One of the greatest challenges of the orthopedic examination is confident localization of lameness. Little by little, I am coming to discover that more often than not, my patients want to tell me where it hurts, but only if they trust me. I've compiled a collection of tips for a meaningful lameness exam:
Watch Them When They Don't Know You Are Looking
I prefer to watch my patients when they are unaware that I am interested in them. As I greet my client, walk to the exam room and take a history, I watch the way my patient stands and moves. During this time the pet is quite relaxed because they haven't come to realize that they are my focus. Almost out of the corner of my eye, I pay close attention to how he shifts his weight at a stance or while sitting. Dogs will tend to subtly shift their weight away from their painful limb(s) at a stance.
Be Their Friend Before You Try to Be Their Doctor - Build Relationship First
I work to become a friend of my patients before I am their doctor. I like to get down to their level on the floor and allow them to approach me first (rather than the other way around). I learn my patient's name and use it often as I speak to him. In this way I am emulating the relationship that many of them have with their owner - their most trusted companion. A few minutes invested into the relationship with the pet will be many minutes saved later as you try to get him to communicate with you what is bothering him. The more your patient trusts you, the more accurately he will convey what is going on. Just as you are not likely to open up and tell all your concerns to a stranger, neither will your patient. Remember, it is the smell of your hand, the feel of your touch and hearing you speak his name that builds your patient's trust (not your diploma and lab coat).
Seek Your Patient's Comfort; Not Your Own
For years I would simply grab my patients, lift them to my exam table and start manipulating. It is no wonder that I had difficulty defining all but the most obvious causes of lameness. Now I consciously attempt to create an environment where my patient and I can relate to one another in a setting that is comfortable to my patient and has few things to distract either of us.
Sometimes it is more difficult initially to gain the trust of the pet-owner than that of the pet. It is amazing, however, how quickly pet owner trust can be gained by a "patient-centric" approach...when they see you get down on the floor and really meet their pet, they are usually very comfortable that their pet is in good hands. If, during the course of the exam, I sense that the owner's response to my manipulations is making the pet nervous, I will later request a second exam done by myself. In fact, there are some pets that are most comfortable being examined by only myself without the distraction of an assistant.
Floor vs. Exam Table
The majority of my patients are more comfortable on the floor than they are on an examination table. I will typically sit down on the floor as I learn their name and greet them. As I am petting them, I look for evidence that they are beginning to relax and trust me. If they are comfortable on the floor, I will gradually transition from petting to my palpation examination. As I move from sitting in front of my patient to kneeling behind or beside them, I am careful to keep at least one hand in contact with them at all times; this helps to make the transition to examination as seamless as possible. In the initial stages of the exam, I am feeling for regional muscle atrophy, joint swelling, regional warmth, etc. and this closely resembles the petting/massage stage that we started with. While most dogs seem to prefer examination on the floor, I will use an examination table if that is more comfortable to the dog.
Recumbent vs. Standing Examination
I prefer to start the examination with the patient in a symmetrical stance. In this way, I can kneel behind my patient while I use both of my hands to simultaneously palpate both front limbs, then both sides of the trunk and spine and then both pelvic limbs. For instance, by feeling both elbows at the same time, I am much more able to detect small amounts of swelling, effusion or warmth around one of the elbows that may go undetected if I were to examine each independently. As I transition from feeling for asymmetry to performing specific manipulations on each limb, I will allow the animal to lay down or remain standing - whatever seems most comfortable to him.
Encourage and Look for Your Patient's Responses
If your patient is relaxed and comfortable, you should be able to detect a response to painful stimuli. It is best to seek an examination area that is free of other distracting stimuli (phones, doors opening/closing, other pets, people moving by, etc.). The goal is to detect subtle responses so that you do not have to push your patient to extreme responses such as sharp vocalization, biting, etc. The response may be a subtle shift in weight, a change in respiratory pattern, a look in his eyes, pupil dilation, or an increase in muscle tension. Since you are looking for subtle clues that a body region is uncomfortable, it is okay (and a good idea) to repeat the maneuver to see if the detected response is repeatable (rather than a coincidence or a response to some other stimulus of which you were unaware). I will often praise a dog for telling me where it hurts even if his response was dramatic. I certainly don't want to reprimand him for giving me that feedback (protect myself - yes; reprimand his understandable behavioral response - no).
While I am an advocate of avoiding patient over-restraint, we obviously have to be protect ourselves. If the patient gives any clues that his response may put me in danger, then I need to provide enough restraint to protect myself. With anxious, dominant-behavior dogs, I can often (not always) overcome some of the challenges by asking the owner to give me the leash and allowing me to lead the pet and give commands such as heel and sit. In this way, the pet begins to understand that he is subordinate to me. At times, simply establishing that the "pecking order" in this way will put the animal at ease. Additionally, my first physical contact with the patient is in the form of praise when he responds to my commands. After the dog has begun to relax in this subordinate role, I will usually hand the leash off to an assistant who will keep just enough tension in the lead to prevent the pet from biting me as I stand behind him or towards his side. I will, once again, transition from praise and petting of his head to massage of his chest, back and abdomen. I will consciously keep at least one hand in contact with his skin at all times as I talk to him. When he is ready, I will begin to palpate down his limbs starting in the form of petting/massage and working toward an examination. With a slightly tensioned leash and an assistant keeping his focus, I can usually do a standing exam of his pelvic limbs while praising him for "being such a good boy." The standing thoracic limb examination puts me in a more vulnerable position with a potentially aggressive animal. Often, I will perform this examination from his side because I don't really want to stare into the eyes of an anxious, aggressive male Rottweiler while I examine his painful limbs! If necessary, a muzzle can be donned. Likewise, heavy sedation may become necessary in the very aggressive animal, but this interferes with my patient's ability to "tell me where it hurts."
Ways to Destroy a Meaningful Orthopedic Examination
Make quick, loud or sudden movements, noises, etc.
See the exam as a 'sterile' list of specific orthopedic tests and manipulations
Suppress your patient's response to your stimuli
Lose your focus on subtle patient responses
Look for vocalization as the only evidence of pain
Over-interpret a single patient response
Rush to sedate your patient
Rush to perform radiographs
Forget that if the maneuver you are performing on your patient would be painful to you too, a response from your patient may not be indicative of pathology.