A case study of bicipital tenosynovitis and rehabilitation
by Alan Gardner, PgD A. Phys, MDip, DipMgmt, IAAT.
One of the most frequent shoulder conditions seen in Agility dogs is bicipital tenosynovitis which involves the biceps brachii muscle and its tendon which crosses the shoulder joint¹.
Being a canine physiotherapist and conditioning practitioner, I understand the impact that canine sports such as Agility place on the dog. That means targeted conditioning programs, regular physical check-ups and paying attention to factors such as pre-competition warm-ups and cool downs. Unfortunately, that doesn’t prevent my dogs succumbing to sports injuries. Fortunately, it does facilitate the early diagnosis, intervention and subsequent rehabilitation the canine athlete. Additionally, ‘being in good shape²’ before an injury can also help with a full recovery.
This case study is about my own dog ‘Jaidi’ a seven-year-old Border Collie. Jaidi successfully competes at the highest level (Championship grade) and this story is about the cross functional team work which has restored him back to a full and successful Agility career. Our story starts in December 2017…
Weekly ‘MOT’ and understanding that “somethings not right”
My dogs receive a weekly MOT and stretch session to both check on the physical wellbeing and to maintain their flexibility³. During one session in early December 2017, I noticed that during (right) shoulder flexion (with elbow bent) there was a lot of resistance. This stretch engages many muscles of the shoulder joint including the biceps brachii, deltoids, trapezius, rhomboids and Supraspinatus⁴.
Subsequent checks by myself confirmed this (resistance) and so it was off to our veterinary for a professional diagnosis. X-rays and palpation under sedation confirmed calcification of the biceps brachii btendon, of which surgery was probably the best option to improve the ROM and probably relive any chronic pain in the joint. I think this demonstrates the importance of regular check-ups on performance dogs and early professional diagnosis by your veterinary. In this case it has probably prevented, or at least delayed the early onset of osteoarthritis.
Interestingly Jaidi showed no obvious signs of pain at this time (i.e. no offloading from limb, limping etc) and was still jumping very well. I did record his gait analysis score on the Gait4Dog⁵ (fitfurlife⁶) at my consulting rooms at Hawksmoor hydrotherapy. The results also showed no obvious lameness, with the noticeable factor being that the right fore limb was some 6% less in both pressure (i.e. limb loading) and stance distance (distance body travels while limb is placed on the treadmill).
Surgery – Arthroscopy
The arthroscopy is designed to clean out the calcification of the biceps tendon and investigate any other potential shoulder ligament damage. The arthroscopy also revealed a partial tear in the medial glenohumeral ligament. The surgeon did explain that the prognosis for a full recovery for this procedure is very good, but I knew there would be months of rehabilitation ahead to restore Jaidi back to full competitive Agility. Figure 2 shows X-rays of both right (tendon calcification) and left shoulders.
The aims of physiotherapy post-operation are laid out in Table 1. Our initial objectives at the acute post-procedure stage were to reduce pain / swelling, aid joint mobility and encourage controlled limb usage. As well as the electrophysical agents and cryotherapy, throughout the rehabilitation we used treadmill walking, discussed later in the article. The full program that we follow can be summarized in the rehabilitation pyramid (see figure 3) and the relevant modalities used at each stage (see Table 2).
- PROM (Passive Range of Motion)
- Cryotherapy (i.e. ice packs)
- PEMF⁸ (Pulsed Magnetic Field Therapy)
PROM involves moving the limb in a controlled and pain free manner, using grade 1 movements⁹, so within his early natural range of movement during the acute stage. This technique helps alleviate pain as well as mobilization of the soft tissue, facilitating improved recovery¹⁰.
Cryotherapy and PEMF were employed to restrict blood flow to the area and therefore help in reducing swelling and pain. PEMF offers much deeper penetration into the muscle joints, whereas ice works at a relatively superficial level (so is more targeted at the surface operational wound). Typically, these were applied after PROM.
Our goals for week 2 included improving ROM and encouraging better use of the affected front limb, so our modalities for that week were:
- LASER (LLLT)
- Active forelimb targeting
The reason for using LASER during this stage were to stimulate the cells and tissue leading to an increase of antibodies, specific enzymes, ATP formation and aid lymph drainage. Collectively these optimise the healing process¹¹.
By increasing the PROM movements, we were able to go to mid-range of Jaidi’s natural range on movements, therefore further mobilizing the soft tissue.
Finally, we introduced Paw Pods placing them to his right side and encouraging Jaidi to find the pod with his right forelimb, therefore stimulating his proprioception and building foundation for the next strengthening phases¹². This phased approach is demonstrated in Figure 4.
Our goals for week 3 were to further develop his independent limb use, so our modalities for this week included:
- Inducing isometric muscle contractions
As we moved from ROM manipulations to stretching of the limb, I incorporated PEMF and massage pre-stretching to improve blood flow by vasodilation thus increasing circulation, oxygenation and removing toxins.
Stretching is an important modality and aids rehabilitation¹⁴ by:
- Further improving ROM
- Reduce tightness in tendons
- Improving flexibility by increasing the number of sarcomeres and giving sensory feedback
We also carried on with the Paw pod proprioception and introduced a phase 2 (balance) activity. This involved using a 4" x 2" plank which means that Jaidi must stand with his paws adducted, inducing isometric contractions in the shoulder stabilizers¹⁵. This is demonstrated in Figure 5, you can see the closeness of his front paws, which induces the desired muscular contractions.
At this stage we had our post operation follow up with the surgeon. He confirmed that Jaidi now had good ROM, but still advised to avoid any high-speed twisting of limb and potentially damaging the repair. Taking this into account, we continued with lead and treadmill walking and advanced our therapeutic sessions¹⁶ to phase 3 exercises which included:
- Balance (e.g. all 4 legs up on inflatables)
- Joint flexion (high cavalettis)
These avoided placing any rotational forces on the limb. Additionally, we continued with stretching, now extending to all limbs and spine, not just the right fore.
Land based Treadmill
A land-based treadmill encourages controlled even limb use and helps with ROM due to the slightly longer stride length¹⁷. Combined this meant we could carry out very controlled walking, with a systematic increase in time / speed and complement our PROM sessions.
We started at 0.4 kph for 2 mins, then 0.5 mins rest with a further 0.4 kph for 2 mins. Each day I added 0.1 kph to the speed. We continued in this way until day 15, when we dispensed with the rest phases. On day 19 we introduced some incline and decline work reaching Jaidi’s normal treadmill walking speed (3.2 kph) after 6 weeks. This progression can be seen in figure 8. After this stage we worked up to pre-operation ‘full’ sessions which included:
- 30 minutes walking with various change in speed and incline / decline
- Trotting sessions which increases the weight bearing per limb¹⁸
Return to Agility
When Jaidi had reached his preoperation treadmill protocols, we began to allow phased free running during normal walks. Again, when he had reached ‘normal’ free running sessions we re-introduced our Agility sessions. Initially we started with simple lines of low height jumps. Each week we would progress this to include turns, higher jumps before eventually allowing him to negotiate obstacles which put a lot of twisting and concussive stress on the forelimbs (i.e. weaves, see-saw and A-frame).
Jaidi started back in full competition in June 2018, some 6 months after the operation. The time off meant that it took some weeks to re-discover that ‘match fitness and sharpness’. I am pleased to say that there has been no pain or lameness and that Jaidi is again competition successfully at the highest level in Kennel Club Championship Agility shows.
A frequent shoulder condition for Agility dogs is bicipital tenosynovitis. Procedures such an arthroscopy, designed to clean out the calcification of the biceps tendon, has a good prognosis for a full recovery. Postsurgery physiotherapy to supplement this and offer the best chance for a return to competitive Agility is also recommended.
This article gave a practitioner’s real-life experience of rehabilitating and returning a dog to competition at the highest level in the UK. The protocol involved the initial use on electrophysical and thermal agents complemented with manual manipulations to help restore tissue integrity and relieve pain. These modalities were then further developed to optimise the healing process and lay the foundation for proprioception and muscle strengthening exercises. Throughout the whole rehabilitation program, a land-based treadmill was used to initially encourage limb work, improve cardio vascular properties, supplement muscle strengthening and provide feedback for the direction of the program.
Jaidi made a complete and full recovery to competitive Agility. Physiotherapy played a key part in this with initially identifying the issue before it became painful and debilitating and then after surgery to design, implement and execute a holistic rehabilitation program.
Alan Gardner PgD A. Phys, MDip, DipMgmt, IAAT. Alan is an animal physiotherapist and practices at Hawksmoor, Nuneaton. 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 can quickly demonstrate compensatory patterns. Alan also competes at Championship Agility level with his Border Collies and is sponsored by Vet Spec.
“I am delighted that Vet Spec supported my dogs for over 10 years now. As an animal physiotherapist I know how important joint supplements are. They improve the normal structure and function of the joint by providing natural pain relief, reducing the effect of degenerative and inflammatory enzymes and stimulation of synovial fluid and collagen production Vet Spec Joint Mobility is recommended for both our younger, hardworking agility dogs and to support the older dogs in retirement. Joint Mobility contains the correct balance of glucosamine, chondroitin and MSM. It is added to the dogs’ normal food at mealtimes”.
For his rehabilitation programs, Alan uses Canine Exercise Solutions to design his client Home Exercise Programs (HEPs). This is an essential clinical tool for physio and other therapists. The online program is used to create home exercises programs and informative advice for their clients. Advantages include HD videos of each exercise which are accessible on any kind of device. New exercises can be created on demand.
For more information contact Karen Goyette - email@example.com
2 https://health.usnews.com/wellness/ articles/2017-04-27/why-do-some-peoplehealfaster-from-injuries
3 Marcellin-Little, D. Levine, D. (2014) Principles and Application of Range of Motion and Stretching in Companion Animals, Veterinary Clinics of North America Small Animal Practice 10/2014; DOI:10.1016/j.cvsm.2014.09.004
4 Foster, S. Foster, A. (2009) The healthy way to stretch your dog, Dogwise publishing Wenatchee, Washington
7 Rehabilitation pyramid (from Hertel, Deneger: A rehabilitation paradigm for restoring neuromuscular control following injury. Athl Ther Today, 3:12–16; 1998)
8 Vasoconstriction setting
9 Gross Saunders, D. Walker, J.R. Levine, D. (2005) Joint mobilization, Vet Clin Small Anim 35 (2005) 1287–1316, VETERINARY CLINICS, SMALL ANIMAL PRACTICE
10 Millis, D.L, Levine, D. & Taylor, R. (2004) Canine Rehabilitation and Physical Therapy, Saunders, Missouri USA
11 Fernandes de Jesus, J. Spadacci-Morena, D. Rabelo, N. Pinfildi, C. Fukuda, T. Plapler, H (2014) Low-Level Laser Therapy on Tissue Repair of Partially Injured Achilles Tendon in Rats, Photomedicine and Laser Surgery Volume 32, Number 6, 2014 Pp. 1–6 DOI: 10.1089/pho.2013.3694
13 Vasodilation setting
14 Kaeding, C.Best, T. (2009) Tendinosis: Pathophysiology and Nonoperative Treatment, Sports Health, The Ohio State University, Columbus, Ohio, Medicine Center, 2050 Kenny Road, Suite 3100, Columbus, OH 43221 DOI: 10.1177/1941738109337778
15 www.Daisypeel.com online classroom Psos and shoulders (2016)
16 Gardner (2018) Rehabilitation and strengthening, Animal Therapy Magazine Spring 2018, https://animaltherapymedia.co.uk/restoration-of-strength-and-balance/
17 Kinematics of selected therapeutic exercises in dogs, university of Tennessee (2012)
18 The weight bearing per limb (at a walk its around 100 - 110% body weight per limb, rising to 200% at a trot, as only 2 limbs contact ground at any one time at this gait.