Rehabilitation of Pediatric Canine Disorders - Hip Dysplasia, Elbow Dysplasia, and Angular Deformities
Pediatric canine patients present to rehabilitation with many injuries and impairments. We will focus upon the three most commonly seen issues in patients presented to rehabilitation services: Canine hip dysplasia, canine elbow dysplasias, and angular deformities of the radius and ulna. Surgical intervention may or may not be indicated for this patient group. All will present with soft tissue impairments that can be addressed through rehabilitation techniques. Here the emphasis is upon obtaining a proper, thoroughly investigated soft tissue diagnosis, using good problem solving to create and meet goals that are functional, with a focus upon safety for this immature patient group. Canine rehabilitation is the application of physiotherapeutic techniques to evaluate and treat musculoskeletal impairments in our canine patients. It incorporates the use of objective outcome measures (goniometers, girthometers, etc.), manual assessments (including palpation, joint glides, and neurological assessment), gait analysis, and special tests brought from the field of human physiotherapy. This allows the therapist to tease out the specific structure and tissue type causing the impairments. The therapist evaluates the presenting complaint, subjective information from the owner, and objective assessment carried out during the examination to create a problem list. Each item on the problem list is addressed in the plan of care.
Therapeutic plans generally involve a combination of manual therapies (joint mobilizations and soft tissue mobilizations/stretches), physical modalities (laser, therapeutic ultrasound, e-stim, shockwave), and therapeutic exercises. The modalities are generally used to prepare the tissues for the manual therapies and therapeutic exercises. Physical modalities should never be the sole therapeutic method applied to any patient. Therapeutic exercise plans are based upon the weight bearing status of the patient, with early interventions focusing upon functional weight bearing exercises, later progressing to functional strengthening exercises. All exercise plans incorporate, balance, strength, flexibility, and endurance. Exercise equipment includes physioballs (shaped as rolls, peanuts, eggs, donuts, and balls), cavaletti poles, therapy band, rocker/wobble boards, and treadmills. Exercise programs are always started within the patient’s comfort zone. This is especially important with puppies. The intensity of the exercise is gradually increased until the goals are met. Then, the exercise is changed. The key with keeping puppies engaged in the exercise program is remembering to keep each exercise fun, recognizing early signs of boredom or stress, and being ready to change the program to address each.
Physical modality parameters are chosen based upon the acuity of the injury. They are used to prepare the tissues for additional therapy and can generally be applied by trained veterinary nurses. The most commonly used physical modalities include neuromuscular electrical stimulation, laser, therapeutic ultrasound, extracorporeal shock wave therapy, and ice/compression units. Precautions for using modalities with pediatric patients involve issues with open physes. Laser and therapeutic ultrasound are both contraindicated in the physeal areas for this patient group. Puppies who have hip dysplasia, elbow dysplasia, or angular limb deformities will present with soft tissue impairments that can be addressed through rehabilitation techniques.
Puppies who present with canine hip dysplasia will have joint capsule pain, lack of gluteal muscle development, and pectineus muscle pain. Elbow dysplasia patients present with joint capsule pain and shortening, muscle atrophy, and adaptive shortening of the muscles around the joint. Puppies who have angular limb deformities involving the radius and ulna will present with of carpal range of motion, elbow incongruity with pain, and adaptive shortening of the muscles around the carpus and elbow. Puppies with hip dysplasia pain related to joint capsule and periosteal pain can be treated via manual therapies including Grade 1–2 joint mobilizations to alter nociceptor response. If the physes are closed, laser can be applied to treat pain. Lack of gluteal development can be addressed through manual therapies, stretching the hip flexors that have become shortened. Therapeutic exercises that encourage hip extension and abduction include applying peanut butter to the groin of the puppy who will then actively abduct and extend the hip to lick the peanut butter. Cavaletti poles as well as backward and sideways walking will assist with muscle strengthening. Tummy rubs can be used to encourage active hip abduction. Hip stabilizer muscles can be strengthened through use of wobble boards and blocks. Pectineus pain can be treated via manual therapies to stretch the muscle after therapeutic ultrasound to heat and soften the tissues and laser to address pain. Puppies with elbow incongruity due to elbow dysplasias may present after surgical interventions. Joint capsule pain can be addressed through Grade 1–2 joint mobilization. Laser can be used to address pain and cryotherapy can be applied after activity. Muscle atrophy is addressed through therapeutic exercises including cavaletti poles, physioball work, and training to complete ‘‘High 5s.”
Elbow stabilizers can be strengthened via block work and proprioception exercises. Adaptive shortening around the elbow is treated via Grade 2–3 joint mobilizations and passive as well as active stretches focusing upon the biceps brachii and brachialis muscles. The most common cause of angular deformity in the radius and ulna is premature closure of the distal ulnar physis. This results in the distal radius having cranial-medial convexity and secondary elbow subluxation. The age at the time of the injury and the time from injury to therapy determine the degree of deformity. Angular deformity generally occurs before 4 months of age, with premature closure occurring 3–4 weeks post injury. The gross deformity happens 2–3 weeks later.
Surgical options include CORA based procedures and proximal ulnar osteotomy. When these puppies present to rehabilitation immediately postoperatively, treatment includes cryotherapy to decreases swelling, Grade 1 joint mobilizations of the carpus and elbow as well as laser to treat pain. The soft tissue impairments associated with angular deformities include loss of carpal ROM, elbow incongruity with pain, and adaptive shortening of the muscles associated with elbow and carpus movement. Loss of carpal ROM is addressed through manual therapies: Grade 1–2 joint mobilizations and stretches, especially of the flexor carpi ulnaris and digital flexors.
Therapeutic exercises are aimed at early weight-bearing work, later moving to strength exercises. Ultrasound is used to warm muscles prior to stretching, and laser is applied to speed wound healing. Elbow incongruity with pain and adaptive shortening are treated via joint mobilizations, triceps stretches, therapeutic exercise moving from early weight-bearing to later elbow flexion work, and ultrasound and laser as above. In conclusion, the proper approach to rehabilitation therapy involves an emphasis on proper, thorough soft tissue diagnosis, an emphasis on problem solving and creating and meeting goals that are functional for our patients, and an emphasis on safety for our immature patients.