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Armchair Vets, Need Diagnosis

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  • Armchair Vets, Need Diagnosis

    My agility Pap's sudden left leg lameness was initially thought to be soft tissue injury due to lack of evidence. Finally a PT said 'his left first rib is dislocated. See xyz on the xrays?' She manipulated it back into place, prescribed crate rest, specific exercises during rest, and exercises during his gradual return to activity over 4 weeks.

    A few hours after she popped it in, he jumped off the couch (my fault I thought he was asleep so left him laying there 2 seconds ) and started limping again. Returning to PT, Jen, on Tues.

    Jen said it is a common jumping injury "usually a faceplant, like they took a header off the couch." Different PT, M, has never heard of this.

    1. Anyone PT or chiros in Northern VA? South Paws' PT is out of the office. Vet Referral Center's M has never heard of it.

    2. Anyone heard of this? Your experience?

    3. Is a dislocated bone a dislocated bone? Or do some hurt or matter more than others. Cuz ouch! He's walking around with a dislocated bone!!
    Last edited by Bicoastal; May. 17, 2013, 11:34 AM.

  • #2
    Interesting...Ive heard of subluxated ribs in people before, but usually a T11+ rather than T1. Havent ever seen it in a dog before. I would assume if its still sore, you should probably get your dog to a vet for an assessment/pain meds. Last pap that came in after a similar front leg lameness issue ended up being a herniated disc in the neck. Its possible there are a few things going on as a subluxated rib, I wouldnt think, would cause a severe lameness. If you look at a thoracic radiograph, a T1 rib should be quite a bit behind the shoulder joint. Although, if that rib was subluxated enough to be causing a lameness...I'd probably want to be sure that it really IS that rib causing it.

    Have you had any problems manipulating the neck at all?

    Having a rib disclocate (and not break) is very rare. I wouldnt consider it a "common" jumping injury at all. And if it really has dislocated twice already,I would think there would be some major intercostal muscle damage. Not saying it isnt a subluxated rib...just rare

    I might seek a second opinion from a boarded surgeon or neurologist- just to be sure you arent dealing with a hidden neck issue.

    I'd be really interested to see the radiographs!

    Comment

    • Original Poster

      #3
      Thanks for your thoughtful reply, Squish. The radiologist said consider the neck if lameness doesn't resolve with rest & NSAID. Ortho surgeon manipulated* his neck (and everything else) in ways that make me blurt, "ok ok stop! now!" I mentioned the neck and ortho quickly shot that down.

      Timber is so wittle it is a shame rads captured a bunch of empty space below his legs instead of including spine with his legs.

      We are headed to Dr. Lesser, a doggie chiro, today. Cross yer paws for Timber.

      *I thought wrist flexion was surprisingly limited, especially left. Mentioned to primary vet who agreed. Mentioned to ortho as he is achieving full flexion of left carpus. What is limited is my ability to manipulate fully. Ortho vet is fearless! You do not want to see what he was doing to Timber's "chronic right bicipital tendon stretching." Pup's paw pads were skyward over his spine. Yuck.

      Comment


      • #4
        Yes, from a chiropractic perspective the first rib can subluxate. Tend to be very painful. Not sure if it would be noticeable on radiographs

        Comment


        • #5
          Double post

          Comment


          • #6
            Hope the chiro fixed your dog! Interested to hear the update. Dogs can be so difficult because they cant tell us exactly where it hurts. If the chiro doesnt work, has your vet mentioned an MRI of the brachial plexus/biceps? If the actual leg/shoulder is ruled out, and the neck is, and the rib issue (if not fixed with chiro), this is another common thing to cause sudden lameness. Even an ultrasound can often see strains/mineralization in the shoulder area. At least there's a few options still if the chiro doesnt pan out (hopeully it does because Im sure its the cheapest!)

            The orthopods always scare clients with manipulations...but...unfortunately its the way they have to manipulate to rule in/out things. Glad to hear the neck manipulation went well though.

            Comment

            • Original Poster

              #7
              Chiro said back. Unloading RIGHT leg. What now?

              Around the house, he is unloading the RIGHT leg. This all started May 5 with non-weight bearing on left leg. May 9, day of ortho & PT, he decided to spice things up by unloading right foreleg.

              Saw Chiro Tues who said left first rib is in. Said all problems are coming from really funked up back. After hearing history of show dog kennel environment for 7 years, exclaimed that explains it and labeled him "crate dog." My homework is to verrry lightly push down on vertebrae to increase mobility and decrease roach. Told me to stop Previcox and increase activity.

              Tried walking 20 mins. He crashed into a slow pace with a long tongue. Sudden heat? Out of shape? Or pain? Remember he's tiny so many more steps for him to cover 1 mile than a Lab.

              He trots, canters, or paces with lots of gait changes. Either the trot is funky or I've been staring at his movement so long I'm seeing things -very possible! I don't know what the heck he's doing with his legs.

              What next? Wait & see? Rads of neck, spine, right shoulder? Ultrasound?

              Comment

              • Original Poster

                #8
                Originally posted by Marshfield View Post
                Yes, from a chiropractic perspective the first rib can subluxate. Tend to be very painful. Not sure if it would be noticeable on radiographs
                Only the PT identified rads as showing L first rib different position than R first rib. The limping was acute and followed jumping off the couch, if that matters. Chiro said his rib is in because it is extremely painful if out "and these guys really scream." He didn't react. I replied, "three vets have remarked on how stoic he is. He doesn't react." I wish that prompted her to scoop him back up and have another feel but it did not. I felt rushed and not fully heard.

                Of course, some clients worship this DVM. She comes to MD once a month so I have to wait til June.

                Comment

                • Original Poster

                  #9
                  Originally posted by SquishTheBunny View Post
                  If the chiro doesnt work, has your vet mentioned an MRI of the brachial plexus/biceps?

                  The orthopods always scare clients with manipulations...
                  Ortho found, you'll have to forgive me it's been too long out of the biz and I don't have the report in front of me, 'right bicipital stretching.' In case that is the wrong term, I'll try to describe:
                  the right foreleg can be bent against the body and keep going passing beyond the ribcage* until the paw is above the spine, pads skyward. The left stops at the body, like normal. It was totally icky.

                  Funny, I've known the ortho for years. Worked there for years. The neck manipulation still scares me, maybe moreso now that I have degenerative disc disease. The right bicep thing? GROSS! Like watching a slow motion vid of a soccer player blowing their knee out.

                  If you can't picture it, try yourself. Arm at your side with palm facing behind you. Raise your straight arm to the sky, backwards like you're receiving a baton in a relay race. Doggie arms aren't supposed to do that!

                  Comment


                  • #10
                    sudden limping in hind legs in dogs is often a CCL injury, and jumping down from a height is a common cause of CCL tears. or a problem with the muscle on the inside of the thigh.
                    not a vet. well-versed in biology and human medicine and common sense. Broken ribs don't cause hind-end lameness, and there's no way a rib can "be out" unless it breaks. Look at the chicken you eat next- the ribs don't really move.

                    Comment


                    • #11
                      Wendy - I think this is a FRONT end lameness. Issues with Biceps (which OP has stated) is related to the front legs, not hind. And yes, a rib CAN subluxate without being fractured. Its not common, and is is painful. However, usually doesnt cause a significant lameness.

                      OP - I would make your next step with a neurologist. Any gait change (front or hind) that can not be diagnosed through the orthopedist, and who could potentially have a back issue should really be assessed by one. An MRI of entire spine (cervical included) may show you a chronic, or acute on chronic disc. In the cervical area, this could explain a front end lameness. In the thoracic region, it could explain overall gait change. Generally TL or lower is exhibited by hind end ataxia. Might not be the back at all, but the neurologist can at least rule out spinal pain And not to scare you at all, but early nerve sheath tumors can also cause bizarre lamenesses...but usually not shifting to both legs Assuming here that dog is negative for lymes and other tick borne issues.

                      Comment


                      • #12
                        Cant edit post - but wanted to add if they think its also really related to that biceps, have a boarded radiologist ultrasound it. We actually see a LOT of dogs with bicep issues similar to your dog. Often times on ultrasound we will see mineralization within the muscles and tendons. Current "treatments" include platelet rich plasma injections (similar to IRAP). Fairly inexpensive and just takes a few minutes to do.

                        I also know another dog who required a tendon release. She was never lame, but had a flipper like movement (sudden) in a front right leg. Once the tendon was released, she went back to normal. Her neck was also worked up, but on ultrasound and after second opinion with another surgon it was finally diagnosed.

                        Good luck!!

                        Comment

                        • Original Poster

                          #13
                          Going to see a different vet this Wed who is a friend of a friend and was recommended as having a good eye for lameness and extensive knowledge of sports. We'll see what she says.

                          Over the weekend, he yelped when I picked him up to put in car crate. That's a first. He continued to unload Right foreleg. He had an odd, rolling or shuffling to his gait on hard surface after 15 mins on the beach. Very subtle til I asked my sister: "I didn't notice til you said anything but yea he is moving kinda funny."

                          This morning, I was ready to throw money into blind xrays of every other piece of the dog. Not the wisest but the cheapest, unless rads show nothing and only deplete funds. Last I knew, MRIs were $3k. If I want to be able to fix what the MRI may show, I will have to finance it.

                          Comment


                          • #14
                            Originally posted by Bicoastal View Post
                            Going to see a different vet this Wed who is a friend of a friend and was recommended as having a good eye for lameness and extensive knowledge of sports. We'll see what she says.

                            Over the weekend, he yelped when I picked him up to put in car crate. That's a first. He continued to unload Right foreleg. He had an odd, rolling or shuffling to his gait on hard surface after 15 mins on the beach. Very subtle til I asked my sister: "I didn't notice til you said anything but yea he is moving kinda funny."

                            This morning, I was ready to throw money into blind xrays of every other piece of the dog. Not the wisest but the cheapest, unless rads show nothing and only deplete funds. Last I knew, MRIs were $3k. If I want to be able to fix what the MRI may show, I will have to finance it.
                            An MRI shouldnt be $3000 for a pap unless you want to image absolutely everything. You should be able to do brachail plexus with C-spine, and to be honest if she is small you could probably do entire lumbar spine within the same coil as well. However...always better to localize area first. Front end lameness, I would start with imaging brachial plexus and c-spine. If they can also get in thoracic spine that wouldbe ideal too. Doesnt take much more time and as long as no coil change is needed there is ususally no extra charge. We are a very expensive clinic, and charge $1750 for an MRI, (and that includes everything like general anesthetic, exam, IV fluids, meds, induction, recovery etc.) I would think you would be able to get one done at or below that price at a specialty practice. I would bet vet schools would do them around $1200.

                            I thought you had already done radiographs? If not, yes...especially shoulder/c-spine a place to start but in the majority of cases radiographs wont show you much as far as fine detail. If its a disc, radiographs will not help you will need MRI or myelogram/CT. If its soft tissue, radiographs will not help, MRI or ultrasound will. If its something fine like a shoulder OCD, CT will diagnose..maybe radiographs. Bracial plexus tumor, MRI. If its biceps injury, ultrasound or MRI. Either way, sounds like unfortunately an imaging specialist may be in the future for your pup. I would ensure your vet works closely with a boarded radiologist who can be part of the imaging.

                            Comment

                            • Original Poster

                              #15
                              Have rads of both forelegs. Rads were sent to boarded radiologist who suggested, due to lack of anything else, soft tissue. 'If it doesn't resolve with a week of rest and NSAIDs consider cervical even though there is no...' Two vets, after physical exam, also said soft tissue based on lack of reaction to manipulation.

                              I ended restriction & NSAID on 5/14 per chiro. (This all started 5/5 so received 7 days rest but not 7 consecutive days NSAID; NSAID withheld before exam.) Maybe that was wrong .

                              At the specialty practice, MRIs are referred to separate MRI-only facility. I cannot remember nor google the name! Maybe they changed their name. It is in VA; accepts CareCredit. Do many specialty practices have MRI capabilities?

                              Since he is still unloading right paw, I'm going to make sure tonight's vet sees the report about right bicipital excessive stretching.

                              Thank you for providing suggestions, even just acknowledging my concerns. I'm observant, not an anthropomorphizing hypochondriac.

                              Comment


                              • #16
                                Originally posted by Bicoastal View Post
                                Have rads of both forelegs. Rads were sent to boarded radiologist who suggested, due to lack of anything else, soft tissue. 'If it doesn't resolve with a week of rest and NSAIDs consider cervical even though there is no...' Two vets, after physical exam, also said soft tissue based on lack of reaction to manipulation.

                                I ended restriction & NSAID on 5/14 per chiro. (This all started 5/5 so received 7 days rest but not 7 consecutive days NSAID; NSAID withheld before exam.) Maybe that was wrong .

                                At the specialty practice, MRIs are referred to separate MRI-only facility. I cannot remember nor google the name! Maybe they changed their name. It is in VA; accepts CareCredit. Do many specialty practices have MRI capabilities?

                                Since he is still unloading right paw, I'm going to make sure tonight's vet sees the report about right bicipital excessive stretching.


                                Thank you for providing suggestions, even just acknowledging my concerns. I'm observant, not an anthropomorphizing hypochondriac.
                                MRI's are VERY expensive to buy, so no...not all referral practices have them. If you find a neurologist however, there is likely an MRI or outsourced MRI closeby.

                                Dont forget, an MRI MAY not show you anything. Its really important to localize the area first.

                                There's also nothing wrong with doing more rest and NSAIDs (but would recommend no chrio at this point). As long as things arent getting progressively worse, you likely arent causing any harm.

                                If you do want to diagnose, it would be great if you could find a hospital which had a rehab/sports medicine specialist, boarded radiologist, neurologist and ortho who could all put their brains together. I dont suspect you'd want to drive to Canada eh? Are you in VA?

                                At least youve noticed somethings wrong with your pup!!! Usually its easy to diagnose because people wait until they are dead lame or paralyzed before they come in!!

                                Comment

                                • Original Poster

                                  #17
                                  Cervical disc?

                                  Saw different vet last night (who also does acupuncture). She thinks it is either soft tissue or cervical disc. Said it is difficult to tell, within a soft tissue injury, if shoulder or neck. Shoulder is common in agility dogs.

                                  She noticed the very slight limp when trotted out. Phew. I'm not hallucinating! Thought limp was on left not right. I can't tell: I look down over his back. I just know he off loads or lifts up right foreleg the past ~1.5 weeks.

                                  She said he reacted to manipulation of his neck. And a neck disc could explain the shifting left to right lameness. Does not recommend MRI because symptom is so subtle that the findings would not change treatment.

                                  Her treatment recommendation is strict crate rest for 2 weeks, Pred, and a breakthrough pain med (Tramadol) as needed. Call her to re-evaluate. She gave me the choice between continuing NSAID Previcox or upping to steroid. Since it may be disc, I chose steroid.

                                  Completely opposite of chiro. Because problem is enduring, I'm following this advice. It is conservative and like Squish said, you can do no wrong with rest. Maybe the chiro (also a DVM) would have suggested the same if this length of time had lapsed -and she paid more attention to what I was saying .

                                  I'm trying not to let my anxiety project the worse case future scenarios. I'm going to take this 2 weeks at a time.

                                  Comment


                                  • #18
                                    Depending on where you are in Va, there are MRI's available in Winston-Salem/Greensboro, NC and Raleigh that may be much more cost effective.
                                    You can't fix stupid.... but you can breed it!

                                    Comment


                                    • #19
                                      Don't know if they have an MRI (and from what I've heard, they're pretty $$), but have you considered taking the little guy to VOSM? As I recall, OP, you're on the MD side of DC, right?
                                      http://vetsportsmedicine.com/index.html
                                      I see Dr. Zink and one of their rehab specialists with their dogs at agility trials all the time, so I know they "get" agility dogs.

                                      Comment


                                      • #20
                                        Rest....for your dog and yourself. As long as nothing gets dramatically worse, you are in no need to worry. Reassess in two weeks.

                                        If you are concerned after 2 weeks, an MRI can at least rule OUT (or rule in) a disc in the neck. Its very sensitive to disc disease and should give you an answer within that respect.

                                        Hope to hear some good news in 2 weeks

                                        Comment

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