Diagnosing and treating forelimb conditions in dogs can be very challenging. Many dogs present with a similar history including
minimal responsive to rest and non-steroidal anti-inflammatory drugs and increased lameness following exercise and heavy activity.
It can be difficult to localize the lesion on palpation as many dogs may show increased sensitivity in the shoulder and elbow
from referred pain and compensation. To further challenge the veterinarian it is not uncommon for diagnostics such as radiology
to be within normal limits due to the soft tissue nature of these injuries (tendon, ligament, and cartilage). Fortunately,
with the availability of advanced diagnostics (arthroscopy, MRI, CT scan, ultrasound, etc) the definitive diagnosis can be
determined and an appropriate treatment plan created. Depending on the diagnosis (tendon, ligament, cartilage lesions, etc)
treatment options may include arthroscopic treatments, stem cell therapy (SCT), platelet rich plasma (PRP), rehabilitation
therapy and medical management.
Supraspinatus Tendinopathy
In humans and dogs, several degenerative disorders in the insertion of the supraspinatus tendon have been identified,
including rotator cuff tears, calcifying tendonitis or tendinosis, and tendinosis as a result of overuse. Degeneration of
the supraspinatus tendon has been suggested to be a factor in the development of rotator cuff tears in humans. Overuse injury
has been suggested as the cause of this disorder, and the role of overuse in the pathogenesis has been supported by findings
of experimental studies. Histologically, affected tendons contain discontinuous and disorganized collage fibers. Typically,
no inflammatory cells are detected. In chronic cases, a proliferative nodule develops which can cause biceps brachii tendon
displacement and pain.
Dogs commonly present with a history of a chronic unilateral weight-bearing lameness that is exacerbated with activity
and often refractory to treatments. Supraspinatus atrophy may be noted and discomfort may be elicited by direct palpation
over the tendon and during flexion of the shoulder. It is not uncommon to identify concurrent BT or medial shoulder instability
(MSI), therefore a thorough shoulder exam including biceps test and abduction angles are required.
Enhanced imaging using MRI is able to readily visualize the condition in the acute phase. Plain radiography and CT Scan
may reveal mineralization just cranial to the greater tubercle in chronic cases. Ultrasound may also a useful modality for
diagnosing this condition. Arthroscopic exploration may identify "impingement" of the biceps tendon secondary to supraspinatus
tendon swelling as well as possible MSI pathology.
Depending on the severity, treatment options may include rehabilitation therapy (manual therapy, modalities, therapeutic
exercise, etc), platelet rich plasma (PRP), and stem cell therapy. In chronic cases, it is necessary to re-initiate the inflammatory
process to stimulate the healing response.
Surgical treatment is warranted for those that do not respond to conservative medical management and rehabilitation therapy.
Surgical treatment should include arthroscopic exploration to identify and treat concurrent BT and/or MSI if noted, or resection
of abnormal tissue through an open approach. Surgery has been considered the treatment of last resort in humans with tendinosis
because of the small reported difference in treatment success between surgical intervention and conservative management.
Bicipital Tenosynovitis
Another common shoulder condition seen in active dogs is bicipital tenosynovitis (BT), which involves the biceps brachii muscle
and its tendon that crosses the shoulder joint. The biceps flexes the elbow and extends and stabilizes the shoulder joint
during standing or during the weight-bearing phase of locomotion.
Cause
The cause of injury in performance dogs appears to be related to repeated strain injury. This includes two-on/two-off contacts,
landing vertically on the forelimbs from a misjudged jump, overstretching of the muscle, quick turns, and repetitive contractions
of the muscle with the shoulder flexed and/or the elbow extended. Injury to the tendon can occur in a number of ways including
strain from overloading, degeneration, or disruption. A single less than maximum load may injure some of the fibers without
complete failure of the tendon, but the blood supply to the tendon proper is poor, leading to a longer healing time. Repetitive
strain injury may initiate actual degeneration of the tendon. As the area continues to be reinjured, the tendon may weaken
sufficiently for inflammation and/or microtears (tendinopathies) in the connective tissue in or around other tendons to form,
ultimately leading to shoulder joint instability.
Diagnosis
Performance dogs with BT commonly have difficulty with quick turning to the affected side and are reluctant to jump. Agility
dogs may also have issues performing two-on/two-off contacts and knocking bars with their forelimbs. On gait analysis, dogs
with BT often have a shortened stride and a weight-bearing lameness (subtle to severe) that becomes worse with activity.
Pain may be elicited by direct palpation over the biceps tendon. Pain and spasm may be noted when flexing the shoulder while
at the same time extending the elbow. Radiographs are of minimal assistance when the injury is in its acute phase, but may
reveal mineralization of the tendon when the condition is chronic. MRI (magnetic resonance imaging) and ultrasound may be
used to identify the condition in acute and chronic situations. Shoulder arthroscopy is recognized as superior to other diagnostic
procedures for diagnosis of bicipital tenosynovitis.
