The Art of the Orthopedic Exam
World Small Animal Veterinary Association World Congress Proceedings, 2015
Rico Vannini1, Dr. med. vet., DECVS
1Bessy's Kleintierklinik, Watt, Switzerland

Rico Vannini graduated 1981 from the University of Zürich. 1987 he completed his surgical residency at The Ohio State University. For nine years he was faculty surgeon and lecturer at the University of Zürich. 1994 he became Diplomate of the European College of Veterinary Surgeons. Since 1996 he is owner of Bessy's small animal clinic, one of the largest private clinics in Switzerland. He was president of AO and ESVOT. He maintains an active interest in continuing education among others being international speaker and international chairmen of the Education Commission of AOVET. His hobbies are agility, scuba diving and cooking. He is mobile cash machine for two young adults, master of 8 dogs and food provider of a cat.


A thorough orthopedic examination (OE) is the key for a successful diagnosis and treatment of a dog with lameness. Well and systematically performed, the OE should allow us to rule out non-orthopedic problems as cause of lameness, to define the source of the lameness, to get a tentative clinical diagnosis and to decide, which further diagnostic technique will be most useful to reach a final diagnosis. Imaging techniques such as radiographs, CT, MRT or arthroscopy should primarily confirm our clinical diagnosis and not be used as a general searching tool. If we use it as such, there is a risk to detect and to treat abnormal findings, which are of no clinical importance.

A good OE starts with a detailed, careful history. This should include at least onset and duration of the lameness, possible cause of lameness (trauma), any previous orthopedic problems, course of the disease, type lameness (intermittent, permanent, warm up effect, etc.), treatments and success of these.

The OE should always go through the same basic steps:

1.  Observe the animal while it is moving, standing and sitting

2.  Palpate & manipulate the dog

3.  Perform specific tests and examinations

A systematic approach helps to avoid missing important pieces of information.

1. Observe the Animal While It Is Moving, Standing and Sitting

Analyze the gait and the type of lameness. Determine which leg the dog is limping on, the type and severity of the lameness. This is often different to what the client told you. Have the dog walk, trot and gallop. Repeat if necessary on different grounds (lawn, asphalt, gravel). Look for signs of ataxia, toe dragging and other gait abnormalities. When a dog with painful joints has to go faster, it will most likely shift from walk to gallop to avoid the trot. Gallop allows shorter strides and distribution of the weight on two legs at the same time. This is less painful than a trot. Thus a dog that avoids the gallop but prefers the trot has more likely a (neuro)muscular problem causing weakness than an orthopedic disease. The trot is an energy saving gait, which is easier for these dogs than the gallop. Remember not all gait abnormalities are caused by pain. Neurological as well as muscular disorders can cause of very typical gait abnormalities.

Look always how the dog sits down and stands up. This is a great test to look for stifle problems. A dog with a painful stifle hesitates to flex its knee while sitting down and avoids full flexion. Thus it prefers to move the foot outward and to extend the stifle.

Next, evaluate the dog while it is standing. Look at the joint angulations, the loading and position of the feet and toes, look for asymmetries, abnormal swellings or atrophies. Does the dog assume a specific posture while standing? Dogs with lumbosacral pain for example often show a typical pelvic tilt with the tail pulled between the legs.

2. Palpate & Manipulate the Dog

This is best done, while the dog is standing or sitting. Use minimal restraint to keep the dog as relaxed as possible. Stand behind the dog and start palpating the back, then the rear legs. Palpate both legs simultaneously. This is the easiest way to detect subtle differences between the right and left leg.

Look for any abnormalities such as atrophies, swellings, abnormal heat, effusions, scar tissue, muscle spasms or contractions, and pain, etc. Do a deep palpation of the long bones to rule out pain. Always check the local lymph nodes.

Once the dog gets used being touched, move all the joints through a full range of motion.

I usually start with the rear legs. Gently lift up one leg and put all joints in full flexion, then gradually extend the hip. Do each manipulation on both legs, before you proceed to the next joint. Not all dogs show obvious pain if you hit the sore spot. But most will show some resistance to a painful manipulation. By comparing the two legs, subtle differences can be identified best. Not only check for pain, but also note if range of motion is normal, increased or decreased. Listen for abnormal sounds and feel for crepitus.

Partially flex the hip and hyperextend the stifle. Watch for pain response. Work your way down to the tarsus and foot. Careful palpate the toes and flexor tendons of the toes. Palpate the sesamoid bones of the metatarsus.

Check the lumbosacral and caudal lumbar area with the pelvic tilt and lordosis test.

Have the dog sit down and repeat the exam with the front legs. Do not forget to manipulate the head and neck. Try to motivate the dog to move his neck itself by offering him some treats. With this technique, subtle problems are a lot better identified than by forceful manipulations of the head, that most dog resist to begin with.

Gently lift up the paws and flex the elbow, then hyperextend the shoulder followed by hyperflexion of the shoulder. Keep the shoulder slightly flexed and hyperextend the elbow only. Flex and extend the carpus.

3. Perform Specific Examinations of Each Joint

If a joint is suspected to be painful, a more specific examination will be performed to confirm the suspicion and to find the source of pain. Deep palpation of the joint at specific points is usually helpful to test for pain, swelling or thickening. Specific tests are used to look for specific causes of pain. A classic example is the tibia compression test to check for ACL rupture. If palpation and manipulation are not helpful to localize the problem to a single joint, then all joints should systematically go through these specific examinations.

Remember: The joint most commonly causing obscure and chronic rear leg lameness in dogs is the stifle and the joint most commonly causing obscure and chronic front limb lameness is the elbow joint (most likely associated with medial coronoid disease). Thus: if a dog is lame on its front, it is the elbow causing the problems - if a dog is lame on its rear, it is the stifle causing the problems, until proven otherwise.

The most common cause of stifle pain is cruciate ligament disease. With stifle pain the sit test is positive and hyperextension of the joint is painful. With a partially or fully torn ACL, there is usually a swelling over the medial side of the stifle joint ("medial buttress"). In the very early cases of ACL tears, there is no obvious thickening yet, but the distinct groove between the medial femoral condyle and the tibia plateau is filled in and can't be palpated any more. Pressure over this area does cause a pain response. To check this joint groove it is best to elevate the tibia and put the stifle joint in a 90° flexion.

Do a tibia compression test and check the drawer movement. This can be well done in the standing dog. Always compare to the healthy side to detect subtle differences! Remember: With early partial ACL tears, drawer - and tibial compression test might still be negative!

Elbow pain is most commonly caused by medial coronoid disease. Dogs might assume a typical posture while sitting, pushing the elbows to the chest while they rotate the paws outward. To check for medial coronoid disease, flex the elbow 90 degrees and palpate the area cranio-ventrally to the medial epicondyle. Normally, there should be a distinct indentation and even firm pressure over this area is not painful. With medial coronoid disease you might feel an effusion or thickening and most of the time pain can be provoked with firm pressure. If there is no clear response, repeat the pressure, while you pronate and supinate the elbow joint in 90° flexion and then in hyperextension. These are probably the most sensitive tests to discover medial coronoid disease. In fact the clinical findings are often more sensitive than the radiographs in the early course of the disease.

Front limb lameness diagnosis can be much more challenging than in the rear leg. There are dogs with medial coronoid disease, which have no obvious clinical or radiological abnormalities! Therefore it is important to carefully evaluate all other joints to rule out other problems.

It can be difficult to distinguish shoulder from elbow problems. If a dog has a shoulder disease of clinical importance, there is usually some pain response during manipulation such as hyperextension and hyperflexion, external and internal rotation as well as abduction. Always palpate the biceps tendon. Check not only for pain, but also for swelling, nodules and irregularities.

If there is no pain on shoulder manipulation and the dog has a normal biceps tendon, it is unlikely the dog has a shoulder problem causing lameness.

References

1.  Fischer MS, Lilje KE, ed. Hunde in Bewegung. Stuttgart: Kosmos Verlag; 2011.

2.  Zink MC, VanDyke JB. Canine Sports Medicine and Rehabilitation. Wiley-Blackwell; 2013.

  

Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Rico Vannini, Dr. Med. Vet., DECVS
Bessy’s Kleintierklinik
Watt/Regensdorf, Switzerland


MAIN : Ortho/Neurology : Art of the Orthopedic Exam
Powered By VIN

Friendly Reminder to Our Colleagues: Use of VIN content is limited to personal reference by VIN members. No portion of any VIN content may be copied or distributed without the expressed written permission of VIN.

Clinicians are reminded that you are ultimately responsible for the care of your patients. Any content that concerns treatment of your cases should be deemed recommendations by colleagues for you to consider in your case management decisions. Dosages should be confirmed prior to dispensing medications unfamiliar to you. To better understand the origins and logic behind these policies, and to discuss them with your colleagues, click here.

Images posted by VIN community members and displayed via VIN should not be considered of diagnostic quality and the ultimate interpretation of the images lies with the attending clinician. Suggestions, discussions and interpretation related to posted images are only that -- suggestions and recommendations which may be based upon less than diagnostic quality information.

CONTACT US

777 W. Covell Blvd., Davis, CA 95616

vingram@vin.com

PHONE

  • Toll Free: 800-700-4636
  • From UK: 01-45-222-6154
  • From anywhere: (1)-530-756-4881
  • From Australia: 02-6145-2357
SAID=27