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Non Surgical Management of Soft Tissue Injuries Megan LeFave, DVM cVMA
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Non Surgical Management of Soft Tissue Injuries
� Biomechanical Principles � Common front limb and hind limb injuries � In hospital treatments � At home treatments � When to refer patient to physiotherapist � Questions about specific cases � Other treatment modalities WestVet
physiotherapy department offers
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Experience With Rehab?
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Biomechanics � How do structures function together?
� Bone, joint, muscle, tendon, ligament, nerve � Think about origin, insertion and action � Wolff’s Law
� Tissues adapt to forces placed on them � “If you don’t use it, you loose it” � Balance between rest and early controlled
weight bearing
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Biomechanics � Immobilization
� Scar tissue/adhesions
� Cartilage atrophy � Decreased
synovial fluid production
� Changes seen in 6 days
� Compensation � Loss of range of
motion in one limb or joint leads to compensation in other structures
� This causes increase stress on other structures
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Tendon and Ligament Terminology
� Tendinopathy: Generic term that includes clinical and pathologic characteristics
� Tendinitis: implies inflammation is present � Tendinosis: degenerative condition with lack
of inflammation � Over-use injury, painful and decrease
mechanical strength � Strain: Stretching or tearing of muscles or
tendons � Sprain: Stretching or tearing of ligaments
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Tendon and Ligament Biomechanics
� Poor blood supply � Chronic use = pain but not always
inflammation � Tendons and Ligaments remodel in response
to the demands placed on them � Healing without loading leads to disorganized
and weak structure � Six weeks after surgical repair, tendons have
50% original strength � One year after repair – 80% original strength
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Muscle Biomechanics � Muscle Contraction
� Nerve signal causes a release of calcium resulting in a muscle contraction
� Denervation Injury � Leads to rapid atrophy of Type II fibers
� Fast, high intensity fibers � Immobilization
� Leads to atrophy of Type I fibers � Prolonged, low intensity fibers
� Muscle Sprain � Both fibers can be injured
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Thoracic Limb Common Soft Tissue Injuries
� Shoulder � Glenohumeral ligament � Subscapularis muscle tears � Biceps brachii muscle tear/tendinopathy � Supraspinatus muscle tears and
mineralization � Supraspinatus tendinopathy � Infraspinatus tears and bursa mineralization
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Shoulder Anatomy
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Shoulder Anatomy
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Localize The Lesion � Gait Analysis “Down on the Sound”
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Localize The Lesion � Palpation
� Muscle symmetry � Painful when muscle or tendon is palpated
� Range of Motion (ROM) � Painful when shoulder joint is flexed vs extended � Biceps stretch test
� Shoulder flexion, elbow extension � Medial Shoulder Instability
� Abduction angles � Normal: </= 35 degrees � Abnormal: >/= 50 degrees
� COMPARE TO THE NON LAME LIMB
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Medial Shoulder Instability � Rotator Cuff Injury � Glenohumeral ligaments are the primary
stabilizers in the canine shoulder joint � Subscapularis muscle attaches scapula to
the body � Causes: Repetitive stress injury, rarely
traumatic, sudden abduction with valgus at the shoulder
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Medial Shoulder Instability � Fly Ball � Weave poles
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Medial Shoulder Instability � Presentation:
� Refusing tight turns � Shortened stride � Worse after exercise � Poor response to rest and NSAIDs
� Diagnosis: � Thorough palpation of shoulder structures � Atrophy of shoulder muscles � Decreased shoulder ROM (extension) � Discomfort on abduction � Abduction angle >50
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Medial Shoulder Instability � Treatment
� Mild/moderate/severe trauma
� Expect 4-6 months of rehabilitation
� Stop the repetitive stress � Hobbles:
� Mild trauma 6-8 weeks � Moderate to severe
trauma 2-4 months
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Medial Shoulder Instability � Prevent Secondary Complications � Weeks 1-8
� PROM of all joints bilateral � Pain control
� Medications: Opioids, NSAIDs � Acupuncture, laser therapy, E stim
� Isometric Exercise: Strength training in which the joint angle and muscle length do not change during contractions � Weight shifting and lifting opposite limb � Theraband exercises – target adductors
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Medial Shoulder Instability � Months 2-4 Active Range Of Motion
� With hobbles still in place � Down to standing position � Walking over cavaletti poles � Under Water Treadmill � Stairs � Continue isometric exercises but increase
intensity � Stand on wobble board or peanut
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Medial Shoulder Instability � Months 4-6
� Recheck abduction angle � If improved then start exercises with out
hobbles
Important: Start with isometric exercises, then slowly work up to what patient was able to do with hobbles
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Tendinopathy � Biceps tendon, Supraspinatus
tendon, Infraspinatus tendon � Goals: Decrease pain and any
acute swelling, improve range of motion, prevent secondary compensation, remember Wolff’s Law.
� Medium-large breed, adult, active dogs
� Becomes chronic, intermittent lameness, worse after exercise
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Tendinopathy � Treatment: Surgical vs Non surgical
� Surgery � Biceps tendon: tenodesis, biceps release � Supraspinatus surgery: Removal of mineralized
portion, Longitudinal incisions in tendon, Tenectomy
� Usually favorable long term results � But can develop fibrous adhesions
� Rehab Therapy
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Tendinopathy � Treatment Goals � Pain and Inflammation Treatment
Modalities � Ice, laser therapy, shockwave, therapeutic
ultrasound, PRP, stem cells. � Stimulate Tissue Healing
� Laser therapy, isometric exercise, controlled weight bearing exercise
� Maintain Joint ROM and Flexibility
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Tendinopathy � Treatment Schedule � Month 0-2
� At Home 2x per day � 5 min of walking in house slow and controlled,
every 2 weeks increase by 2 minutes � PROM 10-20 � Weight shifting for 5 minutes � Ice for 10 min after exercise
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Tendinopathy � Treatment Schedule � Month 0-2
� In Clinic � Shockwave every 2-3 weeks for 2-3 treatments � PRP injection into the tendon and around the
tendon, with shockwave � Laser therapy 2x per week for 4-8 weeks in
between shock wave and PRP � E stim the muscle to encourage blood flow to
the tendon
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Tendinopathy � Treatment Schedule � Month 0-2
� In Clinic Physiotherapy � Start slow – isometric exercises
� Picking up opposite limb, Joint compression, Standing on uneven surface
� Cross friction massage � Moderate pressure perpendicular across desired
tissue � Break adhesions and realign fibers
� Passive Stretching and Joint ROM
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Isometric Exercise
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Tendinopathy � Treatment Schedule � Month 2-4
� Pain and inflammation should be resolved � Start active range of motion � Neuro muscular re education � Work on confidence
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Tendinopathy � Treatment Schedule � Months 2-4
� Under water treadmill – low intensity AROM � Swimming for 5 minutes � Walk over cavaletti poles – 2 inches off ground � Walk up 5 stairs � Down position to standing, repeat 5 times � Increase walks at home � Continue isometric exercises and stretching
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Tendinopathy � Treatment Schedule � Months 4-6
� Over next 2 months slowly increase exercise intensity and reps.
� Expect 6 months of rehab
� At 6 months can start training again, but have to start small
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Carpal Hyperextension Injury � Biomechanics of the
carpus � Flexors under tensile stress
at rest, while standing � No muscles insert on the
carpus, so stability is dependent upon the ligamentous structures
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Carpal Hyperextension Injury � Large/sporting dogs � Usually associated with a fall � Tear in palmar fibrocartilage and short
ligaments � Avulsion/chip fractures common � Diagnosis
� Palpation and radiographs � Visualize carpal hyper extension
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Carpal Hyperextension Injury � Treatment
� Mild – Support carpus and rehabilitation
� Severe – Surgical arthrodesis
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Carpal Hyperextension Injury � Rehab Therapy
� In brace only for 2-3 months � Laser therapy 2-3x per week for 2-3 months � Continue passive range of motion while in
brace � E stim of muscles to prevent atrophy � Isometric exercises
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Carpal Hyperextension Injury � Rehab Therapy 3-4 months � Add in active range of motion at the
clinic and at home with brace on � Under water treadmill � Walking over cavaletti poles � Wobble discs and wobble boards � Down to stand exercises
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Carpal Hyperextension Injury � Rehab Therapy 4-6 months
� Start doing exercise at the clinic with out brace � Slowly increase how much time with out the
brace � At 6 months goal is to be with out brace at rest
and use brace during intense exercise
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Pelvic Limb Common Soft Tissue Injuries
� Muscles at risk of injury � Cross multiple joints � Myotendinous junction (origin and insertion) � “Groin muscles”--hip flexors, adductors,
hamstrings � Iliopsoas Strain
� Partial achilles tendon rupture � Patella Luxation � Cruciate Ligament Disease
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Muscle Injuries � Diagnosis
� Palpate muscles � Put muscle in stress
position � Iliospsoas strain - hip
extension, internal rotation
� Ultrasound, CT and MRI
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Muscle Injuries � Treatment
� Rest for 3-5 days � Pain medication, NSAIDs, acupuncture, laser
therapy � Controlled re mobilization for 4-8 weeks
� 0-2 weeks PROM � 2-4 weeks AROM � 4-8 weeks increase exercises over time
� Minimize scar tissue � Laser therapy, therapeutic ultrasound, massage
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Muscle Injuries � Anatomy!!!
� Know origin, insertion and action � Do action passively to stretch the muscle
� Semimembranosis/semitendinosis trauma � Origin: Ischiatic Tuberosity � Insertion: Tibia � Action: Extend the hip � To Stretch Muscle: Flex the hip
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Partial Achilles Tendon Rupture � Made up of
– gastrocnemius – biceps femoris, semitendinosis, gracillis and superficial digital flexor tendon
� Action: Tarsal extension, stifle flexion
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Partial Achilles Tendon Rupture � Injury can occur
without trauma � Most common in
Labradors, Dobermans
� Gait: Stifle extended, hock flexed, and digits flexed
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Partial Achilles Tendon Rupture
� Treatment � Complete tears
require surgery � Conservative
management for partial tears
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Partial Achilles Tendon Rupture � Rehab Therapy
� In brace for 3-4 months � Laser therapy 2-3x per week for 3-4 months � Continue passive range of motion while in
brace � E stim of muscles to prevent atrophy � Isometric exercises
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Partial Achilles Tendon Rupture � At 4 months should be able to stand on
limb with out hyperflexion of tarsus � 4-5 months AROM with brace
� Hydrotherapy, cavaletti poles, stairs � 5-6 months start isolation exercises with
out brace and goal is at 6 months can add in AROM with out brace.
� But have pet always wear brace when active
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Patella Luxation � Medial more common than lateral � Grades I-IV; can progress from I-III � – I: IN-IN;
� – II: IN-OUT; tibial rotation <30o � – III:OUT-IN; tibial rotation 30-60o � – IV: OUT-OUT; tibial rotation 60-90o
� May be associated with limb deformity � 25-50% bilateral � Considered heritable--DO NOT BREED
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Patella Luxation � Gait evaluation
� Intermittent hopping, skipping, reluctance to jump
� If non weight bearing � Check for CCL tear � Grade luxation
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Patella Luxation � Treatment
� Depends on grade � EarlyI,II – Rehab � III,IV – Surgical
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Patella Luxation � Goals: � Decrease pain and inflammation
� Ice, Pain medication, NSAIDs, laser therapy, E stim, shockwave
� Improve strength � Isometric exercises, hydrotherapy, cavaletti
poles, stairs/ramps � Increase intensity over time
� Wobbles boards, jets during hydrotherapy, land treadmills, jumps
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Cruciate Ligament Disease � What do we know
� Most common cause of hind limb lameness and OA in dogs
� Multifactorial disease complex
� ~50% bilateral � <20% due to trauma � Individualized
approach to treatment
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Cruciate Ligament Disease � Developmental/ genetic � Immune-mediated � Metabolic—fat metabolism, nutrient
deficiency � Hormonal—early spay/neuter, thyroid
hormone, PTH � Primary CCL cell abnormalities � Joint incongruity, compensation, activity,
trauma � Genetics/ breed conformation
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Cruciate Ligament Disease � Physical Exam
� Gait evaluation - usually WB lameness, positive sit test
� Standing evaluation - hip, stifle flexion, hock extension. Joint effusion
� Palpation – Pain in extension +/- meniscal click
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Cruciate Ligament Disease � Treatment – Surgery is gold standard � But sometimes surgery is not an option
� Control pain and inflammation � Ice, pain medication, NSAIDs, laser therapy, E
stim
� Stabilize joint with brace � Try light exercise with brace
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Questions
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Other Services � Advanced lameness evaluations � Post surgical rehabilitation
� Improve pain and swelling faster, decrease compensation related complications, improve range of motion, decrease scar tissue, return to activity sooner
� Non surgical management of neurologic disorders � Weight loss programs � Pain management
� Arthritis, neoplasia, trauma/wounds � Sports medicine
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Thank You