Rehabilitation and Strengthening

by Bobbie Lyons CCFT, FP-MTI, Cert CF and Alan Gardner PgD A. Phys, MDip, DipMgmt, IAAT, ASSVAP

Introduction

According to Canape (2007) “The shoulder joint is an intricate network of over 25 interlinked muscles designed to withstand large forces, provide extraordinary mobility and maintain forelimb stability and control”.

Taking these factors into account, it is not surprising that various authors report that injuries (to the shoulder) are not uncommon for performance dogs. In addition to non-specific soft tissue sprains / strains, explicit problems associated with the shoulder joint include:

  • Bicipital Tenosynovitis
  • Rhomboids / Trapezius (general tightness)
  • Medial Shoulder Instability or ‘Rotator Cuff’ strains (Infraspinatus, Supraspinatus, Teres minor, and Subscapularis)
  • Supraspinatus Tendinopathy
  • Teres Major strains

Evaluation

Following the veterinary referral diagnosing the causes for the front limb lameness a comprehensive physiotherapy based evaluation generally includes:

  1. Gait analysis, on the Gait4Dog treadmill system
  2. Palpation of the shoulder joint soft tissues
  3. ROM

GLS score is designed to show a grade for ‘off’ loading and ‘over’ loading of a limb. A perfect score is 100. Numbers below 100 can indicate a level an off-loading of a limb i.e. lameness. Numbers above 100 indicate over loading of a limb (compensation)

This multi-evaluative approach is carried out to both assess both primary and any possible compensatory / related issues. The gait analysis uses the GAITRite® software to produce a GLS score derived from factors such as stance time / distance and limb pressure / reach. Additionally, visual assessment (while on the treadmill) demonstrates the dog’s gait at the time of testing. This data provides guidance for the subsequent palpation, giving the therapist areas to concentrate on. Finally, ROM tests can confirm limitations in limb movement due to issues such as soft tissue strains and trigger points.

Common Forelimb Muscle Stress Areas

Table 1 (below) demonstrates the common stress areas associated with shoulder issues, the related muscles and their primary functions. As can be seen from this list many muscles do exhibit similar functions. This knowledge, coupled with the professional diagnosis and the physiotherapy based evaluation guides the potential treatment protocols.

 

 

Common Issues that Can Contribute to an Injury of These Muscles (Lyons, Gross)

Shoulder problems may start from a simple slip on a foreign surface such as tile, hardwood or Laminate flooring, ice, snow, new training grounds, or wet grounds.

Other things that might cause shoulder injury are:

  • Mistimed bite during bitework
  • Two on two off (stopped) contacts in agility
  • Poorly trained turn or hitting the box in Flyball
  • Performance on a “new” surface that has not been trained
  • Injury to the rear assembly (secondary or compensatory injury)
  • Folding a shoulder upon landing a jump or leaping off a high surface
  • Slipping / tripping coming down a hill or out of a natural body of water

 

The shoulder joint is an intricate network of muscles designed to withstand large forces, provide extraordinary mobility and maintain forelimb stability and control

Predisposed to a shoulder injury

  • Straight shoulder assembly
  • Previous rear assembly injury
  • Poor conditioning and strength
  • Dog’s involved in any canine sports
  • Limitations or problems in the wrist or carpal area
  • Problems with the dogs’ neck, thoracic or lower back
  • Inherent problems in their elbows, such as elbow dysplasia
  • Inherent problems in their shoulders, such as Osteochondritis dissecans

Signs of a shoulder soft tissue problem:

  • Avoidance of jumps or the down side of the A frame or problems with the long jump
  • Decreased stride length or weight bearing on the forelimb
  • Decreased movement, specifically in extension, compared to the other side
  • Diminished tracking turns to the affected shoulder
  • Head bobbing lameness when turning in to the shoulder
  • Knocking bars in agility
  • Increased head extension or an upward movement while the dog is landing
  • Lameness during movement (front or rear)
  • Lameness or stiffness upon rising from a down position (crated) for a prolonged period
  • Loss of control at the end of the teeter (seesaw)
  • Pacing while moving instead of trotting
  • Pain with palpation to the area
  • Reluctance to take turns to one side
  • Slipping on stock or avoidance of turns to one direction while working stock
  • Warmth to the shoulder complex
  • Weave pole pop outs or rejections
  • Verbalization while landing, jumping out of the car or coming down stairs

Do’s and Don’ts (Lyons, Gross)

It is important NOT to stretch an acute or ‘fresh’ muscular injury. The stretching will cause micro tears in the already injured muscle. If the dog selfstretches, that is fine, but we do not want to force the stretch. Range of motion is fine, but only to the point of no pain or discomfort.

Short leash walks will be beneficial and modified crate rest should be adhered to. Many times, strict crate rest can stiffen a soft tissue injury and it is not beneficial. But you want to make sure you can control the movements. Any movement that causes lameness should NOT be performed.

Always keep in mind – lameness equals pain and inflammation and this will continue the problem causing weakness, loss of motion and more pain and inflammation.

Experience Based Rehabilitation Protocols

The first stage in physiotherapy based rehabilitation is to reduce pain / inflammation and restore integrity of the damaged tissue. Electrotherapies are an excellent method to achieve this. With the shoulder area, we must take into consideration that (i) it is an area with a dense fur covering (ii) many muscles can exhibit similar lameness, when selecting the preferred modality.

We typically use LASER and Pulse Magnetic Field Therapy (PEMF) for treating shoulder issues for 2 primary reasons:

  • They can be used to treat large areas in single sessions
  • Canine fur* is not an issue when using animal specific equipment (particularly useful if the issue is general in nature)

Depending on the injury (acute or chronic / specific or larger area), we would use 4 – 16 j/cm3 of energy (IIIB LASER) and / or PEMF at 50 Hz Base / 5 to 17.5 Hz Pulse.

Arguably therapeutic Ultrasound and Electrostimulation (NMES) can also be successfully employed. However, these do present additional challenges for shoulder treatments in the canine patient (namely fur covering and point specificity).

Table 2 (below) outlines the advantages and disadvantages with various electrotherapies for treatment of shoulder injuries.

 

 

LASER reduces local pain and inflammation by stimulating cell mitochondrial activity, increasing production of adenosine triphosphate (ATP) / specific enzymes, growth factors, and the formation of anti-bodies. PEMF facilitates redistribution of ions across the cell membrane, thus modifying resting membrane potential and certain cellular metabolic processes. PEMF is particularly suitable for home use. Typically, for a new case, we will be applying LASER during consultation supplemented by home treatments of PEMF.

The second stage involves overcoming muscle inhibition and restoring range of movement. Massage and stretching regimes are excellent modalities for achieving this.

Massage

Given that there are well defined stress points identified for the canine forelimb which relate directly to the muscles outlined in table 1, it is practical to focus on these areas. Actual massage techniques employed will be dictated by (i) ROM evaluation (ii) Type / size of patient (iii) Practitioners preferences (iv) any active trigger points [TrPs]. This is a typical regime we might employ:

  1. Warm up the area with effleurage and wringing.
  2. Apply myofascial release using the MKW Laser comb system to the large muscles around withers and shoulder blades with the aim of relieving any adhesions.
  3. Mixture of compression, kneading and friction techniques
  4. TrP release if required
  5. Drain area

 

Massage increases blood flow and oxygen supply, aids removal of waste products and mobilizes adhesions. Stretching improves flexibility by increasing the number of sarcomeres and alters muscle sensory feedback.

Stretching improves flexibility by increasing the number of sarcomeres and alters muscle sensory feedback.

In conjunction with stretches outlined below we may apply rocking of the shoulder blade and if required an advanced stretching technique called ‘Soft Tissue Release’ or STR.

Canine stretches for the forelimb include:

  • Shoulder extension, elbow straight (targets the caudal muscles), elbow bent (triceps)
  • Shoulder flexion, elbow straight (targets the cranial muscles), elbow bent (biceps brachii)
  • Shoulder adduction (withers) and abduction (pectorals)

The authors advise that stretching (see do’s & don’ts) is continued into the strengthening and maintenance stages as it should form a part of any performance dog’s training program. Using both static stretching and active range of motion movement techniques applied to all the main muscle groups is recommended. When ROM has been restored, the patient can be moved the next stages.

Strengthening and Return to Work (Lyons/Gross)

One of the more frustrating aspects of a shoulder injury is knowing when the shoulder is getting better and when to get back to activity. Soft tissue injuries in general are very difficult to recover from in that the process may be lengthy.

Soft tissue injuries in shoulders are a bit more difficult because it is such a strong weight bearing area – especially in the performance dog. The process may take weeks to months, and it is so important to follow the steps of the entire rehabilitation process.

The steps are as follows, and are very general. The phases may vary in length depending upon the severity of the problem and the overall condition of the dog.

  • Recognize the injury
  • Reduce the pain and inflammation and begin range of motion and weight bearing exercises
  • Begin static exercises such as weight shifting, standing on uneven objects, stretching, and controlled leash walking
  • Begin dynamic exercises such as controlled trotting, light jumps, controlled stops
  • Return to activity – gradually

One of the steps to assist with the returning to activity after shoulder issues is stretching, especially shoulder extension or reach. Range of motion should be performed lightly before any activity and a static stretch is recommended after activity when the dog is properly warmed up.

Shoulder extension stretching may be performed by ‘scooping’ the dogs’ elbow from behind and moving it slowly forward. This motion is similar to performing a high five and care should be taken to move the shoulder straightforward and not out to the side (not like a chicken wing). Asking the dog to perform a “play bow” with forelimbs extended is an option that allows the dog to be in charge of the stretch. See photos below.

 

Stretching should form a part of any performance dog’s training and physical maintenance

Recommended Exercises (Lyons)

Strengthening exercises should be performed when the healing process has moved out of the acute phase and when lameness is reduced. Strengthening the scapular muscles – or the large muscles of the shoulder blade – is important to begin the base of strengthening. This area needs to be strengthened first and foremost to establish the strength for the rest of the shoulder region.

Asking the dog to place the front feet up donut with rear feet on a K9FITbone (or rear feet can be on the floor) and beginning rocking motions will encourage the facilitation or activity of the scapular muscles. It will be important to watch the elbows – when the elbows start to turn out – the dog is fatiguing and requires a rest. The dog should be given a rest and then the exercise can be started again. The goal is quality over quantity.

In the photo below, the dog is placing his front legs on the donut and we are encouraging the activity of the scapular muscles as well as the triceps muscle group. As the dogs is placing weight on the donut (in the photo above, the handler is using a nose touch “hold” to assist the dog in shifting weight forward) – he should be encouraged to rock forward and backward.

This is performed until fatigue. Fatigue will be evident when the dog either places all of their weight on the forelimbs or the elbows begin to point outwards. The dog’s elbow should point str aight backwards. When fatigue begins to occur, the elbows will start to point outward.

Tight turns

Tight turns help to activate the shoulder stabilizers while offering an active stretch through the shoulder complex, spine and rear assembly.

Weight shifting off handler movement

Two Fitpaws discs may be utilized to assist with the general core and scapular stabilizers. Placing the dog with front feet on a disc and rear feet on another disc will initiate contractions of these muscles.

Walking around the dog will encourage them to follow you with their head. When they turn their head to the right, it will shift weight to their left. As you round behind the dog it will shift weight to the rear and then back to the right as you complete the circle.

Crawling forward

Crawling forward activates the scapular muscles, lengthens through the spine while strengthening the core and trunk of the dog. Using something the dog can crawl under in continuous movement is ideal. Poles should be set so that the dog can crawl under with his sternum as close to the ground as possible. Each limb should rotate forward individually. No “frogging” out of the hind legs should be accepted.

Look for signs of fatigue such as unable to reach forward and rear leg extension. Proper movement is all four limbs rotating forward.

Backing up over poles flexes through the elbow and shoulders while increasing strength in flexion. Poles can be placed low to the ground and up to hock height. Backing up in a one step at a time or continuous is ideal. Note that many dogs will hit the poles (they do not have eyes in the back of their head!) and that is OK. This exercise should be focused on backward motion and lifting limbs over the poles.

Lateral movement must be added in a controlled manner prior to adding freedom of movement with speed in all directions.

Side stepping on the flat activates the muslces needed to stabilize (for example Infra / Supraspinatus) lateral movement, turning, and over all balance. The proper motion is to have the dogs nose above spine level with both front and rear feet reaching laterally – crossing of the limbs is ideal. It is important to move laterally in both directions.

Increase difficulty by elevating rear legs to increase weight bearing to the forelimbs. Ask the dog to step laterally to each pod while abducting and adducting the forelimbs. This will increase strength in the stabilizing muscles surrouding the shoulder complex.

Endurance activities (Lyons/Gross)

Endurance activities should be an integral part of the shoulder conditioning program. Endurance activities are considered aerobic. The American College of Sports Medicine (ACSM) defines aerobic exercise as “any activity that uses large muscle groups, can be maintained continuously, and is rhythmic in nature.” It is a type of exercise that utilizes the heart, lungs and large muscle groups in order to get them to work more efficiently at rest and at movement. The exercise helps increase oxygen consumption and helps the body work more efficiently. Ideally, the exercise should be at least twenty minutes in length and there are many options.

  • Hiking
  • Swimming
  • Underwater treadmill
  • Walking at a fast pace
  • Land treadmill designed for dogs
  • Sustained trot work by running or biking with your dog

However, we need to make special considerations with a dog with prior shoulder injury.

 

Swimming should only be pursued when the dog possesses full and pain free range of motion in the shoulder. In other words, the motion of the shoulder should be normal compared to the other shoulder and the dog should not be exhibiting any pain. While swimming is a great activity, it involves mostly flexion or bending of the joints. If the dog is already lacking extension or straightening, the continuous activity of swimming could accentuate the negative.

Bicipital tenosynovitis is a common soft tissue problem and if the area is not healed and the dog begins swimming, it can cause more problems. Part of the rehabilitation process of bicipital tenosynovitis is extension and strengthening. The continuous flexion or bending while swimming will stress the area. If full range of motion is not present, and the dog continuously works the muscle in a shortened position, it will continue the inflammatory process.

Bicipital tenosynovitis, supraspinatus and infraspinatus tendinopathy, and medial shoulder instabilities are prime examples. Continuously working in the shortened position will cause more problems. Full range of motion should be present before swimming is pursued. In the end stages, swimming will be fine, but it should be as mentioned, when the shoulder possesses full pain free motion. When swimming is pursued, the activity should be controlled as much as possible. Some dogs are ‘wild’ swimmers while others possess a sense of control. Appropriate flotation devices (dog life jacket) should be utilized but care should be taken not to inhibit or restrict shoulder motion. And of course, the dogs need to be able to swim!

Some dogs are much better swimmers than others, and some are just not meant to swim. If your dog falls into the category of just cannot do it, then skip it and find another aerobic activity. (Lyons/Gross, taken from Balance Your Blades online Class)

Summary

Strains of the shoulder complex are not uncommon in performance dogs with it being one of the leading causes of soft tissue injury in canine athletes today.

Diagnosing an injury early can mean the difference between;

  • An acute injury possibly taking less time to heal.
  • A chronic injury that develops scar tissue/lesions that impairs the healing process.

Following diagnosis by the suitable qualified professional, conservative treatment should be carried out in conjunction with an experienced rehabilitation team, particularly because these soft tissue injuries are highly susceptible to re-injury. The treatment protocol will involve rehabilitation using modalities such as LASER, PEMF, Massage, Trigger Point Release and stretching followed by strengthening exercises. All these are taken during the relevant stages of the healing process.

When the dog has returned to work, the owner should consider continuation of strengthening and stretching exercises. Finally, a concern is that handlers can be in a hurry for their dog to return to activity and do too much too fast. The rehabilitation team can guide the owner and help to avoid this.

We hope this experience based article has outlined potential protocols which practitioners and owners can use as a reference for rehabilitation and strengthening of similar injuries.

ACKNOWLEDGEMENTS

Canapp, S.O. Jr., D.V.M., M.S., Diplomate ACVS, Shoulder

Conditions in Agility Dogs, Clean Run Magazine, January 2007

AUTHORS

Bobbie Lyons CCFT, FP-MTI, Cert CF has eleven years of experience training handlers and their performance dog’s safe canine fitness practices. She obtained this knowledge by consulting with the leading veterinarians, rehabilitation specialist, and canine PT’s to ensure proper position and technique to maximize the benefits of each exercise. Bobbie has completed the FitPAWS/University of Tennessee Certified Canine Fitness Trainer Program and is a FitPAWS Master Trainer “Program Instructor”. She has also completed the Certificate Canine Fitness program through the Companion Animal Science Institute.

www.pawsitive-performance.com

bobbie@pawsitive-performance.com

Alan Gardner PgD A. Phys, MDip, DipMgmt, IAAT, ASSVAP. Alan is an animal physiotherapist and practices at Hawksmoor, Nuneaton and Dunton Veterinary Clinic in the UK. He specializes in rehabilitation of performance dogs and improving gait post-surgery. At the Hawksmoor practice, there is a GAIT4DOG gait analysis treadmill which is exceptionally good for evaluating imbalances in pressure distribution of the canine limbs.

This evaluation is invaluable when studying issues related to shoulder injuries.

VetSpec

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