance imaging.
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21.3 Neurological Diseases Affecting the Pelvic Lim 381
and form the lumbosacral plexus. The lumbar portion of this plexus innervates the cranial and
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medial muscles and skin of the thigh while the sacral plexus supplies the caudal muscles and skin
of the thigh, tarsus, and foot. Because the series of sacrocaudal nerve roots are forming the S1‐
caudal spinal cord segments and their respective nerves resemble a horse’s tail, this portion of the
spinal cord and spinal roots is called the cauda equina. Thus, the cauda equina is part of the PNS.
Injury or disease affecting only the cauda equina will not cause paresis or lameness because of no
contribution to the femoral and sciatic nerves.
The major spinal nerve contributions to the lumbosacral plexus are summarized in Table 21.2,
though individual variations exist on the actual contributions to the named nerves. The two nerves
that would result in a monoparesis are the femoral nerve and the sciatic nerve with its tibial and
fibular branches. Clinically significant deficits in the obturator and genitofemoral nerves are rarely
reported in dogs. Sensory loss to the skin innervated by the genitofemoral nerve may be appreciated
during testing and can further aid in mapping of deficits.
The femoral nerve arises predominantly from the fifth lumbar spinal nerves, along with substan-
tial portions from L4 and L6. It is formed within the psoas major muscle and continues caudally,
protected within this muscle. Proximally it supplies the psoas major and iliopsoas muscles as well
as sending the saphenous nerve before diving between the rectus femoris and vastus medialis. It
supplies all four heads of the quadriceps (rectus femoris, vastus medialis, vastus intermedius, and
vastus lateralis) and therefore plays the major role in extending the stifle. Consequently, injury to
this nerve will result in inability to support body weight in the affected limb(s); when the dog
attempts to bear weight on the limb, the stifle will passively flex. The saphenous branch of the
femoral nerve innervates the skin on the medial surface of the foot, stifle, and thigh.
The sciatic nerve (also known as the ischiatic nerve) is a mixed sensory and motor nerve that arises
from the spinal cord segments L6, L7, S1, and occasionally S2 and is the extrapelvic continuation of
the lumbosacral trunk (the largest part of the lumbosacral plexus). As the nerve exits the plexus, it
continues as the sciatic nerve and exits the pelvis caudomedial to the coxofemoral joint, deep to and
in between the tuber ischii and the greater trochanter of the femur. It courses distally along the thigh
between the semimembranosus and biceps femoris muscles. Branches of the sciatic nerve supply
the muscles that extend the hip (biceps femoris, semimembranosus, and semitendinosus), flex the
stifle (biceps femoris, semimembranosus, and semitendinosus), and extend the tarsus (biceps femo-
ris). The sciatic nerve divides at the level of the distal femur into fibular (previously called peroneal)
and tibial nerves. The fibular nerve innervates the muscles that flex the hock (cranial tibial and long
digital extensor muscles) and extend the digits (long digital extensor muscle). Therefore, injury to
this nerve will result in unopposed extension of the tarsus and knuckling of the digits. The tibial
nerve supplies the tarsal extensors (gastrocnemius, semitendinosus, and superficial digital flexor
muscles) and digital flexors (superficial digital flexor and deep digital flexor muscles). Therefore,
injury to this nerve will result in hyperflexion of the hock and plantigrade posture.
21.3 Neurological Diseases Affecting the Pelvic Limb
21.3.1 Myelopathies and Radiculopathies

Unilateral spinal cord lesions caudal to the T2 spinal cord segment (i.e. T3–L3 or L4–S3) can cause
pelvic limb monoparesis; however, the quality of paresis will depend on the location of the injury.
A lesion at the lumbosacral intumescence affecting the L4–S3 spinal cord segments will result in a
lower motor neuron (LMN) paresis and coinciding deficits, while a lesion in the T3–L3 spinal cord
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Table 21.2 Summary of the major motor and sensory distribution of the lumbosacral plexus.
Spinal cord Segmental

Nerve segments Muscle innervated Motor function Cutaneous sensory zone spinal reflex Signs of dysfunction
Sciatic L6, L7, S1, S2 Biceps femoris, Extension of hip, Entire limb (via tibial Flexor Severe gait dysfunction
gastrocnemius, cranial extension and and peroneal branch) withdrawal Paw is knuckled, but able to
tibial, semitendinosus, flexion of stifle except for medial reflex (stifle support weight
and semimembranosus (see tibial and aspect and first digit flexion) Hip cannot be extended, hock
peroneal branches) cannot flex or extend (in more
proximal lesions, hip is flexed and
drawn toward the midline)
Absent flexor reflex
Loss of cutaneous sensation distal
to stifle (except for areas supplied
by saphenous nerve)
Fibular L6, L7, S1, S2 Tarsal flexors and Flexion of hock Dorsal aspect of Cranial tibial Hock is straightened, and foot
(peroneal) digital extensors and extension of metatarsus and paw reflex and tends to knuckle
branch of the digits withdrawal Poor hock flexion on flexor reflex
sciatic nerve reflex Loss of sensation on cranial
(hock flexion) surface distal to stifle
Tibial branch L6, L7, S1, S2 Tarsal extensors and Extension of hock Plantar aspect of Gastrocnemius Hock is dropped
of the sciatic digital flexors and flexion of digits metatarsus and paw reflex Loss of sensation on caudal
nerve surface of limb distal to stifle
Femoral L3, L4, L5, L6 Quadriceps group Extension of stifle Medial aspect of thigh Patellar reflex Severe gait dysfunction
and psoas group and flexion of hip and paw, first digit Non‐weight‐bearing
Decreased or absent patellar
reflex
Anesthesia in medial limb and
medial digit
Obturator L4, L5, L6 Adductors Adduction of None None Little gait abnormality
pelvic limb Abduction on slick surface
Genitofemoral L3, L4 None None Proximal aspect of the None Loss of sensation medial thigh
medial thigh and
pudendal region
The major spinal cord segments that for the nerve are underlined.
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0004507104.INDD
region will produce a bilateral upper motor neuron (UMN)‐paresis (i.e. paraparesis) with general
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proprioceptive (GP) ataxia (Chapter 4). Sensory deficits usually accompany motor deficits. If the
injury is at the level of the intumescence, multiple spinal cord segments are typically involved in
most cases, causing a polyneuropathy.
21.3.1.1 Neoplasia
Tumors affecting the nervous system of the pelvic limb, either at the intumescence or the nerves,
commonly cause pelvic limb monoparesis. For any lameness that does not quickly respond to
empirical therapy, such as anti‐inflammatory medications, neurologic conditions should be con-
sidered. Particularly in older animals, neoplasia is a common differential diagnosis (Chapter 11).
21.3.1.2 Spinal Cord Injury

Hansen Types I and II intervertebral disc herniation (IVDH), acute non‐compressive nucleus pul-
posus extrusion (ANNPE), and fibrocartilaginous embolism (FCE) are also frequent causes of
myelopathies and radiculopathies affecting the pelvic limbs. The clinical features of these diseases
are discussed in Chapter 16. Vertebral fracture and luxation (VFL) in the lumbar spine constitute
almost one‐third of all VFL (Jeffery 2010). Multisite VFL also occurs with some frequency. In con-
trast to thoracolumbar IVDH, prognosis is grave if nociception is absent secondary to VFL.
Degenerative myelopathy (DM) can result in LMN paralysis but only with longer disease dura-
tion (Coates and Wininger 2010). The classic presentation of DM is a slow and progressive clinical
course with asymmetric signs localizing to the T3–L3 spinal cord segments. Thus, it would not be
a differential for monoparesis or lameness.
21.3.1.3 Degenerative Lumbosacral Stenosis and Foraminal Stenosis

In degenerative lumbosacral stenosis (DLSS; also called lumbosacral disease, lumbosacral instability,
and cauda equina syndrome), stenosis results from chronic bony and/or soft tissue proliferation,
especially Type II IVD protrusion, reducing the size of the spinal canal and/or intervertebral fora-
men, with resulting compression, inflammation, or entrapment of the cauda equina and/or seventh
lumbar nerve as it exits, respectively (De Risio et al. 2000). This is a disease of older, large‐breed,
working dogs, especially the German Shepherd Dog, with a predilection for males. The L7–S1
intervertebral disc (IVD) is the most commonly affected site, but any site from L5 to S3 can be
affected. Stenosis of the intervertebral foramen, called foraminal stenosis, can also occur anywhere
in the lumbar spine but is most prevalent at the L7–S1 and is frequently a component of DLSS. The
resulting nerve entrapment is a common cause of pelvic limb lameness or monoparesis. Clinical
signs will be dependent on the specific nerves roots or spinal nerves affected. Dogs usually present
for vague pelvic limb problems such as trouble rising, reluctance to jump, difficulty climbing stairs,
lameness, and pain which can be ambiguous. Lameness is reported commonly and may be intermit-
tent, shifting, unilateral, or bilateral. Regional pain, either occurring spontaneously or detected dur-
ing physical examination, is common and, occasionally, may be the only historical problem. Care
should be taken to differentiate discomfort on vertebral extension from hip extension. Applying digi-
tal pressure over the lumbosacral junction (Figure 20.8 and Video 3.1) and extending the lumbosa-
cral junction by lifting the pelvis while pressing on the lumbar vertebrae (lordosis test) are two
specific methods of assessing lumbosacral pain. Extension or traction of the tail and palpation of the
lumbosacral joint on rectal examination are other methods. Careful assessment of pain responses
during hip palpation and extension is required to identify coxofemoral disease (Chapter 20). If other
neurologic deficits such as limb, tail, or anal sphincter paresis are apparent, a tentative diagnosis of
DLSS can be based on these findings. Fecal and/or urinary incontinence may be historically reported.
384 21 Neurological Disease of the Pelvic Limb
Radiography is of some benefit, though, it rarely provides enough information to define or even
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diagnose DLSS. Many clinically normal older dogs will have degenerative abnormalities on
radiographs, like spondylosis. However, conventional radiographs are indicated in patients having
signs consistent with DLSS, as part of a complete workup. Special attention should be paid to the
vertebrae (e.g. L7–S1 orientation, ventral spondylosis, erosive bony changes, facet changes, end
plate sclerosis or osteophytes, and intervertebral foramen size and shape), hips (conformation and
osteophyte presence), and intrapelvic structures (lymphadenopathy, prostate and colon/rectal
abnormalities, and bladder or urethral stones).
Advanced imaging studies are necessary to define and diagnose DLSS, with MRI being preferred
to CT for soft tissue detail and three‐dimensional analysis of anatomy. Images may show impinge-
ment of the cauda equina and/or L7 nerve(s) from a central vertebral canal lesion (IVD protru-
sion), foraminal protrusion, or dorsal interarcurate ligamentous compression. However, this does
not rule out the potential for disease elsewhere in the pelvic limbs, nor does it prove the compres-
sion is causing the clinical signs. Similar to radiographs, many older dogs that are apparently nor-
mal can have degenerative changes in the lumbosacral region. Furthermore, the apparent severity
of cauda equina compression does not correlate with the severity of clinical signs. Electrodiagnostics
can support diagnosis of a nerve disorder. Consequently, a final diagnosis of DLSS must be based
on historical and clinical presentation combined with neuroimaging findings.
Conservative management is generally pursued for mild cases; surgical decompression may be
warranted in more severe cases or those that fail medical management. Fecal and urinary inconti-
nence should insight urgency in considering surgical decompression, as chronicity carries a poor
prognosis in reversing these clinical signs.
21.3.1.4 Discospondylitis
Discospondylitis and associated osteomyelitis are typically bacterial (and less commonly fungal or
algal) infections that begin either at the cartilaginous end plates of the vertebral bodies and spread
to the IVD or remain confined to the vertebra, respectively (Thomas 2000). The L7–S1 disc space is
most commonly affected, but other spaces including those affecting the thoracic limbs can be
involved. Discospondylitis affects large, middle‐aged dogs most commonly, especially those used
for hunting, and male dogs outnumber females by about two to one.
Most patients affected with discospondylitis present with clinical symptoms associated with spi-
nal pain (e.g. decreased activity and unwillingness to jump). Other nonspecific clinical signs
include fever, weight loss, and anorexia. Presentation can be peracute or can wax and wane.
Lameness can be part of the presenting signs and may be unilateral or bilateral but more com-
monly affects the pelvic limbs. Chronic discospondylitis can cause a myelopathy or radiculopathy
if the infection extends into the surrounding soft tissues (e.g. muscles and ligaments). This can lead
to IVDH or instability resulting in vertebral subluxation.
With vague clinical signs, discospondylitis is notoriously difficult to diagnose. Imaging is critical
to establish the diagnosis of discospondylitis. Radiography (Figure 21.1A-C) is usually diagnostic
(Ruoff et al. 2018). However, radiographic abnormalities may not appear until two to six weeks
after onset of infection. Thus, normal spinal radiographs do not rule out a diagnosis of discospon-
dylitis. Nevertheless, radiographs are warranted in a dog presenting with poorly localizable pain,
paraspinal pain, and minimal to no neurologic deficits including lameness. Sedated radiographs of
the entire vertebral column are recommended. In one study, 40% of dogs had multiple lesions at
diagnosis and in almost 20% of cases, the number of affected disc spaces increased during the
course of treatment (Burkert et al. 2005). The earliest radiographic signs of discospondylitis appear
as subtle irregularity of the vertebral end plates. The IVD space may be narrowed due to destruction
of the disc. As the infection progresses, lysis of the vertebral end plates and osteolysis of adjacent
vertebral bodies becomes more pronounced. As bone regeneration occurs, there will be a variable
amount of sclerosis adjacent to the lytic regions. Because radiographic abnormalities are often
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delayed, establishing a diagnosis may require advanced imaging (CT, MRI, or nuclear imaging).
Alternatively, serial radiographs may be appropriate, particularly if positive culture results support
the tentative diagnosis of discospondylitis.
Identification of the infectious agent is important to determine appropriate treatment. Prior to
initiation of antibiotic therapy, urine and blood culture samples should be obtained. A thorough
physical examination is also important to detect other sites of infection, such as bacterial endocar-
ditis, prostatitis, skin, teeth, and ear canals. Combining bacterial cultures of urine and blood is
thought to provide the greatest chance in isolating the causal organism and infection by multiple
agents is reported. Testing for Brucella canis is critical from a zoonotic standpoint. More invasive
techniques have been used such as fluoroscopically guided percutaneous needle aspiration of the
IVD and surgical biopsies with variable success.
(A) (B)
(C) (D)
(E) (F)
Figure 21.1 Survey spinal radiographic studies: (A–C) Lateral and ventrodorsal survey radiographic images
of a dog with discospondylitis displaying vertebral end plate lysis of (A) thoracic and (B, C) lumbar vertebral
bodies. (D, E) Lateral and ventrodorsal survey radiographic studies of a dog with a narrowed disc space
secondary to IVDH. (F) Lateral radiograph demonstrating spondylosis deformans. Note that typically these
degenerative changes alone do not indicate clinical relevance.
Treatment of discospondylitis most commonly involves pain management and long‐term

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antibiotic therapy (typically 12–24 months). Since relapse is very common following cessation of
antibiotics, follow‐up diagnostic imaging is suggested prior to stopping therapy. There is no
published data to guide the best method in decision‐making for discontinuation of treatment.
Serial radiographs performed until there is no evidence of disease has been recommended by some
authors. Radiographic markers of quiescence used include absence of the lytic focus, smoothing
and then loss of the lytic focus, and replacement by bridging of the involved vertebrae. However, it
can be difficult to differentiate discospondylitis from normal healing processes, as well as degen-
erative end plate changes or new infection superimposed with degenerative spinal disease. Nuclear
imaging, MRI, and CT have all been used for monitoring disease resolution and may be more reli-
able, but with limitations, including general anesthesia requirements, expense, and availability.
The author typically performs radiographs at three‐ to six‐week intervals until there is evidence of
static changes over at least three serial studies.
21.3.2 Neuropathies (Nerves and Lumbosacral Plexus)

21.3.2.1 Sciatic Nerve Injury
The anatomic location of the sciatic nerve makes it particularly subject to injury from lumbosa-
cral fractures and subluxations, lumbosacral stenosis, and pelvic or femoral fractures. The
proximal portion of the nerve can be damaged by fractures of the ilium, acetabulum, and proxi-
mal femur. Iatrogenic injury can occur during surgical procedures (e.g. retrograde intramedul-
lary pin placement in the femur, suture entrapment during hernia repair). More distal portions
of the sciatic nerve (i.e. the fibular or tibial nerves along the caudal aspect of the femur) can
incur injury from intramuscular injections given in the caudal thigh or distal femoral fractures.
Less commonly, severe hip dysplasia can be associated with sciatic nerve damage (Sorjonen
et al. 1990).
Clinical signs will depend on the location of the injury. Traumatic injuries to the lumbosacral
region rarely result in a mononeuropathy since axons forming other nerves, such as pelvic, puden-
dal, and caudal nerves, are also injured. If there is damage to the nerve fibers in the spinal canal,
at the level of the cord, then the injury and deficits will usually be bilateral. Lesions at, or proximal
to, the lumbosacral trunk will result in complete loss of sciatic nerve function as well as signs of
fibular and/or tibial nerve dysfunction where the patient will be unable to extend the hip, flex the
stifle, or flex and extend the hock and digits. The animal will be able to extend the stifle and thus
bear weight on the limb since femoral nerve function is intact but may stand or walk on the dor-
sum of the foot “knuckled over” or otherwise assume a plantigrade stance. Sensation will be com-
promised laterally (fibular nerve), caudally (tibial nerve), and dorsally (fibular nerve) but preserved
medially from the intact saphenous branch of the femoral nerve. The withdrawal reflex is weak or
absent with lack of flexion in the stifle, hock, and digits, especially with stimulation of the lateral
digits. Stimulation of the medial digits might still elicit a conscious response and flexion of the hip
due to femoral innervation. Severe pain may occur with nerve entrapment and self‐mutilation may
be an accompanying sign.
Treatment will vary with the cause and severity of the neuropathy but at minimum should
include intense physiotherapy and adequate skin care. Nerve regeneration following iatrogenic
injury is determined by the degree of injury (Chapter 16), with crushing injuries having a worse
prognosis. When due to impingement from an intramedullary pin, removal of the pin usually leads
to clinical improvement. Prognosis depends on the severity of injury making careful assessment of
both sensory and motor function crucial to determine distribution and nerve involvement. Most
injuries are neuropraxic and will often resolve in one to two months. Cutaneous sensation is typi-
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cally preserved in these cases and supports a better prognosis. However, markedly decreased or
absence of pain perception suggests severe injury. Similar to brachial plexus injuries, limb amputa-
tion may need to be considered if self‐mutilation or injury from dragging the limb occurs.
21.3.2.2 Fibular (Peroneal) Nerve Injury

The fibular nerve is most susceptible to injury as it crosses the lateral aspect of the stifle joint.
Injury to the fibular nerve can occur as a result from a damaging insult to the lateral aspect of the
stifle; this can occur with trauma, surgery (such as lateral suture placement for cranial cruciate
ligament rupture), or inadvertent intraneural injections.
Clinically affected animals will have weak hock flexion, the hock may be overextended, and the
foot may also “knuckle over.” There will be decreased cutaneous sensation on the dorsal surface of
the paw and cranially overlying the hock and tibia; however, the dorsal surface of the foot does not
tend to get as ulcerated as with more proximal sciatic nerve lesions. Most dogs learn to accommo-
date by greater flexion at the hip and extension at the stifle giving the impression of a “high‐
stepping gait” and the classic “sciatic gait” (Video 21.1). This must not be confused with hypermetria
associated with cerebellar ataxia or the overreaching stride sometimes seen in GP ataxia (Chapter 4).
Hock flexion will be severely decreased during testing of the withdrawal reflex and the conscious
response will be diminished with stimulation to the dorsal aspect of the foot or digits; if the plantar
surface of the digits is pinched (tibial nerve), then the animal will have a conscious response (affer-
ent arm of the reflex) but the flexor reflex will be reduced (efferent arm of the reflex). Proprioceptive
deficits are usually present.
Video 21.1:
Fibular nerve injury gait (sciatic gait).
Treatment and prognosis are variable depending on cause and severity as for other injuries.
Removal of inappropriately placed sutures usually results in improvement and therefore should be
performed immediately if severe pain is noted after stifle surgery (lateral suture).
21.3.2.3 Tibial Nerve Injury

Tibial nerve injury is less common than fibular nerve injury but can occur secondary to similar
causes. In most animals, tibial nerve injuries occur together with fibular nerve lesions. Animals
presenting with pure tibial nerve injury will display loss of hock extension, loss of sensation on the
plantar surface of the paw, and proprioceptive deficits. The hock is dropped when the dog walks or
when weight is supported on the limb. Trophic ulceration on the plantar surface can occur. The
flexor withdrawal reflex is decreased when the plantar surface of the paw is stimulated but may be
present when the dorsal surface is pinched. Dogs with tibial nerve dysfunction alone can usually
accommodate well, and therefore treatment is conservative in most cases. Pantarsal arthrodesis
and/or the use of orthotic devices may be helpful in those animals who do not improve. If sensory
function remains intact, then the animal has a fairly good prognosis and conservative treatment is
recommended. The presence of sensory deficits (decreased or absent nociception) carries a more
guarded to poor prognosis.
21.3.2.4 Femoral Nerve Injury

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Femoral nerve injuries are less common than those of the sciatic nerve, largely because of better
protection afforded by the sublumbar and quadriceps musculature. Unilateral lesions restricted to
the ventral gray matter of the L4–L6 segments can result in femoral neuropathy. Injury can be
associated with trauma, iliopsoas myopathies (Stepnik et al. 2006), retroperitoneal abscess, hema-
toma, neoplasia, and positioning in ventral recumbency during surgery (i.e. extreme extension of
the hips).
Clinical features with femoral nerve injury are distinct. They include severe monoparesis, with a
loss of the ability to extend the stifle to allow for weight‐bearing. The limb may be carried or may
collapse when weight is placed on it and the patellar reflex will be reduced or absent. However, the
flexor withdrawal reflex is almost normal, except there may be decreased flexion of the hip. With
complete support, proprioceptive placement will be normal, although the hopping postural reac-
tion will be greatly diminished because the dog will be unable to support weight on the affected
limb. Rapid neurogenic atrophy becomes apparent in the quadriceps muscles and cutaneous sen-
sation may be lost to the medical aspect of the limb and medial digits, regions of sensory innerva-
tion by the saphenous branch of the femoral nerve.
Generally speaking, lesions closer to the muscle innervated carry a more favorable prognosis
than those more proximal. Treatment recommendations and prognosis are as described in
Section 21.3.2.1. If there is no improvement seen in three months, recovery is unlikely; amputation
may need to be considered.
21.3.3 Myopathies and Junctionopathies

Myopathies and junctionopathies can begin as shifting leg lameness or stiff gait, sometimes affect-
ing the pelvic limbs before the thoracic. Idiopathic polymyositis is the most common example;
others include endocrine and infectious myopathies. Junctionopathies refer to conditions altering
the neuromuscular junction, with myasthenia gravis being the most reported and investigated. In
most cases, these conditions are characterized by pain, generalized weakness/paresis, exercise
intolerance, and/or stiff and stilted gait. Clinical signs are typically bilaterally symmetric but can
occasionally demonstrate a shifting or unilateral leg lameness, particularly in the early stages.
Many times, spinal reflexes are normal, discerning these from spinal cord diseases. Distinguishing
features that point towards these PNS disorders rather than orthopedic disease include gait abnor-
malities that worsen with activity, neurogenic muscle atrophy, and elevated muscle enzyme levels,
and electrodiagnostic abnormalities.
Serum muscle enzyme levels, including creatine kinase (CK), lactate dehydrogenase, and aspar-
tate aminotransferase, may be significantly elevated in inflammatory conditions like myositis.
Myoglobinuria may be detected with inflammatory myopathies (e.g. idiopathic polymyositis). In
cases of endocrine myopathies, such as hyperadrenocorticoid (Cushing’s) myopathy, for example,
other supportive evidence is usually seen on serum chemistry analysis (e.g. elevated alkaline phos-
phatase). Total serum protein can be elevated in infectious myositis due to the presence of increased
β‐ and γ‐globulins. Electrodiagnostic tests can be used to confirm that PNS disease is present, but
they will usually not diagnose the specific condition. However, in most cases, muscle and nerve
biopsy samples are required to establish a final diagnosis; these techniques are described in detail
elsewhere (Dickinson and Lecouteur 2002; Lecouteur and Williams 2012). Definitive diagnosis of
myasthenia gravis relies on detecting serum antibodies to the acetylcholine receptors. If signs of
megaesophagus are present, thoracic radiographs are also warranted. Some clinical features aid in
deriving a list of differentials. For example, neurogenic, generalized muscle atrophy is a classic
Reference 389
characteristic of polymyositis, especially when CK levels are elevated; whereas, dogs affected with
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myasthenia gravis rarely develop neurogenic muscle atrophy.

Ischemic neuromyopathy in dogs, most commonly caused by aortic thromboembolism (ATE),
can have subacute or chronic onset with milder neurologic deficits that can be intermittent, in
contrast to cats. Clinical signs usually involve the pelvic limbs and generally present as lameness,
knuckling, paresis, or paralysis. Pelvic limb reflexes may be abnormal, and the extremities can be
cool and/or painful. Serum CK levels are markedly elevated. Underlying conditions associated
with ATE include cardiac disease, neoplasia, renal disease, immune‐mediated hemolytic anemia,
sepsis, and endocrine disorders (e.g. hypothyroidism and hyperadrenocorticism).
While not a neurologic condition, fibrotic myopathies such as quadriceps, gracilis, and/or sem-
itendinosus contracture may be confused with a neurologic condition. They cause classic gait defi-
cits without neurologic deficits (Chapter 20).
21.3.4 Other Neurologic and Spinal Diseases Affecting the Pelvic Limb

Rarely, other inflammatory diseases such as myelitis or meningomyelitis and protozoal neuritis
cause acute progressive monoparesis; more typically these are generalized conditions. Some dogs
with immune‐mediated polyarthritis (IMPA) first present with shifting leg lameness and spinal
hyperesthesia (Chapter 16).
Spondylosis deformans, diffuse idiopathic skeletal hyperostosis (DISH), multiple cartilaginous
exostosis (MCE), and spinal dural ossification may all affect the pelvic limb. These conditions have
been described in Chapter 16.
R
eferences
Burkert, B.A., Kerwin, S.C., Hosgood, G.L. et al. (2005). Signalment and clinical features of
diskospondylitis in dogs: 513 cases (1980–2001). J. Am. Vet. Med. Assoc. 227 (2): 268–275.
Coates, J.R. and Wininger, F.A. (2010). Canine degenerative myelopathy. Vet. Clin. North Am. Small
Anim. Pract. 40 (5): 929–950.
De Risio, L., Thomas, W.B., and Sharp, N.J.H. (2000). Degenerative lumbosacral stenosis. Vet. Clin.
North Am. Small Anim. Pract. 30 (1): 111–132.
Dickinson, P.J. and Lecouteur, R.A. (2002). Muscle and nerve biopsy. Vet. Clin. North Am. Small Anim.
Pract. 32 (1): 63–102.
Jeffery, N.D. (2010). Vertebral fracture and luxation in small animals. Vet. Clin. North Am. Small Anim.
Pract. 40 (5): 809–828.
Lecouteur, R.A. and Williams, D.C. (2012). Neurodiagnostics. In: Veterinary Surgery: Small Animal
(eds. K.M. Tobias and S.A. Johnston), 340–356. St. Louis: Elsevier/Saunders.
Ruoff, C.M., Kerwin, S.C., and Taylor, A.R. (2018). Diagnostic imaging of discospondylitis. Vet. Clin.
North Am. Small Anim. Pract. 48 (1): 85–94.
Sorjonen, D.C., Milton, J.L., Steiss, J.E. et al. (1990). Hip dysplasia with bilateral ischiatic nerve
entrapment in a dog. J. Am. Vet. Med. Assoc. 197 (4): 495–497.
Stepnik, M.W., Olby, N., Thompson, R.R., and Marcellin‐Little, D.J. (2006). Femoral neuropathy in a
dog with iliopsoas muscle injury. Vet. Surg. 35 (2): 186–190.
Thomas, W.B. (2000). Diskospondylitis and other vertebral infections. Vet. Clin. North Am. Small Anim.
Pract. 30 (1): 169–182.
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22
Neoplastic Conditions of the Pelvic Limb

Bernard Séguin
Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Flint Animal Cancer Center, Colorado State University,
22.1 Introduction
Neoplastic conditions of the pelvic limb are similar to those of the thoracic limb though
osteosarcoma is less prevalent, and neoplasia of the peripheral nervous system is also less fre-
quently seen. On the other hand, the lumbar area is the most common site for spinal metastasis.
Please refer to Chapter 11 for details regarding the diagnostic workup of neoplasia.
22.2 Neoplasia of Specific Regions
22.2.1 Distal Limb Region

Digital and non‐digital tumors should be considered as differential diagnoses and the diagnosis
and treatment options are the same as for the thoracic limb (Section 17.2.1). Digital squamous cell
carcinoma affects the pelvic limb less frequently than the thoracic limb.
22.2.2 Tarsal Region

Similar to the carpus region of the thoracic limb, the lack of soft tissue coverage surrounding the
tarsus frequently results in earlier diagnosis of neoplasia of the region since owners may observe a
swelling, particularly in short‐haired dogs.
In contrast to the thoracic limb, osteosarcoma occurs in the metaphyseal areas of the proximal
and distal femur and tibia at a similar rate (Brodey et al. 1963). Therefore, the maxim “osteosar-
coma stays close to the stifle,” meaning osteosarcoma is more common in the distal femur and
proximal tibia and rare in the distal tibia and proximal femur, is not true. In fact, if a bone tumor
of the distal tibia is diagnosed, it is most likely an osteosarcoma. The diagnostic approach and
treatment is similar to primary bone tumors of the distal radius. Limb‐sparing techniques for
primary bone tumors are not well developed for the pelvic limb, and full limb amputation is most
frequently performed as a treatment.

392 22 Neoplastic Conditions of the Pelvic Limb
22.2.3 Stifle Region

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Osteosarcoma is frequently diagnosed in the distal femur and proximal tibia (Figure 22.1). While
osteosarcoma may occur independently, there is an ongoing discussion about a possible association
with Tibial Plateau Leveling Osteotomy (TPLO) surgery. Explanations for this possible association
include corrosion of the bone plate or local infection leading to an altered local cellular activity
(Selmic et al. 2018). Implants that are not meeting the current regulatory standards (such as cast
TPLO plates which are not sold anymore) are associated with an increased metal ion release when
(A) (B) (E)
(C) (D) (F)
Figure 22.1 Radiographs of stifle joint neoplasia associated with (A, B) proximal tibial osteosarcoma, (C, D)
histocytic sarcoma, and (E, F) distal femoral osteosarcoma: (A) lateral and (B) craniocaudal radiographs of a
dog that developed osteosarcoma of the proximal tibia after Tibial Plateau Leveling Osteotomy (TPLO).
Note the enlarged popliteal lymph node (red arrow); (C) lateral and (D) craniocaudal radiographs of the
stifle joint with histiocytic sarcoma and an enlarged popliteal lymph node (red arrow). Note the severe soft
tissue opacity in the stifle joint and subtle lysis of the proximal tibia, fibula, and intercondylar fossa of the
femur (white arrows); (E) lateral radiograph at time of initial presentation and at (F) follow-up showing
progression of the osteolytic and proliferative changes classic for distal femoral osteosarcoma.
compared to forged plates (i.e. currently used TPLO plates). This corrosion‐related increased ion
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release may place patients at risk of tumor development (Sprecher et al. 2018). The risk of
developing osteosarcoma after TPLO has been described to be very low. Sartor et al. (2014) retro-
spectively evaluated 2464 dogs with at least one‐year follow‐up after TPLO. In that study, 11 dogs
developed osteosarcoma at the TPLO site (0.4% incidence) and 29 dogs developed osteosarcoma at
a different site (1.2%). The authors calculated incidence density rates of OSA at the TPLO site to
be between 10.2 and 30.4 per 10 000 dog‐years at risk. Interestingly, all dogs that developed osteo-
sarcoma at the TPLO site had cast TPLO plates implanted (Sartor et al. 2014). In a more recent
matched case‐control study, dogs that had received a TPLO in the last year were 40 times as likely
to develop proximal tibial osteosarcoma as were dogs with no history of TPLO (Selmic et al. 2018).
Unfortunately, the type of implant was not disclosed in that study. Regardless, proximal tibial
osteosarcoma should be considered as a differential after TPLO which can easily be diagnosed
with radiographs.
Presence of the classic findings of cranial cruciate ligament rupture, such as joint effusion and
cranial drawer, do not rule out the possibility of neoplasia (Lahmers et al. 2002). While extremely
rare, it is possible that stifle instability is secondary to neoplasia rather than due to degeneration.
Several tumors of the stifle joint have been described. Specifically, the stifle is one of the three most
common joints to develop periarticular histiocytic sarcoma. Villonodular synovitis has also been
described in the stifle region of two dogs, one of which was bilateral (Marti 1997). Lymphoma of
the synovium of the stifle joint has been reported in one dog (Lahmers et al. 2002).
Unfortunately, joint fluid analysis cannot be used to reliably diagnose stifle neoplasia and even
in the case of synovial lymphoma, it failed to provide the diagnosis (Lahmers et al. 2002).
Additionally, because radiographic abnormalities may be subtle, a biopsy is required to establish a
diagnosis.
22.2.4 Hip Region

Osteosarcoma is the most common bone tumor of the proximal femur. Osseous tumors of the
pelvis or soft tissue tumors of the pelvic canal can also cause a lameness. Lipomas in the inguinal
area rarely cause a lameness unless they become large enough to interfere with normal range of
motion. Another type of lipoma rarely associated with lameness is the intermuscular lipoma,
which is typically encountered in the thigh region. This lipoma grows between the muscle bellies
of the thigh, particularly those of the caudal thigh, and unlike the infiltrative lipoma does not
invade the muscle bellies. Villonodular synovitis has also been described in the hip region of one
dog (Kusba et al. 1983).
The rectal exam is an essential part to detect neoplasia of the hip region since it can reveal
tumors of the pelvic canal or the pelvis (mostly caudal aspect, depending on the size of the dog and
length of the finger of the examiner). Because of the large muscles surrounding the hip area, subtle
lesions of the bones can be more easily missed on radiographs. Therefore, computed tomography
is frequently used since it is more sensitive to show both soft tissue and bone pathology. Fine‐
needle aspirates and biopsies in this area frequently require imaging guidance. When tumors of
the femoral neck or head are treated by amputation, an acetabulectomy en bloc is recommended.
22.2.5 Nervous System

Neoplastic diseases affecting the nervous system of the pelvic limb are similar to those of the
thoracic limb (Chapter 17). Peripheral nerve sheath tumors can affect any component of the periph-
eral nervous system, but they are less commonly observed in the lumbosacral area compared to the
394 22 Neoplastic Conditions of the Pelvic Limb
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(A) (B)
(C) (D)
(E)
Figure 22.2 Vertebral tumors: (A) lateral and (B) ventrodorsal radiographs illustrate a case of metastatic
anal gland adenocarcinoma affecting the sixth lumbar vertebrae (white arrow) that is easily visible on the
lateral radiographs; (C) lateral and (D) ventrodorsal radiographs of a vertebral body mass that is easily
missed on radiographs (white arrow indicates faint periosteal reaction), but clearly visible on (E) MRI.
cervicothoracic area (Brehm et al. 1995). On the other hand, the lumbar area is the most common
site for spinal metastasis of tumors from other anatomic locations and therefore any diagnosis of
neoplasia should trigger thorough staging of the patient (Figure 22.2).
Specific to the pelvic limbs, spinal cord blastoma (also called ependymoma, medulloepitheli-
oma, neuroepithelioma, and nephroblastoma) has been described in young, large‐breed dogs,
especially German Shepherds and Retrievers. Liebel et al. (2011) located the tumor consistently
between T9 and L2 and found that cytoreductive surgery improved survival time.
References
Brehm, D., Vite, C., Steinberg, H. et al. (1995). A retrospective evaluation of 51 cases of peripheral
nerve sheath tumors in the dog. J Am Anim Hosp Assoc 31 (4): 349–359.
Brodey, R.S., Sauer, R.M., and Medway, W. (1963). Canine bone neoplasms. J Am Vet Med Assoc 143:
471–495.
Reference 395
Kusba, J.K., Lipowitz, A.J., Wise, M., and Stevens, J.B. (1983). Suspected villonodular synovitis in a
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dog. J Am Vet Med Assoc 182 (4): 390–392.

Lahmers, S.M., Mealey, K.L., Martinez, S.A. et al. (2002). Synovial T‐cell lymphoma of the stifle in a
dog. J Am Anim Hosp Assoc 38 (2): 165–168.
Liebel, F.‐X., Rossmeisl, J.H., Lanz, O.I., and Robertson, J.L. (2011). Canine spinal nephroblastoma:
long‐term outcomes associated with treatment of 10 cases (1996–2009). Vet Surg 40 (2): 244–252.
Marti, J.M. (1997). Bilateral pigmented villonodular synovitis in a dog. J Small Anim Pract 38 (6):
256–260.
Sartor, A.J., Ryan, S.D., Sellmeyer, T. et al. (2014). Bi‐institutional retrospective cohort study evaluating
the incidence of osteosarcoma following tibial plateau levelling osteotomy (2000–2009). Vet Comp
Selmic, L.E., Ryan, S.D., Ruple, A. et al. (2018). Association of tibial plateau leveling osteotomy with
proximal tibial osteosarcoma in dogs. J Am Vet Med Assoc 253 (6): 752–756.
Sprecher, C.M., Milz, S., Suter, T. et al. (2018). Retrospective analysis of corrosion and ion release from
retrieved cast stainless steel tibia plateau leveling osteotomy plates in dogs with and without
peri‐implant osteosarcoma. Am J Vet Res 79 (9): 970–979.
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Glossary
Name Definition
Amble Accelerated walk, maintaining the four‐beat gait pattern

Apophysis The site of a tendon or ligament attachment, such as the tibial tuberosity, that
does not contribute to a joint; compare to epiphysis
Arthrokinematics Joint surface movement, i.e. small amplitude movements of the bones at the
joint surface such as roll, glide, spin; compare to osteokinematics
Ataxia Failure of coordinated muscle movement; arises from disease affecting the
spinal cord, cerebellum, or vestibular system
Axon An elongated extension of the nerve cell that carries nerve impulses; a nerve
fiber
Cauda Equina Sacral and caudal spinal nerve roots
Central nervous The part of the nervous system comprising the brain and spinal cord
system
Concentric Shortening of a muscle during contraction – this happens when the force
contraction generated by the muscle is large enough to overcome the resistance, e.g. flexion
of the elbow joint during biceps contraction (such as when lifting a glass of
water from the table); compare to eccentric/isometric contraction
Crepitus Grinding or grating sensation or sound that is caused by severe degeneration of
the joint or intra‐articular fractures
Diaphysis Main (central or long part) of the bone; compare to metaphysis
Dimelia Duplication of the whole or part of limb
Dysostoses Constitutional bone diseases characterized by abnormal development of
individual bones or parts of bones (such as ectrodactyly)
Eccentric Lengthening of a muscle during contraction – this happens when the force
contraction generated by the muscle is less than the resistance, e.g. extension of the elbow
joint during biceps contraction (such as when lowering a glass of water to the
table); compare to concentric/isometric contraction
Ectrodactyly Congenital split formation (separation) between metacarpal bones
Encephalopathy Brain disease/pathology
End‐feel Subjective description of the sensation that the observer experiences at the end
of joint range of motion
Epiphysis The end of a bone that contributes to a joint
(Continued)

398 G
lossary
(Continued)
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Name Definition
Flaccid paresis Paresis with decreased muscle tone (i.e. loss of muscle “power”). Flaccid paresis
is indicative of an LMN lesion; compare to spastic paresis
Flexibility Evaluation of muscle extensibility, i.e. the ability of the muscle to stretch or
passively elongate when an external manual force is applied
Ganglion Collection of nerve cell bodies in the PNS (i.e. the spinal ganglia is in the dorsal
nerve root of spinal nerves; previously called dorsal root ganglia)
General The sense of the relative position of parts of the body; muscle and joint position
proprioception and movement, tactile input from the body, limbs, and head
Goniometry Measurement of (joint) angles
Hamstrings Caudal thigh muscles originating from the ischial tuberosity, i.e. the biceps
femoris, semitendinosus, and semimembranosus (and abductor cruris caudalis)
muscles
Hemimelia Congenital absence of a part or all of one or more bones
Horner syndrome Combination of clinical signs related to deficits in sympathetic innervation to
the eye: enophthalmos, pupillary constriction (miosis), narrowing of the
palpebral fissure (ptosis), and protrusion of the third eyelid. Partial Horner
syndrome manifests as ipsilateral miosis due to ipsilateral sympathetic
dysfunction
Intumescence Normal spinal cord enlargement (cervical and lumbar)
Isometric Unchanged length of a muscle during contraction – this happens when the
contraction force generated by the muscle matches the resistance, e.g. maintaining the joint
angle of the elbow joint during biceps contraction (such as when holding a glass
of water); compare to concentric/eccentric contraction
Junctionopathies Pathology of the neuromuscular junction
Kinematic gait The evaluation of motion throughout the complete gait cycle, frequently focused
analysis on joint angle evaluation
Kinetic gait analysis Evaluates the forces produced when an animal’s foot is in contact with the ground
Lameness In orthopedics defined as a gait abnormality; compare to neurogenic lameness
Lower Motor The neurons related to motor function that have their cell bodies in the grey
Neuron matter of the CNS (brainstem and spinal cord) and axons that exit the CNS as
nerves; in the spinal cord, this is via the ventral nerve roots to innervate skeletal
muscles of the limb, head, or trunk
Metaphysis Portion of the bone in between the epiphysis and diaphysis that contains the
physis
Mononeuropathy Disease or injury affecting a single nerve
Multiple Dysfunction of multiple (peripheral) nerves in the same limb (e.g. brachial
mononeuropathies plexus injury)
Myelopathy Spinal cord disease
Myofascial pain Muscle, sensory, motor, and autonomic nervous system symptoms caused by
syndrome stimulation of myofascial trigger points (MTPs), i.e. myalgia that is
characterized by the presence of MTPs
Myofascial trigger Discrete, focal, hyperirritable spots located in a taut band of skeletal muscle
point
Myopathy Pathology of the muscles
Nerve A collection of axons in the PNS that is usually grossly visible; Note: since a
“nerve” by definition is part of the PNS, it is redundant to say “peripheral nerve”
Glossary 399
(Continued)
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Name Definition
Nerve fiber See axon

Nerve root signature See neurogenic lameness
(lameness)
Neurogenic Discomfort caused by pathology affecting the nerve roots and/or surrounding
lameness meninges (e.g. from a lateralized disc herniation), also frequently referred to as
“nerve root signature (lameness)”
Neuron Nerve cell (i.e. composed of a cell body and the nerve fibers)
Neuropathy Pathology of the (peripheral) nerves
Osteokinematics Gross movements of bones at joint (e.g. flexion/extension; abduction/adduction;
and supination/pronation); compare to arthrokinematics
Pace Two‐beat, lateral gait in which ipsilateral limb pairs move in synchrony
Paralysis Complete loss of voluntary motor function resulting in an inability to support
weight (i.e. the most severe degree of paresis)
Paraparesis Paresis of the pelvic limbs; Note: It is redundant to say, pelvic limb paraparesis
Paresis Partial loss of voluntary movement that is due to disruption of the signal
transmission from either the level of the upper motor neuron (UMN) or lower
motor neuron (LMN). Note that in clinical neurology the term is sometimes
used as synonym for weakness
Paronychia Nonspecific inflammation of the nail/claw fold
Peripheral nervous Comprising cell bodies, bilateral spinal nerves arising as dorsal (sensory) and
system ventral (motor) nerve roots, nerves, neuromuscular junction, and muscle; the
nerve cell bodies of the efferent (motor) axons are located in the ventral gray matter
and the cell bodies of the afferent (sensory) axons are located in the spinal ganglia
Plegia Paralysis
Polydactyly Occurrence of one or more extra digits
Polyneuropathy Disease or injury of multiple nerves (e.g. polyradiculoneuritis)
Radiculopathy Nerve root disease
Somatic Relating to, innervating or involving the voluntary (striated) muscle as opposed
to the visceral (involuntary) muscle and its (autonomic innervation)
Spastic paresis Paresis with increased muscle tone (i.e. inability to initiate gait voluntarily)
which is caused by a disruption of signal transmission from the UMN to the
LMN. Spastic paresis is indicative of a UMN lesion; compare to flaccid paresis
Spinal nerve Spinal nerves arise after the fusion of the dorsal and ventral nerve roots at the
level of the intervertebral foramen
Stretching See flexibility
Synapse Gap connection between one axon terminal and a neuron, muscle, or gland
Syndactyly Partial or complete lack of separation between adjacent digits
Trigger point See myofascial trigger point
Upper Motor The neurons related to motor function that have their cell bodies in the grey
Neuron matter of the CNS (cerebrum and brainstem) and axons that synapse on a LMN
or interneuron
Weakness Difficulty initiating gait due to LMN disease; Note: in clinical neurology
sometimes used as synonym for paresis; however, weakness can be caused by
other diseases
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List of Abbreviations
ALD Angular Limb Deformity

ANNPE Acute Non‐Compressive Nucleus Pulposus Extrusion
CCLD Cranial Cruciate Ligament Disease
CNS Central Nervous System
CSM Cervical Spondylomyelopathy
CT Computed Tomography
DISH Diffuse Idiopathic Skeletal Hyperostosis
DJA Diagnostic Joint Anesthesia
DM Degenerative Myelopathy
ED Elbow Dysplasia
FCE Fibrocartilaginous Embolism
FCU Flexor Carpi Ulnaris
FVA Femoral Varus Angle
GP General Proprioception
HD Hip Dysplasia
HOD Hypertrophic Osteodystrophy
IMPA Immune‐Mediated Polyarthritis
IOHC Incomplete Ossification of The Humeral Condyle
LDE Long Digital Extensor
LMN Lower Motor Neuron
MCD Medial Compartment Disease
MCE Multiple Cartilaginous Exostoses
MPL Medial Patellar Luxation
MPS Myofascial Pain Syndrome
MRI/MR Magnetic Resonance Imaging
MSI Medial Shoulder Instability
MTP Myofascial Trigger Point
OCD Osteochondrosis/Osteochondritis Dissecans
OGA Objective Gait Analysis
PNS Peripheral Nervous System
PROM Passive Range of Motion
RUIN Radioulnar Ischemic Necrosis
SH Salter‐Harris

402 List of Abbreviations
SI Sacroiliac
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TNCC Total Nucleated Cell Count

TPLO Tibial Plateau Leveling Osteotomy
TP Total Protein
UAP Ununited Anconeal Process
UMN Upper Motor Neuron
403
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Index
Note: Page numbers in italics refer to figures, those in bold to tables and inset boxes.
a of the elbow 99, 100

Abductor pollicis longus muscle equipment 96–97
radiographic appearance of sesamoid 174, 183 of the hip 102, 103
tendinopathy 187, 188 indications 95
Acceleration. See Kinematic gait analysis of the shoulder 100, 101
Accessory carpal ligaments 150 of the stifle 102, 103
Accessory caudal glenoid ossification center. See of the tarsus 101, 102
Shoulder joint/region, caudal glenoid Arthrography 248
fragments Arthrokinematics 77, 78
Achilles tendon. See Common calcanean tendon Arthropathies 120–121
Acral lick dermatitis 161, 163 Arthroscopy 109, 184, 195, 205–209, 235, 241,
Acral lick furunculosis/granuuloma. See Acral 243, 248–249, 249, 324, 337, 339
lick dermatitis Aseptic necrosis of the femoral head. See Hip
Acute non‐compressive nucleus pulposus joint/region, avasucular necrosis of the
extrusion 261–263, 383 femoral head
Adhesive capsulitis 248–249, 249 Ataxia 7, 41–42, 42, 43, 46, 51–52, 383, 387
Amble 7
Angular limb deformity 175, 179, 186, b
340–341, 342 Barden’s test 360
Arthritis Barlow test 360
degenerative (See Osteoarthritis within each Biceps brachii muscle. See Shoulder joint/region,
specific joint/region) biceps brachii muscle
immune‐mediated 120, 175, 176 Biceps tenosynovitis. See Shoulder joint/region,
erosive polyarthritis 175, 176 biceps brachii muscle
types of 175, 176 Body weight distribution 19, 20
joint fluid cytology 115, 117, 119 Bone cyst 218, 375
radiographic appearance 217, 375 Bone scan. See Scintigraphy
septic 214, 301, 342 Bowed tendon 159
Arthrocentesis 95–104 Brachial plexus 38, 219, 249, 255, 258–259, 263
approaches 98 injury 51, 61, 188, 256, 257, 264–265
of the carpus 99 neurologic deficits 61

404 Index
Brachial plexus (cont’d) Central nervous system 42, 44, 45, 46, 49, 53, 64,
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sensory distribution 258, 264 65, 263, 379, 398

tumors of the 53, 105, 249, 271, 274, 276 Cerebrospinal fluid 65, 260, 274–275
Brachial plexus avulsion. See Brachial plexus, Cervical spondylomyelopathy 260, 262
injury Chondrodystrophy 174, 185
Bunny hopping 7, 46, 360 Chondroid metaplasia 260
Chondrosarcoma 137–138, 273–274
c Choroid plexus papilloma 275
Calcinosis circumscripta 217, 273 Claw conditions. See Distal limb region
Calve‐perthes disease. See Hip joint/region, Common calcanean tendon 6, 33, 35, 126, 281,
avascular necrosis of the femoral head 283, 294, 297
Campbell’s test. See Elbow joint/region, anatomy 288, 294, 313
Campbell’s test clinical appearance 294, 296
Canter 7 examination/stretching 289
Capitulum 195, 199 grading 295
Carcinoma 138, 272, 276, 391 injury 295, 297
Carpal flexural deformity. See Carpal laxity radiographic appearance 296
syndrome traumatic 281, 295, 296
Carpal hyperextension injury 179, 180, 181, 302 Common disease schematics
levels of injury 180 carpal joint/region 173
radiographic appearance 182 distal limb region 148
Carpal joint/region 171–193 elbow joint/region 198
anatomy 171 hip joint/region 350
arthrocentesis of 98, 99 neurologic disease 43
common disease schematic 173 shoulder joint/region 226
common disease table 172 stifle joint/region 310
deformities 185, 186 tarsal joint/region 284
effusion 176 Common disease tables
examination 34–38, 35, 176, 182 carpal joint/region 172
fractures 175, 177 distal limb region 146
immune‐mediated polyarthritis 175, 176 elbow joint/region 196
incomplete ossification of the radial carpal hip joint/region 348
bone 176, 179, 190, 191 monoparesis
ligamentous injuries 180, 183–184, 183 pelvic limb 380
luxation 181 thoracic limb 256
neoplasia 272, 273 shoulder joint/region 224
normal radiographic anatomy 174 stifle joint/region 308
osteoarthritis 174 tarsal joint/region 282
osteosarcoma, radiographic appearance 190 Compensatory lameness. See Lameness,
range of motion 73, 171 compensatory
retained cartilaginous core of the ulna 190 Computed tomography 64, 125, 126, 127, 128,
Carpal laxity syndrome 172, 187 137, 260, 393
Carpus valgus/varus 185, 186 Corns 147, 159–160, 160
Cauda equina 45, 60, 381, 383–384 Coronoid process 128, 199, 203–208, 204, 207,
Cauda equina syndrome. See Degenerative 208, 212
lumbosacral stenosis Crab‐claw stance 290, 294, 295, 296
Index 405
Cranial cruciate ligament 5, 6, 35, 71, 77, 86, 87, digital and paw pad conditions 159, 160
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89, 233, 298, 302, 307, 311, 316–320, 318, dorsal digital ligament sprains 157
319, 320, 322–329, 324, 328, 332, 333, fractures 154
336–342, 338, 342, 360, 366, 387, 393 metacarpophalangeal osteoarthritis 152, 153
anatomy 311 neoplasia 271
avulsion 328 normal radiographic anatomy 149
drawer testing 320, 322 forepaw 150
etiology 317 hindpaw 152
excessive tibial plateau angle 326 other conditions 164
physical examination 34–38, 35, 318, 320 Dropped back muscle. See Gracilis muscle, injury
pivot shift 328 Dysostoses 165
radiographic appearance 127, 325–328
sit‐test 319 e
tibial thrust testing 317, 320, 324 Elbow dysplasia 196, 199, 203, 204, 207
traumatic 317 incongruity 128, 204
Cranial tibial extensor muscle 151 medial compartment disease 36, 128, 196,
Crepitus. See Joint crepitus 200, 204–210, 215–216, 216
Cytospin 112, 116 CT apperance 204
radiographic apperance 208
d osteochondrosis dissecans 209
Deep digital flexor muscle 150, 157–159, 158, ununited anconeal process 204, 209, 210
288, 303, 381 Elbow joint/region 195–221
anatomy 151 anatomy 195
injury 158 arthrocentesis of 98, 99, 100
stretching 72, 73 calcinosis circumscripta 217–218
Degenerative lumbosacral stenosis 60, 380, 383 Campbell’s test 206, 207, 211
Degenerative myelopathy 383 common disease schematic 198
Dermatologic conditions of the lower limb 162 common disease table 196
Dermatome. See Nervous system, dermatome effusion 207
Diagnostic joint anesthesia 105–110, 106 examination 34–38, 35, 206, 207, 240
interpretation 108, 109, 114 flexor enthesopathy 215–217
patient selection 105 fractures 200–201
sedation protocols 107 incomplete ossification of the humeral condyle
technique 108 39, 196, 201–202, 203
Diffuse idiopathic skeletal hyperostosis 261, 266 luxation 210
Digit(s) 59, 60, 72, 73, 145, 147, 152–153, 153 congenital 210–212
fracture 155 CT appearance 128
luxation 155 radiographic apperance 211
neoplasia 271, 272 traumatic 210–212
Discospondylitis 64, 260, 263, 266, 380, neoplasia 218
384–386, 385 normal radiographic anatomy 199
Distal limb region 145–168 ossifying myositis of the extensor carpi radialis
anatomy 145 origin 219
claw conditions 163–164 osteochondrosis dissecans 203, 204, 209
common disease schematic 148 panosteitis 212–214
common disease table 146 radiographic apperance 213
406 Index
Elbow joint/region (cont’d) Fragmented coronoid process. See Elbow

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radioulnar ischemic necrosis 217–218, 217 dysplasia, medial compartment disease

range of motion 73 Frontal plane. See Planes of motion
septic arthritis 214 Frozen shoulder. See Shoulder joint/region,
ununited anconeal process 209–210, 210 adhesive capsulitis
Electrodiagnostics 65, 264, 265, 384, 388
Enophthalmos 53, 259 g
Enthesopathy 153, 187, 196, 215, 216, 296, 297, Gait analysis
301, 339, 341 objective 15–30
Ependymoma 275, 394 subjective 5–13
Epiphyseal dysplasia 185, 343, 375 Gait patterns 7, 8, 51
Erosive polyarthritis. See Arthritis Gallop 7
Extradural cystic abnormalities 263, 274–275 Ganglion cyst 343
Extradural neoplasms 276 Gastrocnemius muscle
Extradural synovial cysts 263 anatomy 73, 74, 80, 89, 281, 294–295, 313
myotendinopathy 283, 289, 296, 341–342,
f 342, 353
Femoral nerve 47, 57, 58, 60, 62–63, 313, 351, stretching 289
352, 371, 386 traumatic injury 295, 296, 342
anatomy 62, 63, 381, 386 Goniometry 5, 37, 71, 74, 183, 185, 188
injury 388 landmarks 76
Femoral varus angle. See Stifle joint/region, normal values 71, 72
patellar luxation technique 75
Fibrocartilaginous embolism 64, 256, 262, Gracilis contracture. See Muscle contractures
380, 383 Gracilis muscle
Fibrosarcoma 138–139, 273, 274, 276 anatomy 313, 352
Fibrotic myopathy. See Muscle contractures injury 370, 374
Fibrous metaplasia (of the intervertebral stretching 369
disc) 260 Ground reaction forces 16, 18
Fibular nerve 387 Gulick tape measure. See Rehabilitation
anatomy 63, 381 examination, limb circumference
injury 386–387 measurement
Fine‐needle aspirate 135–137, 164, 187, 271,
274, 277 h
Flexibility testing 38, 67, 69, 72–74, 73, 74, 77, Hamstring muscle group 74, 74, 313, 374
183, 374 defintion 313, 398
how to interpret 80 flexibility testing 74
how to perfom 80 Happy Jack skip 343
Flexor carpi radialis muscle 15 Head bob/nod 6–11, 9, 10, 32
Flexor carpi ulnaris muscle 36, 72 Hemangiosarcoma 138, 272, 274, 276
anatomy 15 Hemarthrosis 114, 119, 122, 317
stretching 74 Hematoidin crystals 119, 122
tendinopathy 186, 187 Hepatocutaneous syndrome 162
Flexor enthesopathy. See Elbow joint/region Hip dysplasia 38, 358–366
Foraminal stenosis 266, 383 clinical presentation 359
Force plate. See Kinematic gait analysis diagnostics
Index 407
Ortolani maneuver 38, 360, 362 stretching 372

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PennHIP 364, 365 tendinopathy 371–373

examination 34–38, 35, 87, 89, 360, 361, 365 Imaging modalities 125–133, 126
radiographic appearance 363 Imaging planes. See Planes of imaging
windup mechanism 364 Immune‐mediated arthritis. See Arthritis,
Hip hike. See Pelvic tilt immune‐mediated
Hip joint/region 347–378 Incomplete ossification of the humeral condyle.
anatomy 347 See Elbow joint/region
arthrocentesis of 98, 103, 104 Incomplete ossification of the radial carpal bone.
avascular necrosis of the femoral head See Carpal joint/region
366–367, 368 Inertial measurement units 27
bone cyst 375 Infectious arthritis. See Arthritis, septic
calcification of the gluteal muscles 375 Infraspinatus muscle. See Shoulder joint/region,
common disease schematic 350 infraspinatus muscle
common disease table 348 Interosseous muscles 145, 150, 187
compression of the sciatic nerve due to hip Intertarsal luxation 288, 290, 291, 292–293
arthritis 375 Intervertebral disc disease 256, 260, 261, 380, 385
examination 34–38, 35, 360, 361, 362 degeneration 260, 261, 262, 266, 383–384, 385
fractures 353–356 herniation 53, 64, 260–262, 383–384, 385
capital physeal fracture 356 Intra‐articular anesthesia. See Diagnostic joint
radiographic appearance 354, 355, 356 anesthesia
sacral fracture 356 Ischemic neuromyopathy 262, 389
sacrocroiliac luxation‐fracture 353, 354, 355
hip dysplasia (See Hip dysplasia) j
luxation 356–358, 359 Jack Russel Tick. See Happy Jack skip
neoplasia 375, 393 Joint blocks. See Diagnostic joint anesthesia
normal radiographic anatomy 351 Joint crepitus 32, 37, 78, 292, 298, 302, 315, 354,
Ortolani maneuver 362 357, 361, 367
osteoarthritis 87, 363 Joint fluid analysis 111–123, 139, 153, 175, 215,
osteosarcoma of proximal femur 375 235, 266, 393
range of motion 73, 75 cytologic analysis 114, 115, 116
septic arthritis 214 immune‐mediated polyarthritis 118, 120
Histiocytic sarcoma 137, 138, 139, 273, 274, 342, normal appearance 116, 117
392, 393 osteoarthritis 117, 121
Horner syndrome 51, 53, 259, 264, 276 septic arthritis 119, 120
Hyperglobulinemia 137–138 synovial cell sarcoma 119, 122
Hyper‐/hypovitaminosis 166 sample allocation 111, 112
Hyperparathyroidism 166 windrowing 116, 118
Hypertrophic osteodystrophy 185, 189, 189, 341 Joint luxation
Hypertrophic osteopathy 147, 165–166, 165 carpus 181
Hypertrophic pulmonary osteoarthropathy. See elbow 210
Hypertrophic osteopathy hip 353, 356, 358–359
shoulder 235
i stifle 334
Iliopsoas muscle tarsometatarsal 292–293
anatomy 351–352 tarsus 290, 291
408 Index
Joint tap. See Arthrocentesis Long digital extensor muscle 73, 151
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Junctionopathies 58, 266, 388 anatomy 311, 313, 381

calcification 342
k extensor fossa 312
Kinematic gait analysis 15, 21–27 injury 341
definition 21 stretching 73
degrees of freedom 23 Lower motor neuron. See Nervous system, lower
equipment 16 motor neuron
forces 17–18 Lumbosacral disease/instability. See Degenerative
kinematic markers 26, 28 lumbosacral stenosis
kinematic models 25, 26 Lumbosacral plexus 45, 381, 386
kinematic variables 27 motor and sensory distribution 382
sources of error 24, 25 Lupoid onychodystrophy 161, 164
3D analysis 21–23 Lupus erythematous cells 118, 120
2D analysis 21–23, 24, 25 Luxation. See Joint luxation
Kinetic analysis 15–21 Lymphoma 138, 260, 274, 276, 342, 393
acceleration 20, 28
beat 7 m
definition 15 Magnetic resonance imaging 64, 125, 126, 130,
equipment 16 131, 234, 394
footfall patterns 8 Malunion 314
force plate 15–20, 16, 17, 18 Marie’s disease. See Hypertrophic osteopathy
habituation 27 Mast cell tumor 137–138, 271–272
normalization of body weight 29 Medial shoulder instability. See Shoulder joint/
pressure sensitive walkway 16–17, 16, 19–21, region
28–29 Meningoencephalitis 263
velocity 20, 28 Meningomyelitis 260, 263, 389
Kissing lesions 196, 209 Meniscus 311–313
meniscal ligaments 312
l meniscal tears 321
Lameness Metabolic bone diseases 166
compensatory 11 Metabolic epidermal necrosis. See Superficial
flexion tests 39 necrolytic dermatitis
grading 12 Metacarpal bones 36, 145, 149, 171, 174,
individual examination steps 35, 36 273, 397
interpretation of head movement 9, 10 luxations 154
joint compressions 39 Metacarpophalangeal arthritis. See Distal limb
multiple limbs 11 region
neurogenic 41–42, 42, 46 Metatarsal bones 35, 145, 151, 152, 273
supporting 11 luxations 154
swinging 11 Miosis 53, 259, 264
Legg‐calvé‐perthes disease. See Hip joint/region, Mononeuropathy 263, 265
avascular necrosis of the femoral head Monoparesis 41, 42, 43, 45, 50, 53, 255, 260, 262,
Limb circumference measurement. See 263, 266, 379, 381, 383, 388–389
Rehabilitation examination, limb clinical features 48, 49, 380
circumference measurement Monteggia fracture 201
Lipoma 70, 138, 274, 276, 393 Mucin clot test 97, 112, 115, 116–117
Index 409
Multiple cartilaginous exostosis 267, 273, spinal cord 274–275, 393–394

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343, 389 staging 137

Multiple epiphyseal dysplasia. See Epiphyseal stifle joint/region 342, 392
dysplasia tarsal joint/region 303, 304, 391
Multiple limb lameness. See Lameness, multiple vertebral body 394
limbs Nerve roots 42
Multiple myeloma 137–138, 276 Nerve root signature. See Lameness, neurogenic
Muscle atrophy Nervous system
disuse 37, 56, 65 anatomy 44, 45, 63
general 33, 35, 37, 49, 81, 86, 231, 238, 245, autonomic 42, 44, 85
247, 276–277, 318, 319, 323, 360–361, 370 cutaneous innervation 63
neurogenic 37, 48, 56, 388–389 dermatome 47, 259
Muscle contractures 367 functional components 44
gracilis 73, 349, 367–369, 369, 370, 374 lower motor neuron 41–47, 42, 45, 46,
infraspinatus 11, 224, 243–246, 245 50–53, 56, 58, 60–61, 260, 262–265,
quadriceps 343, 347, 349, 369, 370, 389 381, 383
Myelitis 263, 389 peripheral 42–45, 46, 47, 50, 54, 55, 64, 65,
Myelography 64, 261 263, 379, 381, 388, 391, 399
Myelopathy 260–263, 381, 383–384 sensory system 47
Myofascial examination 85–91 upper motor neuron 41–47, 42, 45, 46, 50–53,
palpation 88 56, 58, 60, 262, 383
Myofascial pain syndrome 85–88 Neuritis 265
common patterns 87 Neurofibroma 276
Myopathy 36, 58, 86, 388, 398 Neurogenic lameness. See Lameness, neurogenic
ischemic 389 Neurologic examination 41–66, 51, 87, 223,
Myotatic reflexes 56, 57, 58–59 255, 264
components 49
n cranial nerves 53
Necrolytic migratory erythema. See Superficial cutaneous sensory testing 59, 62, 63
necrolytic dermatitis hopping reaction 56
Needle arthroscopy 235 neuroanatomic localization schematic 43
Neoplasia 135–140, 271–277, 391–395 postural reactions 53, 54
biopsy 136 spinal reflexes 56, 57, 58
carpal joint/region 191, 273 toe nail wear 48
clinical approach 136 Neuron 46
clinical history 32, 135 Neuropathy 263, 264, 386
diagnostics 135 Non‐erosive polyarthritis. See Arthritis,
digits 271 immune‐mediated
disal limb region 166, 271 Normal radiographic anatomy
elbow joint/region 218, 273 carpal joint/region 174
hip joint/region 374, 393 distal limb region 149, 150, 152
joint capsule 138 elbow joint/region 199
joint fluid 122 hip joint/region 351
muscles 138 shoulder joint/region 227
peripheral nerves 276 stifle joint/region 312
shoulder joint/region 249, 273 tarsal joint/region 286
skin and subcutaneous tissues 138 Nuclear medicine. See Scintigraphy
410 Index
o Pemphigus foliaceus 160, 162

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Objective gait analysis. See Gait analysis Perineurioma 276

Oligodendroglioma 275 Peripheral nerve sheath tumors. See Neoplasia,
Onychomadesis. See Lupoid onychodystrophy peripheral nerves
Orthopedic examination 31–38, 32, 35 Peripheral nervous system. See Nervous system,
history 32–33 peripheral
palpation 33, 35, 36, 37 Peroneal nerve. See Fibular nerve
recognition of pain 34 PET/CT. See Positron emission tomography
visual examination 33 computed tomography
Ortolani maneuver 33, 37–38, 77, 360–362, 362, Phalanges 145, 149, 150–151
364, 365 Pigmented villonodular synovitis. See
Osteoarthritis. See Osteoarthritis within each Villonodular synovitis
specific joint/region Pivot shift 323, 324, 328
Osteochondromatosis. See Multiple cartilaginous Planes of imaging 129
exostosis Planes of motion 22, 23, 25
Osteochondrosis/osteochondritis dissecans. frontal 22
See specific locations (elbow, shoulder, stifle sagittal 22
joint/region), tarsus transverse 22
Osteokinematics 68, 78 Plasma cell tumor 138, 272, 276
Osteomalacia 166 Pododermatitis 161, 163
Osteopenia 165, 166 Popliteal muscle 311, 343
Osteosarcoma 135–138, 165, 190–191, 249, Positron emission tomography computed
271–276, 304, 324, 342, 374–375, 391–393 tomography 125, 126, 131, 132, 133,
distal femur 392 137, 249
distal radius 190, 273 Premature closure, distal ulnar physis 175, 179,
proximal femur 375 186, 205
proximal humerus 273, 275 Pressure sensitive walkway. See Kinematic gait
proximal tibia 392 analysis
Progressive humeral intracondylar fissure. See
p Incomplete ossification of the humeral
Pacing 7, 8, 10 condyle
interpretation of head movement with Proprioception 34, 47, 55–56
pacing 273 Pseudogout 121
Panosteitis. See Elbow joint/region
Paralysis 46, 52, 56, 264, 265, 383, 389 q
Paresis 41, 42, 52 Quadriceps muscle group 57, 73, 343, 370, 382
Paronychia 161, 164 anatomy 313
Passive range of motion 69, 75, 76 contracture 369, 370
Patellar luxation. See Stifle joint/region, patellar injury 370
luxation stretching 73
Pathologic fracture 166
Paw pad 151, 159, 162, 163 r
anatomy 14, 145, 151 Radial incisure 199, 205
hyperkeratosis 160, 162 Radial nerve 63
injury 159 anatomy 62
ulceration 160 injury 188, 265
Pelvic tilt 8 Radiculopathy 257, 263, 381
Index 411
Radiography 125, 126 fabellae 307, 312, 313

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oblique radiographs 15, 152, 286 intra‐articular tarsometatarsal sesamoid

skyline 241, 242, 299, 300 bone 285
stress radiographs 183, 290, 291, 293, 303 lateral plantar tarsometatarsal sesamoid
Ragocytes 120 bone 285
Rehabilitation examination 67–84 patella 312, 313, 329
components 68 within popliteal muscle 312, 326, 328, 336
end‐feels 69, 70, 71 proximal palmar/plantar sesamoids within
flexibility testing 73, 74, 79 interosseous muscle 145, 149, 150, 152
joint play 77 within supinator muscle 195, 199
limb circumference measurement 81, 81 Sesamoid disease 145, 146, 155–157
passive range of motion 69, 71, 75, 76 anatomy 149, 150
strength testing 81–83, 83 fractures 155
Retained cartilaginous core of the ulna. See fragmentation 156
Carpal joint/region, retained cartilaginous Shoulder joint/region 223–253
core of the ulna abduction test 232, 233
Rhabdomyosarcoma 138 abnormal ossification of the supraglenoid
Rheumatoid arthritis. See Arthritis, tubercle 250
immune‐mediated adhesive capsulitis 248, 249
RUIN. See Elbow joint/region, radioulnar anatomy 223, 228
ischemic necrosis arthrocentesis of 98, 100, 101
avulsion of the supraspinatus and infraspinatus
s tendon 250
Sacroiliac joint 351, 352, 373 biceps brachii muscle
Sacrotuberous ligament 351, 352, 373, 375 anatomy 199, 227, 228, 239
Sagittal plane. See Planes of motion displacement of tendon 250
Salter‐Harris fractures 175, 178, 200, 201, 229, MRI appearance 130
236, 288, 316, 355 palpation/stretching 74, 79–80, 238, 240
carpal joint/region 175, 177 radiographic appearanace 241, 249
classification system 178 rupture of tendon sheath 250
elbow joint/region 200 skyline view 241, 242
hip joint/region 356 tendinopathy 237
shoulder joint/region 229, 236 ultrasonographic appearance 127
stifle joint/region 314, 315, 316 caudal glenoid fragments 248, 249
Scapular luxation 250 common disease schematic 226
Scapulectomy 274 common disease table 224
Schwannoma 276 examination 34–38, 35, 230, 232, 233, 240
Sciatic nerve 57, 60, 63, 375, 381, 382, 386–388 fractures 229
Scintigraphy 126, 131, 137, 214, 217 glenoid dysplasia 236, 248
Semimembranosus muscle 313, 352, 367 infraspinatus muscle
flexibility testing 74 anatomy 228, 244
Septic arthritis. See Arthritis, septic contracture 11, 243–246, 245
Sesamoid bones examination 245
within abductor pollicis longus muscle tendon‐bursa ossification 250
174, 183 luxation 235, 236
dorsal sesamoid within common digital medial shoulder instability 231–235, 234
extensor muscle 145, 150, 151, 152 normal radiographic anatomy 227
412 Index
Shoulder joint/region (cont’d) patellar luxation 329–334, 333

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osteoarthritis 227, 249 femoral varus angle 329, 332–335, 334

osteochondrosis dissecans 246, 247, 249 grading of luxation 330, 331
osteosarcoma of proximal humerus 273, 275 range of motion 73
range of motion 73 tibial tuberosity avulsion 315, 316
stabilizers 223 tibial valgus 342
supraspinatus muscle Stretch reflexes 56
anatomy 239 Stride 20, 52
injury 242 decreased length 11
radiographic appearance 127, 241 phases 11
skyline view 241, 242 Subjective gait analysis. See Gait analysis
stretching 243 Superficial digital flexor muscle 151, 157
teres minor myopathy 250 anatomy 294
Soft tissue sarcoma 138, 271, 274, 276 injury 158
Spinal arachnoid diverticulum 263 stretching 72
Spinal cord tumors. See Neoplasia, spinal cord traumatic, injury 295
Spinal dural ossification 267 Superficial necrolytic dermatitis 160, 162
Spinal tumors. See Neoplasia, spinal cord Suppurative inflammation 120, 175
Spirocerca lupi 166 Supraspinatus muscle. See Shoulder joint/region,
Spondylosis deformans 266, 389 supraspinatus muscle
Spontaneous septic arthritis. See Arthritis, septic Suspension phase 7
Squamous cell carcinoma 166, 272, 391 Synovial cell sarcoma 122, 138, 139, 272, 273,
Stance analyzer 16, 20, 21 303, 324
Stance time. See Temporospatial variables Synovial cyst 343
Standing/static kinetic analysis. See Stance Synovial fluid analysis. See Joint fluid analysis
analyzer Synovial hemangioma 343
Stifle joint/region 307–346 Synoviocytes 116, 121
anatomy 307
arthrocentesis of 98, 102, 103 t
caudal cruciate ligament rupture 311, 336 Tarsal joint/region 281–306
common disease schematic 310 anatomy 281, 287
common disease table 308 arthrocentesis of 98, 101, 102
cranial cruciate ligament rupture (See Cranial common disease schematic 284
cruciate ligament) common disease table 282
effusion 320 cranial tibial tendon trauma 304
examination 34–38, 35, 320, 322, 324 effusion 301
excessive tibial plateau angle 326 examination 34–38, 35, 286, 289
fractures 314, 315, 316 fractures 288, 290, 291
immune‐mediated polyarthritis 307 fragmentation of the medial malleolus 304
long digital extensor tendon 341, 342 idiopathic tarsal hyperextension 302, 303
luxation/ligamentous injury 334, 336 idiopathic tarsal hyperflexion 302
neoplasia 392 ligamentous anatomy 287
normal radiographic anatomy 312 ligamentous injury 291
osteochondrosis dissecans 127, 337, 338 luxation 290, 291
patella 312, 313, 315 neoplasia 304
patellar ligament desmopathy/rupture 339, 340 normal radiographic anatomy 286
Index 413
osteochondrosis dissecans 298, 299, 301 indications 126, 250

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skyline view 300 medial shoulder 234

panosteitis 300 Ununited anconeal process. See Elbow dysplasia
pes varus 301 Upper motor neuron. See Nervous system, upper
range of motion 73 motor neuron
tarsal extensor retinaculum rupture 304
tarsometatarsal luxation 292, 293 v
Temporospatial variables 20 Velocity. See Kinematic gait analysis
Thigh circumference measurement. See Vertebral fracture and luxation 261, 263, 383
Rehabilitation examination, limb Vertebral tumors 394
circumference measurement Vertical impulse 18
Tibial nerve 63, 381, 386, 387 Villonodular synovitis 139, 274, 342, 393
Total nucleated cell counts 113, 116, 120, 121
Transverse plane. See Planes of motion w
Trochlea 128, 195, 199, 205, 209, 211, Weakness 41, 42, 55, 81–83, 86
285, 299 Wobbler syndrome. See Cervical
Tumoral calcinosis. See Calcinosis spondylomyelopathy
circumspripta
x
u X‐rays. See Radiography
Ultrasonography 126
biceps brachii 127 z
iliopsoas 373 Zinc‐responsive dermatosis 162
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Library of Congress Cataloging‐in‐Publication Data

Cover Design: Wiley

Set in 9.5/12.5pt STIX Two Text by SPi Global, Pondicherry, India

List of Contributors xix

Section 1 Lameness Diagnosis 1

1 Subjective Gait Evaluation 5

2 Objective Gait Analysis 15

2.3.3 Kinematic Models 25

2.3.4 Other Methods of Kinematic Analysis 27

3 The Orthopedic Examination 31

4 The Neurologic Examination 41

4.3.7.1 Myotatic (Stretch) Reflexes 58

4.3.7.2 Flexor (Pedal and Withdrawal) Reflexes 59

5 The Rehabilitation Examination 67

6 The Myofascial Examination 85

Part II Diagnostic Techniques 93

8 Diagnostic Joint Anesthesia 105

9 Joint Fluid Analysis and Collection Considerations 111

10 Diagnostic Imaging Techniques in Lameness Evaluation 125

11 Diagnostic Approach to Neoplastic Conditions Causing Lameness 135

Section 2 Regional Diagnosis 141

12 Distal Limb Region 145

12.6 C ­ onditions of the Digital and Paw Pads 159

12.6.1 Trauma 159

Part IV Thoracic Limb Lameness 169

13 Carpal Region 171

13.7 ­Other Diseases Affecting the Carpal Region 187

14 Elbow Region 195

14.13.2 Physical Exam 215

14.13.3 Diagnostics 216

15 Shoulder Region 223

16 Neurological Disease of the Thoracic Limb 255

17 Neoplastic Conditions of the Thoracic Limb 271

Part V Pelvic Limb Lameness 279

18 Tarsal Region 281

18.5 ­Pathology of the Common Calcanean Tendon 294

18.5.1 Traumatic Rupture 295

19 Stifle Region 307

19.10.3 Long Digital Extensor Tendon Injury 341

19.10.4 Stifle Region Neoplasia 342

20 Hip Region 347

21 Neurological Disease of the Pelvic Limb 379

22 Neoplastic Conditions of the Pelvic Limb 391

Denis J. Marcellin‐Little, DEDV, DACVS, DACVSMR Flint Animal Cancer Center

(Charter) Colorado State University

­About the Companion Website

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Subjective Gait Evaluation

Pelvic limb lameness – unilateral CCLD.

Canine Lameness, First Edition. Edited by Felix Michael Duerr.

1.3 ­Observation in Motion

Thoracic limb lameness – case examples.

1.3.2 Gait Patterns

Trotting versus pacing.

1.3.3 Head Nod and Pelvic Tilt

Left thoracic limb lameness Left pelvic limb lameness

12.6 C onditions of the Digital and Paw Pads 159

13.7 Other Diseases Affecting the Carpal Region 187

18.5 Pathology of the Common Calcanean Tendon 294

About the Companion Website

1.3 Observation in Motion

2.4 Making the Best of Your Gait Data Collection

2.5 Evaluating Gait Data

3.2 The Orthopedic Examination