Hind Limb Lameness

1
Hind Limb Lameness

• Andrew Hofeling, DVM, DACVS
• Puget Sound Veterinary Referral Center, PLLC

2
Hind Limb Lameness

• Common presenting complaint
• Multiple causes exist
• Often breed specific
• History PE
• Imperative
• Direction
• Initial rule-outs

3
Signalment History

• Breed
• Age
• Congenital vs. acquired injuries
• Qualification of lameness
• Acute vs. chronic
• Static vs. progressive
• Persistent vs. intermittent
• Exercise vs. rest
• Mild -gt non-weight bearing
• Tumor lame

4
Physical Examination

• Observe walking
• Before exam
• Repeat afterwards
• Complete examination
• Systemic health
• Forelimbs
• Joint swelling
• Asymmetry

5
Anatomy

• Pelvis
• Coxofemoral joint
• Stifle
• Tarsus
• Digits
• Spine
• Lumbosacral joint

6
Hind Limb Examination

• Both limbs simultaneously
• Swelling
• Asymmetry
• Check softly
• Atrophy
• Wounds or abrasions
• Brief Neuro exam
• Postural reflexes

7
Sound Leg

• Whats normal
• Exam
• Reaction
• Standing or lateral
• Comfort
• Start at the toes
• Consistent
• Thorough

8
Foot and Metatarsus

• Palpate each bone joint
• Nail beds
• Sesamoids
• Symmetry
• Swelling
• Instability
• Crepitus

9
Foot and Metatarsus

• Common findings
• Trauma
• Fractures or luxations
• Sesamoid injuries
• Neoplasia
• Nail beds
• Infection
• Hypertrophic osteopathy
• Degenerative
• Rheumatoid arthritis

10
Tarsus

• Swelling
• Base of calcaneous
• Dorsal joint surface
• Range of motion
• Crepitus
• Stability
• Flexion Extension
• Long and short CLL
• Achilles tendon

11
Tarsus Commonly

• Traumatic
• Luxations
• Fractures
• Sheering injuries
• OCD lesions
• Achilles tendon injuries
• HOD
• Neoplasia
• Synovial cell carcinomas
• Cross the joint
• Polyarthropathies

12
Tibia - Crus

• Symmetry
• Swelling and discomfort
• Traumatic
• Fractures
• Often open
• Panosteitis / HOD
• Osgood-Schlatters
• Neoplasia

13
Stifle

• Most commonly effected joint
• Close attention
• Effusion
• Thickening
• Instability
• Subtle findings
• Partial cruciate injuries

14
Stifle

• Effusion
• Check simultaneously
• Standing
• Patellar tendon
• Definition
• Medial joint compartment
• Thickening
• Medial buttress
• Chronic instability

15
Patella Luxation

• With complete ROM
• Internal and external rotation
• Medial and lateral
• Crepitus
• Grinding
• Alta vs. Baja
• Grades I-IV

16
Stability

• Collateral ligaments
• Usually traumatic in origin
• Uncommon injury
• During full range of motion
• Cranial cruciate ligament
• Internal rotation
• Hyper-extension
• Cranial drawer
• Caudal cruciate ligament

17
Cruciate Ligaments

• Most common injury seen
• Most common surgery performed
• TPLO vs. MRIT
• Many partial tears
• Two bands
• Craniomedial and caudolateral
• Requires assessment
• Flexion and extension

18
(No Transcript)
19
Stifle Instability

• Cranial Tibial Thrust
• Finger on tibial tubercle
• Flexion of hock
• Weight bearing
• Cranial Drawer
• Sedate if necessary

20
Stifle Problems

• Cruciate injuries
• Patellar luxations
• Also
• Meniscal tears
• OCD lesions
• Traumatic injuries
• Neoplasia
• Polyarthropathies
• Long digital extensor
• Luxations
• Avulsions

21
Femur and Thigh

• Palpate carefully
• Asymmetry
• Atrophy
• Pain / Swelling
• Commonly
• Fractures
• Neoplasia
• Panosteitis
• Muscular injuries

22
Coxofemoral Joint

• AKA Hip dysplasia
• Common cause of
• Difficulty rising
• Unwilling / unable to jump
• Stiffness
• Reluctance to go up stairs
• Uncommon cause of
• Limping
• Ambulatory lameness

23
Coxofemoral Joint

• Landmarks
• Full range of motion
• Resistance
• Discomfort
• Crepitus
• Ortolani sign
• Lateral recumbency
• Sedate if necessary

24
Coxofemoral Joint

• Commonly
• Canine Hip dysplasia
• Trauma
• Luxations
• Fractures
• Capital physeal fractures
• Frog leg view
• Legg-Calves-Perthes Dz
• Neoplasia

25
Spinal Evaluation

• Unilateral lesions
• Common presentation for lameness
• Reassess proprioception
• Spinal reflexes if indicated
• Palpate firmly for pain
• Weakness
• Rectal exam
• On all physical exams
• Pressure LS junction

26
Spinal Diseases

• IVDD
• Lumbosacral disease
• Stenosis
• Instability
• IVDD
• Neoplasia
• Fibrocartilagenous emboli
• FCE

27
Muscular Injuries

• Seeing more Athletes
• Groin Injuries
• Gracillis
• Pectineus
• Iliopsoas
• Semimembranosis
• Semitendonosis

28
Now.

• Move to problem leg
• Save painful manipulations for last
• Easier
• You
• Patient
• Owner
• Complete in entirety
• Repeat if necessary
• Exercise

29
Additional Diagnostics

• Radiographs
• Focus on problem(s)
• Contra-lateral view
• Joint taps
• Advanced imaging
• CT bony lesion
• MRI soft tissue lesions
• Ultrasound
• Muscle tendon injuries
• Neurological work-up

30
Problem Identified

• Medical vs. surgical problem
• Ideal intervention
• Repair of partial cruciate injuries
• Limit arthritis
• Surgical intervention if applicable
• In house
• Referral centers
• Appropriate aftercare and rehabilitation

31
Case-based Problems

• Most common problems
• With a few common zebras
• Focus
• Diagnosis
• Physical exam findings
• Tricks and tips
• Diagnostics needed
• When and why
• Treatment

???
32
Case 1 - Phoebe

• One year old SF Pug
• Usually happy and healthy
• Intermittent NWB hind limb lameness
• Initial differential list
• Questions we have.

33
Case 1 - Phoebe

• Initial differentials
• Legg-Calves-Perthes Disease
• Luxating patella
• RACL
• Miscellaneous trauma
• Hip dysplasia?

34
Case 1 - Phoebe

• Questions we have
• Frequency of lameness?
• Is she normal between episodes?
• Painful?
• Any prior lameness?
• History of trauma?
• Anything else?

35
Case 1 - Phoebe

• Answers
• Frequency of lameness?
• Couple times a day.. a week
• Painful?
• Not really
• Is she normal between episodes?
• Yes
• Any prior lameness or known of trauma?
• Not that we know
• Anything else?
• Kicks and looks at the leg

36
Physical Exam

• What do you think
• Exam findings
• Grade II MLP
• Stable cruciate
• Recommendations
• Surgical correction
• Check the cruciate
• Tibial tuberosity

37
Case 2 - Maddy

• 4 year old SF Labrador
• Left hind limb lameness
• Treated with NSAIDs
• Duration of lameness?
• Three weeks
• Onset?
• Acute
• Improvement?
• Yes with medications and rest

38
Case 2 - Maddy

• Initial differentials
• Acute onset, middle aged dog
• RACL
• Other traumatic injury
• Exam findings
• Minimal lameness present
• No instability detected
• Questionable effusion???
• No other findings
• Now what

39
Diagnostics

• Sedation
• Grade ½ to I CTT/CD??
• Radiographs
• Lateral stifle
• /- AP
• Findings

40
(No Transcript)
41

• Findings
• Now what??

42

• Opposite stifle
• Findings

43
(No Transcript)
44
Case 2 - Maddy

• Diagnosis
• Probable partial RACL
• Treatment options
• Medical mgt.
• Extra-capsular repair
• TPLO

45
Case 3 - Sassy

• 6 year old SF Labrador
• Left hind limb lameness
• Duration?
• Several monthsyears??
• Severity?
• Mild, improves with time
• Signs noted?
• Difficulty getting up
• Unwilling to get on bed
• Any improvement?
• Yes, warms out of it
• And NSAIDS

46
Case 3

• Exam findings
• Pain with extension of hips
• Normal stifles
• Plan
• Radiographs - hips
• Diagnosis
• Canine hip dysplasia
• Recommendations?
• Clinical signs vs. radiographs
• Medical vs. Surgical

47
Surgical Options - Preventative

• Preemptive strike
• Juvenile pubic symphysiodesis
• lt15 weeks of age
• Penn Hip evaluation
• Wont read lt 16 weeks
• Triple pelvic osteotomy
• Minimal to no arthritis present
• Crisp Ortolani signs
• Anticipating THR in future

a
r
48
Surgical Options Salvage

• Total hip replacement
• Salvage procedure
• Achieve normal or near normal function
• Cementless vs. cemented prosthetics
• FHO
• THR not an option
• Smaller patients
• Salvage procedure
• Clinical signs justify outcome

49
Case 4 - Annie

• 1 year old Pug
• Left hind limb lameness
• Duration?
• One month
• Severity?
• Moderate, progressive

50
Case 4 - Annie

• Differentials
• RACL
• MLP
• Avascular necrosis
• Exam findings
• Grade I-II MLPs
• Left thigh muscle atrophy
• Pain in left hip

51
Case 4 - Annie

• Plan?
• Hip Radiographs
• Diagnosis
• Avascular necrosis
• Capital physeal fracture
• Plan
• FHO

52
Case 5 - Lilly

• 3 year old Burnese Mt. Dog
• Unable to use hind limbs
• Down dog
• Duration?
• 12-24 hours
• Onset?
• Playing in yard and cried out
• No prior problems
• No changes noted

53
Case 5 - Lilly

• Initial Differentials
• Compressive spinal lesion
• IVDD
• Vertebral luxation / fracture
• Neoplasia
• Inflammatory (meningitis)
• FCE
• Bilateral RACL
• Plan??

54
Case 5 - Lilly

• Examination
• Bilateral RACLs
• No neurological deficits

• Plan
• TPLOs
• Bilateral vs. staged procedures
• Multiple variables

55
Case 6 - Samson

• 3 year old Burnese Mt. Dog
• Left hind limb lameness
• Acute onset after playing in yard
• Non-weight bearing
• Examination
• Normal stifles
• Marked discomfort in hip
• Alignment of hip points
• No thumb displacement
• Plan
• Pelvic radiographs

56
Case 6 Samson Spontaneous hip luxation
57
Treatment Options??

• Closed reduction
• lt 12-24 hours
• No underlying hip dysplasia
• No fractures of femoral head
• Frog leg view
• Open reduction
• Toggle pin
• Prosthetic capsule
• THR
• FHO

58
Case 7 - Hannah

• 6 year old Border Collie
• Left hind limb lameness
• Duration?
• 2-3 months
• Improves with rest, NSAIDS
• Returns with activity
• Frisbee
• Other history
• Has been to vets 4 times
• Multiple x-rays
• Arent seeing anything

59
Case 7 - Hannah

• Differentials
• Partial RACL??
• Hip dysplasia??
• Soft tissue injury??
• Spinal injury?
• Plan
• Reexamine
• Evaluate prior radiographs
• Repeat if needed
• Focus on muscular injuries

60
Case 7

• Previous radiographs
• WNL
• Exam findings
• Normal stifles
• Slight hip discomfort
• Marked reaction with iliopsoas palpation
• Diagnosis Iliopsoas strain

61
Case 7

• Confirmatory tests
• Ultrasound
• MRI
• Treatment
• Medical management

62
Medical Management

• Exercise Restriction
• Duration is injury dependant
• 6-8 weeks
• Rehabilitation
• Gradual return to activity
• 4-6 weeks

63
Non-Steroidal Medications

• Use regularly for 1-2 weeks
• Decrease current inflammation
• Break the cycle
• As needed thereafter
• Appropriate doses
• Washout periods
• Steroids or other NSAIDS

64
Case 8 Hank

• 1 year old Doberman Pinscher
• Left hind limb lameness
• Several months duration
• Previous history
• HBC / femur fx repair

65
Case 8 - Hank

• Diagnosis
• Quadriceps tie-down
• Secondary to fibrosis of quads
• No rehabilitation therapy
• Treatment
• Amputation

66
Summary

• Hind limb lameness
• Able to consistently identify problems
• Focus on
• Signalment
• History
• Complete examination
• Systemic health
• Forelimbs
• Sound leg
• Problem leg

67

• The End