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Orthopedic Examination

Chapter 18: Table of Contents

 Orthopedic Examination:

Gait Evaluation:

The gait is assessed by trotting the dog back and forth in an enclosed area of sufficient size. The area must be well lit and have a non-slippery floor. The area must also be of sufficient length to allow the dog to reach a slow trotting speed without being confined (>=10m). Ideally, it should be wide enough to allow examination from the sides. Hallways with multiple doors or traffic are less than ideal as they will distract the dogs during the examination.

Most dogs are examined at a slow trot or at a walk. The handler must ensure that, while trotting the dog, the leash is kept loose so that it does not restrict the dog’s movements.

The dog is examined as he moves away and toward the examiner as well as from both sides.

The dog is examined to detect the presence of a head bob, hip lift/drop, exaggerated swinging of the hips, weight redistribution, general posture etc.

Each leg is observed for abnormalities during the weight bearing phase and the swing phase: Length of the stride, stance time, amount of weight carried by the leg, toe scuffing etc.

This examination should help to determine which leg(s) are affected and to assess the severity of the lameness. Other causes of gait abnormalities such as ataxia or generalized weakness are ruled out at this stage.

Limb Evaluation:

The orthopedic examination must be complete and systematic. Developing a routine will ensure completeness and repeatability of the examination. Some people prefer to start from the distal extremity and make their way up, others work in the opposite direction. If a joint is extremely painful, it may be necessary to assess it last so that the dog does not become resentful to the examination. If a problem appears to be obvious, you may chose to examine all the other legs first to ensure that you do not overlook other significant but less obvious problems.

Neck:

Neck pain is tested by gently flexing the neck in all directions.

In the median plane: In extension the nose should point straight up toward the ceiling. In flexion, the nose should almost touch the sternum.

In the dorsal plane: The head is flexed slowly from side to side. Most dog will be able to look backward with their head almost parallel to the sagittal plane.

WARNING: This test must be performed very carefully: IF NECK PAIN IS DETECTED, it is important not to force the maneuver as it has the potential to aggravate the clinical signs and cause serious neurological injuries. Dogs with suspected vertebral fractures or tetra paretic should not have this test perform due to the potential for aggravating the injury.

If positive, this test can induce severe pain, causing the dog to bite. It is important to have a good grip of the dog’s muzzle or to muzzle the dog if you are unsure of its reaction.

Conscious Proprioception:

Conscious proprioception is assessed for all four limbs. The animal is supported with one hand and each paw in turned over to bring the dorsal surface into contact with the ground. A normal dog will almost instantly return the paw in its normal position.

WARNING: A very stressed and fearful dog may take up to a few seconds to return its paw to a normal position, however, when he does, it should only take a fraction of a second.

Extreme weakness may also complicate the interpretation of his test.

Back:

Back pain is assessed by firmly pressing on each vertebrae, from the sacrum to the base of the neck. It is important to support the dog with the other hand while doing the test as most dog will sit as soon as you apply pressure.

Lumbo-sacral pain can also be detected with the “tail jack” test. The tail is lifted until you encounter resistance. Although the angle at which the tail can be lifted will vary from dog to dog, you should be able to reach the point of resistance without causing undue pain.

Hips and Lower Back:

The hips are fully extended by gently pulling back on the thigh while the dog is standing.

In a normal dog, you should be able to extend the hips so that the leg is almost parallel to the long axis of the body. This maneuver principally tests the hip joint but, when reaching full extension, also tests for back pain, principally at the lumbosacral junction.

Note that when in full extension, both the hock and the stifle joints are also extended. If painful, these joints could also contribute to a positive test.

Shoulder:

The shoulder is fully extended by pulling forward on the elbow joint until full extension is reached. Slight pressure on the joint is maintained for a second or two while assessing the dog’s reaction. While extended, the leg may also be rotated internally and externally. Each leg is usually assessed separately and compared to each other.

Note that in full extension the elbow and the carpus joints are also extended. If painful, these joints could also contribute to a positive test.

Biceps Tendon Test:

While the dog is standing or in lateral recumbency, the shoulder is flexed and the elbow fully extended. This will result in the leg being extended backward, parallel to the long axis of the body. In this position, the biceps tendon will be under tension. Digital pressure is applied to the bicipital groove, just medial to the tip of the shoulder.

A positive test suggests a problem with the biceps tendon although severe pain from the elbow or shoulder could also result in a positive test.

Front Limbs:  Muscle Mass:

While the dog is standing square, the front limbs are palpated simultaneously to detect muscle atrophy, abnormal structures / landmarks, joint effusion…

For example: The scapula are palpated for swelling, pain, muscle atrophy… The shoulder and proximal humerus are palpated for swelling, pain, muscle atrophy, abnormal landmark position (acromion, greater tubercle…)

The elbow joints are palpated for swelling, effusion.

Important: Elbow joint effusion is best palpated while the dog is standing. While standing, contraction of the triceps will force the excess synovial fluid to pouch out laterally, just cranial to the olecranon. When the dog is lying down, muscle tension is decreased and this out pouching has a tendency to decrease and may become difficult to detect.

The radius and the ulna are palpated for swelling, pain, muscle atrophy. The carpi are palpated for swelling, effusion, asymmetry…

Carpal effusion is usually detected on the cranial aspect of the joint.

Symmetry:

While the dog is standing square, the hind limbs are palpated simultaneously to detect muscle atrophy, abnormal structures / landmarks, joint effusion, medial buttress…

For example: The pelvic area is palpated for atrophy of the gluteal muscles, location of landmarks (ilial crest, greater trochanter, ischial tuberosity), swelling, pain…

The thigh muscles are palpated and compared to the opposite side for muscle atrophy, pain, swelling…

The medial aspect of the stifle joints are palpated for thickening of the medial joint capsule (medial buttress). Stifle effusion is assessed by running the fingers cranially on either side of the patellar tendon.

The tibias are palpated for swelling, pain, presence of muscle atrophy.

The Gastrocnemius tendons are palpated for swelling, pain.

Effusion of the hock joints is assessed by palpating the joint cranially, at the level of the tibio-tarsal joint and caudally, just dorsal to the calcaneus.

Warning : If the dog is not standing square and favors one leg, the appreciation of muscle mass may become unreliable.

Recumbancy:

For the orthopedic examination, the dog will be positioned in full lateral recumbency. A skilled assistant is often required to restraint the dog while you perform the examination. A muzzle may be necessary and in some instances mild sedation may be required. It is important to note that sedation may mask significant finding and should therefore be used judiciously.

The restrain the dog in lateral recumbency, the assistant grabs the lower foreleg at the level of the distal radius. This will prevent the dog from using it to right himself up. The assistant’s forearm and elbow are used to gently, but firmly maintain the neck of the dog on the table. If necessary, the assistant can grab the lower hind leg by the tarsus to prevent the dog from using his hindleg to right himself up.

The Toes:

Each toe is palpated for pain, swelling, abnormal findings…

The nails, toe pads, interdigital skin is carefully examined and palpated. Each articulation is flexed, extended and twisted to detect pain, abnormal laxity, swelling, crepitations…

Principal disease(s): Fracture, luxations, lacerations, foreign bodies, dermatological diseases, tumours, osteomyelitis…

Digital Flexor Tendons:

The integrity of the digital flexor tendons is assessed by gently placing a finger on the palmar aspect of the metacarpus / metatarsus, just proximal to the metacarpal/tarsal footpad, and simultaneously extending the toes. The gliding of the tendon should be felt under the skin.

The sesamoids 1, 2, 7 and 8 can be palpated by pressing the metacarpo / metatarso phalangeal articulation on either side of the metacarpal/tarsal footpad.

Principal disease(s): Laceration/rupture of the digital flexors, fractured sesamoids.

Carpus and Metacarpi:

The carpus and metacarpi are examined. Effusion of the carpal joints is best detected on the cranial aspect of the joint, medial and lateral to the digital extensor tendons.

The carpus is put through a full range of motion: Flexion, extension, valgus, varus, internal and external rotation are tested and compared to the other side. The accessory carpal bone and associated tendon is palpated. Each metacarpus/metatarsus is palpated for evidence of swelling, crepitations or pain.

Warning: Hyperflexion of the carpus will induce pain, even in a normal dog. In the majority of the dogs, you should be able to flex the carpus and the toes so that the digital pads touch the plantar aspect of the forearm. This is, however, not always the case and some dogs may have a decreased flexion in the absence of significant pathology. Always check the contralateral leg.

principal disease(s): Fractures, luxation (collateral ligaments), hyperextension injuries, immune mediated arthritis…

Radius and Ulna:

The radius and the ulna are palpated along their length for evidence of swelling, pain and crepitations.

The elbow joint is fully flexed and fully extended, internally and externally rotated. Digital pressure is applied on the medial coronoid process which is located approximately 1 to 1.5 cm distal to the medial epicondyle.

Joint effusion can be detected laterally in the olecranon fossa, just cranial to the olecranon (Joint effusion of the elbow is best detected with the dog standing)

Principal disease(s) [Radius/ulna]: Fractures, primary bone tumour (distal radius), panosteitis, Hypertrophic osteodystrophy, hypertrophic osteopathy…

Principal disease(s) [Elbow]: Fragmented coronoid process, OCD, fractures, luxation, un-united anconeal process.

Humerus and Scapula:

The humerus and the scapula are palpated along their entire length for evidence of pain and swelling. The shoulder is placed through a full range of motion. The shoulder is fully flexed without moving the elbow joint. Internal and external rotation is applied while the shoulder is flexed. Extension of the shoulder is always associated with extension of the elbow joint. Once again, internal and external rotation are tested while the shoulder is extended.

Principal disease(s): OCD, primary bone tumour (proximal humerus, scapula), fractures, bicipital tenosynovitis, luxation, shoulder instability…

Hind Limb: Distal Extremity:

The distal extremity of the hind leg is examined in the same way than the forelimb. The integrity of the superficial digital flexor can be assessed by observing the movement of the Achiles Tendon while extending the toes. Effusion of the tarsus can be palpated cranially, on either side of the tibio-tarsal articulation or caudally, just dorsal and proximal to the calcaneus.

The Achiles’ tendon is palpated along its length. Flexion of the tarsus is always synchronized with flexion of the stifle joint. If it is possible to flex the tarsus without flexing the stifle, rupture of the Achiles’ mechanism should be suspected.

Principal disease(s): similar to front extremity, OCD of the tarsus, Achiles’ mechanism rupture.

Tibia:

The tibia is palpated along its length. The stifle joint is placed through a full range of motion, flexion, extension, internal and external rotation. The patellar tendon is palpated. Effusion is detected on either side of the patellar tendon. The medial aspect of the joint is palpated for a medial buttress. The position of the patella is assessed, relative to the trochlear groove. Patellar luxation is assessed by applying a medially directed force with a finger on the patella while the leg is put through a full range of motion and simultaneously internally rotated. The same maneuver is performed in the other direction for lateral patellar luxation.

Principal disease(s) [tibia]: Panosteitis, primary bone tumour (proximal tibia), fractures, HOD, HO…

Frequently encountered disease(s) [Stifle]: Cranial cruciate ligament rupture, patellar luxation, tibial tuberosity avulsion, OCD…

Cruciate Ligament:

The integrity of the cranial cruciate ligaments is assessed by performing the “tibial compression test” or the “drawer test”:

“Tibial compression test”: The leg is held in a normal weight bearing position. One hand gently grasps the distal femur, the index is placed on the tibial tuberosity. Slight pressure is applied to the tibial tuberosity by the index finger while the test is performed. The other hands grasps the metatarsi and gently forces the tarsus in flexion, placing the Gastrocnemius m. and Achiles’ tendon under tension. It is important to keep the femoro tibial angle constant during this maneuver. If the cranial cruciate ligament is ruptured, the forward movement of the tibia will be felt by the index finger. The test is repeated at different femoro-tibial angles.

“Drawer test”: The drawer test is performed by grasping the distal femur with one hand. The index finger will be placed on the patella, the thumb will be placed on the lateral fabella. The other hand grasps the proximal tibia with the index on the tibial tuberosity and the thumb on the fibular head. The lower hand is moved back and forth trying to displace the proximal tibia in a caudal to cranial direction. Attention: Internal rotation or skin motion may be falsely interpreted as positive drawer sign.

This test is also repeated at different femoro-tibial angles.

Femur:

The femur is palpated along its entire length.

Warning: Undue pressure on any muscle belly will cause pain in any dogs.

The tuber ischii, the iliac crest and the greater trochanter are palpated. An imaginary line joining these three points should form a triangle with its summit oriented downward (or the base of the triangle oriented upward)

The leg is placed through a full range of motion, flexion, extension, abduction and adduction.

The leg is also placed in abduction and slowly extended while maintaining the abduction. This maneuver will be painful in a dog with hip dysplasia.

Principal disease(s) [femur]: Fractures, primary bone tumour (distal femur), panosteitis…

Principal disease(s) [hip joint]: Hip dysplasia, hip luxation, fractures.

Ortolani Sign (Hip Dysplasia):

With the dog in lateral recumbency, the leg is positioned so that the femur is at 90 degrees to the axis of the pelvis in the sagittal plane. The leg is grasped at the stifle joint and very slightly adducted. The other hand is placed flat against the back of the dog, making sure that no pressure is applied directly to the hip joint. Upward pressure is applied to the femur (ie in the same direction as the axis of the femur) While maintaining this pressure on the femur, the leg is slowly abducted until a popping sound is herd or felt as the femoral head falls back into the acetabulum. In a normal dog, no sound would be herd or felt. A positive Ortolani sign is an indicator of hip laxity (hip dysplasia) but some dogs with hip dysplasia may not have a positive Ortolani sign.

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