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Companion animal practice
Andy Moores graduated from
Bristol in 1996, and spent five
years in small animal practice
before returning to Bristol to
complete a residency in small
animal surgery. He subsequently
spent three years as a lecturer in
small animal surgery at the Royal
Veterinary College. He is currently
head of the orthopaedic service
at Anderson Moores Veterinary
Specialists. He holds the RCVS
diploma in small animal surgery
(orthopaedics), is a diplomate of
the European College of Veterinary
Surgeons and an RCVS recognised
specialist in small animal surgery
(orthopaedics).
doi:10.1136/inp.e747
A femur using bone tunnels or suture anchors. Failure
Fig 1: (a) Idiopathic quadriceps contracture in a Labrador
puppy. (b) Radiograph showing genu recurvatum in the
same dog
74 In Practice February 2012 | Volume 34 | 7477
Muscle and tendon disorders in small
animals 2. Conditions affecting the
hindlimb and digital flexor tendons
Andy Moores
A wide range of muscle and tendon conditions are seen in small animals. An
article in the January issue of In Practice (volume 34, pages 22-26) reviewed
some general aspects of managing tendon and muscle disorders together
with conditions affecting the forelimb. This article describes conditions
affecting the hindlimb as well as digital flexor tendon injuries that affect
both the fore- and hindlimbs.
Conditions affecting the hindlimb Gracilis rupture
Gracilis rupture primarily affects racing greyhounds.
Quadriceps contracture There is haemorrhage and swelling (due to displace-
Quadriceps contracture is usually associated with ment of the muscle) on the medial aspect of the thigh.
femoral fractures, particularly if managed con- This is proximal if the distal insertion has ruptured
servatively with extension splints or surgically with or distal if the proximal origin has ruptured. Surgical
inadequate stabilisation. In these situations, the com- repair offers the best chance for a return to racing.
bination of poor limb use and exuberant callus results
in the muscle adhering or tying-down to the callus Gracilis or semitendinosus contracture
with consequent muscle atrophy and eventual fibro- Gracilis or semitendinosus contracture may affect
sis. Quadriceps contracture may also be idiopathic in adult dogs of any age and is usually seen in German
young puppies or occur secondary to Toxoplasma or shepherd dogs. The gracilis is more commonly affect-
ed. Animals with the condition show a characteristic
Neospora species infection. The condition is charac-
terised by immobility and hyperextension of the stifle gait abnormality with a shortened stride and external
(Fig 1a). In chronic cases, the stifle will ankylose and, rotation of the hock (and internal rotation of the paw
in young dogs, genu recurvatum may develop (Fig 1b). and stifle) during the swing phase. Palpation reveals a
Prognosis depends on the duration of the contracture. taut, inelastic band in the caudomedial thigh extend-
Irreversible multifocal muscle fibre necrosis may be ing from the pelvis to the stifle. The condition may
seen from as early as three weeks after limb immobili- or may not be symmetrical. Myotomy or myectomy
sation (Shires and others 1982). Acute cases associated results in an immediate improvement, but is not
with femoral fractures seen before irreversible muscle advised, as all cases present again within one to five
fibrosis and without stifle changes can be managed months of surgery due to the recurrence of fibrous tis-
successfully with surgical release of the muscle, a stifle sue in the wound (Lewis and others 1997). The aetiol-
flexion device and aggressive physiotherapy (Moores ogy is unknown.
and Sutton 2009). Chronic cases or those with deform-
ity or ankylosis of the stifle have a very poor prognosis Avulsion of the origin of the
and may require stifle arthrodesis or amputation to gastrocnemius
improve mobility. Avulsion of the origin of one (more commonly) or both
heads of the gastrocnemius results in a partially col-
lapsed hock and flexed toes due to an increase in ten-
sion on the superficial digital flexor tendon (SDFT).
The injury has been reported in dogs, but the author
has also seen it in a cat. A mediolateral radiograph will
show distal displacement of one or both fabellae (Fig2).
It should be borne in mind that the medial fabella can
be located distomedially in some dogs, especially West
Highland white terriers, and should not be confused
with traumatic displacement. The condition is treated
by reattaching the displaced tendon to the caudodistal
of the repair is a reported complication, so protecting
the repair by maintaining the hock in extension or the
B stifle in flexion for four to six weeks is advised.
 Downloaded from inpractice.bmj.com on June 29, 2012 - Published by group.bmj.com
Fig 2: Radiograph
showing distal
displacement of the
lateral fabella in a cat
indicating avulsion or
rupture of the origin of
the gastrocnemius
Avulsion of the popliteal muscle
Avulsion of the popliteal muscle is a rare cause of lame-
ness in dogs. The condition is recognised by caudo
distal displacement of the popliteal sesamoid on a
mediolateral radiograph of the stifle. Reattachment of
the popliteal tendon by suturing or screw fixation has
been described with good results.
Conditions of the long digital extensor
tendon of origin
The long digital extensor (LDE) tendon may avulse from
its origin at the extensor fossa of the lateral femoral con-
dyle. It is usually seen in large-breed dogs, such as (but
not exclusively) Great Danes, typically at five to eight
months of age. The condition causes lameness, stifle dis-
comfort and effusion. A bony fragment is avulsed with
the tendon, and this fragment may be palpable on the
craniolateral aspect of the tibial tuberosity. The fragment
is also readily apparent radiographically. Treatment is
achieved by reattaching the avulsed bone using screws
if the fragment is large enough or, alternatively, excising
the bone and suturing the tendon to neighbouring soft
tissues on the femoral condyle or proximal tibia, ensur-
ing appropriate tension in the tendon.
The LDE tendon passes through the muscular
groove of the lateral tibia, just caudal to Gerdys tuber-
cle, but may displace from this groove, causing lame-
ness. Displacement of the LDE tendon will be palpable
during flexion of the stifle. The condition can be treat-
ed by reinforcing the connective tissue restraints using
sutures or wire, which should maintain the tendon in
the groove.
Achilles tendon injuries
Type 1 lesions of the Achilles tendon are defined as
complete ruptures of the Achilles mechanism (Box 1)
(Meutstege 1993). Such cases present with complete
collapse of the hock (ie, a plantigrade stance) (Fig 3),
often following direct trauma to the Achilles mechan
ism.
Type 2 lesions result in a lengthened Achilles ten-
don, of which there are three subtypes:
Type 2a. Musculotendinous ruptures;
Type 2b. Achilles tendon ruptures with an intact
paratenon;
Type 2c. Avulsions of the tendon of insertion of the
gastrocnemius with an intact SDFT.
Type 3 lesions cause tendinopathy and are rec-
ognised by swelling of the distal part of the ten-
don of insertion of the gastrocnemius tendon, but
Companion animal practice
Box 1: Components of the Achilles
mechanism
The Achilles tendon has three distinct components:
The gastrocnemius tendon, which inserts on the
lateral aspect of the calcaneal tuberosity;
The conjoined tendon of the biceps femoris,
semitendinosus and gracilis muscles, which
inserts on the medial aspect;
The superficial digital flexor tendon, which
passes over the most caudoproximal aspect of
the calcaneus and, although it does not directly
insert on the calcaneus, its synovial sheath is
firmly anchored to the bone by medial and
lateral retinacular attachments.
without functional lengthening of the mechanism.
Ultrasonography can be useful to help identify the site
of injury if it is not apparent from palpation.
The most commonly seen lesions by the author are
chronic type 2c lesions. Affected animals present with
partial collapse of the hock and claw-like flexion of
the digits, resulting from the increase in tension on
the SDFT that partial collapse of the hock generates
(Fig4). The tendon immediately proximal to the cal-
caneus is thickened. A radiograph will show periosteal
new bone on the calcaneus, including at the retinacu-
lar attachments of the SDFT sheath (Fig5). There may
also be dystrophic mineralisation in the soft tissues
proximal to the calcaneus.
Types 1, 2a and 2b lesions are managed by primary Fig 4: Typical stance of a
repair of the muscle or tendon involved. Achilles ten- dog with a chronic type2c
dons are repaired with a three-loop pulley suture (see avulsion of the Achilles
tendon of insertion
Part 1), which is stronger and resists gap formation to
a greater extent than other suture patterns (Moores
and others 2004b). Monofilament polypropylene (size
3 to 35 metric in medium- to large-breed dogs) should
be used due to its good gliding properties, longevity
and strength. The repair should be augmented with
horizontal mattress sutures in the epitenon using 2 to 3
metric polyd ioxanone. In acute injuries, the individual
components of the Achilles mechanism should be iden-
tified and repaired individually.
Acute type 2c injuries are also managed by direct
repair using a modified three-loop pulley suture to
reattach the tendon to the calcaneus (Fig 6) (Moores
and others 2004a). Cases with chronic type 2c lesions
have extensive scar tissue between the tendon and the
calcaneal tuberosity. It is usually impossible to identify
Fig 5: Mediolateral
radiograph of the hock of a
dog with a chronic type2c
avulsion of the Achilles
tendon. Note the increase in
soft tissue opacity proximal
to the calcaneus, and the
new bone formation at the
point of insertion of the
gastrocnemius and at the
retinacular attachments of
the superficial digital flexor
tendon sheath caudally
(arrowheads)
Fig 3: Plantigrade stance in a dog with a gastrocnemius
tendon rupture
In Practice February 2012 | Volume 34 | 7477 75

Companion animal practice
1 2
5 6
Fig 6: Modified three-loop pulley suture. Reproduced with permission from Moores and
others (2004a)
A
B sitivity testing.
Fig 8: 3-D reconstructed
computed tomography scans
from a dog showing (a) new
bone at the sustentaculum
tali causing DDFT
impingement, and
(b) the unaffected
contralateral hock
(presented as a mirror image
to allow direct comparison
between sides)
76 In Practice February 2012 | Volume 34 | 7477
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3 4
7 8
or separate the individual tendons or to identify a dis-
tinct boundary between a normal and abnormal ten-
don. Some of the abnormal tissue needs to be resected
in order to shorten the Achilles mechanism and restore
function. The amount resected should eliminate slack
in the Achilles mechanism when the stifle and hock
are at standing angles. The repair is similar to that for
the acute lesion but adjusted to take into account the
larger size of the degenerate tendon. When resecting
the degenerate tendon, either a short stump of tissue
should be left attached to the calcaneus to support epi-
tenon sutures or a large bone tunnel should be par-
tially drilled at the site of insertion on the calcaneus
and the tendon pulled into this defect.
Type 3 lesions should be managed by instituting
strict rest or immobilising the hock in extension for a
short period. The prognosis in such cases is good.
Achilles tendon repairs in dogs are unable to sus-
tain weightbearing forces (Moores and others 2004b).
Placement of a calcaneotibial screw is a simple way
of maintaining extension and protecting the repair
(Fig7). A 45 mm cortical screw may be used in most
large-breed dogs, while a 20 mm screw can be used
in cats. The lateral retinacular attachment of the
SDFT sheath should be incised to allow the tendon
to be retracted medially. Large bone-holding forceps
are placed between the distal tibia and the calcaneus
to hold the hock in extension. The screw should be
placed in a positional fashion, and with the head of
the screw countersunk to reduce interference with the
overlying SDFT. The tip of the screw is left long to
allow easy removal should the screw break. After four
to six weeks, the screw should be removed and a semi-
rigid cranial splint, made out of four to six strips of
a resin casting material, should be applied and main-
tained for a further four weeks.
Displacement of the superficial digital
flexor tendon
The SDFT runs over the calcaneal tuberosity between
its lateral and medial processes. Lateral and medial
retinacular attachments either side of the SDFT anchor
the bursa of the tendon to the bone. The medial attach-
ment is smaller than the lateral one. This is likely to be
why lateral displacement of the tendon is more common
than medial displacement, although both have been
Fig 7: Radiograph
showing placement of
a calcaneotibial screw
to maintain the hock in
extension in a dog
reported (Mauterer and others 1993). The condition
has been reported in a number of breeds of dog, but
Shetland sheepdogs are consistently over-represented;
it has also been reported in a cat (McNicholas and oth-
ers 2000). In dogs, the lameness may be intermittent
or more persistent. If intermittent, it is often reported
during turning. Displacement of the tendon may be pal-
pated as the hock is flexed, particularly if the metatarsus
is rotated externally at the same time. A swelling over
the calcaneal tuberosity, representing distension of the
bursa of the tendon, is a consistent finding. Treatment
requires surgical repair of the retinacular attachments
of the bursa of the tendon with permanent suture mate-
rial. A support dressing should be maintained for four
weeks after surgery, with strict rest for a further two
weeks. The prognosis in such cases is good.
Conditions affecting the deep digital
flexor tendon
The deep digital flexor tendon (DDFT) runs caudal
to the tibia and medial to the calcaneus. Distension
of the tendon sheath, which communicates with the
tibiotarsal joint and is located caudal to the distal tibia
and cranial to the distal Achilles insertion, is readily
apparent on palpation. Tarsal osteochondritis dissecans
cartilage fragments may lodge in the tendon sheath
causing tendon sheath distension and should be surgi-
cally removed (Reinke 1998). The tendon can also be
impinged by new bone formation where it courses over
the sustentaculum tali (Fig 8). These cases may respond
to (ultrasound-guided) injection of long-acting methyl
prednisolone (Depo-Medrone-V; Pfizer) injected into
the tendon sheath. Septic tenosynovitis may be seen in
conjunction with septic arthritis of the tibiotarsal joint.
The condition is managed by lavage and four to six
weeks antibiotic treatment based on culture and sen-
Digital flexor tendon injuries
affecting both fore- and hindlimbs
The following anatomical descriptions relate to the
hindlimb but can equally be applied to the forelimb.
Digital flexor tendon injuries are usually caused by lac-
erations. The wound on the skin may be small or hidden
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Companion animal practice

Summary

In small animals, careful clinical examination of mus-

cle and tendon conditions, together with consideration
of the anatomy will generally allow the specific mus-
cle or tendon affected to be identified. Once localised,
referring to Parts 1 and 2 of this article should allow an
appropriate management strategy to be implemented.

Fig 9: Deep digital flexor tendon injury in a dog
between the digital and metatarsal pads, so diagnosis
requires careful examination. The SDFTs are at greatest
risk of injury on the plantar aspect of the metatarsus.
Each SDFT splits into two distal to the metatarso
phalangeal joint and passes around and deep to its asso-
ciated DDFT before joining up again as a single tendon.
The DDFT is therefore at greatest risk of injury distally
where it is more superficial. SDFTs insert on the plantar
tubercles of the middle phalanx, whereas DDFTs insert
on the body of the distal phalanx.
Digital flexor tendon injuries can result in pain
and lameness as well as a postural abnormality of the
affected digit(s). If both tendons are transected, the
associated digit lies flat with the claw raised (Fig 9).
If the DDFT alone is transected, the distal phalanx
and claw is hyperextended and raised off the ground.
Transection of the SDFT alone may have little effect
on posture. Wounds should be explored at the earliest
opportunity and preferably within 24 hours. The use
of a tourniquet avoids haemorrhage and ensures good
visualisation, although the pressure from the tourni-
quet could potentially hinder apposition of the tendon
ends, particularly with a tourniquet just proximal to
the hock. The tendon ends should be located, debri-
ded and anastomosed using a three-loop pulley suture.
The wound should be lavaged and closed, assuming no
ongoing contamination. Following surgery, the paw
should be bandaged in partial flexion for four weeks to
protect the repair. If left untreated, the postural defect
will persist and, as well as the poor cosmetic result,
there is a risk of chronic lameness from scar tissue and
excoriation due to altered digit posture.
References
Lewis, D. D., Shelton, G. D., Piras, A., Dee, J. F.,
Robins, G. M., Herron, A. J., Fries, C., Ginn, P.E.,
Hulse, D. A., Simpson, D. L. & Allen, D. A. (1997)
Gracilis or semitendinosus myopathy in 18 dogs. Journal of
the American Animal Hospital Association 33, 177-188
McNicholas, W. T., Jr, Wilkens, B. E. & Barstad,
R. D. (2000) Luxation of the superficial digital flexor
tendon in a cat. Journal of the American Animal Hospital
Association 36, 174-176
Mauterer, J. V., Jr, Prata, R. G., Carberry, C. A.
& Schrader, S. C. (1993) Displacement of the tendon
of the superficial digital flexor muscle in dogs: 10 cases
(1983-1991). Journal of the American Veterinary Medical
Association 203, 1162-1165
Meutstege, F. J. (1993) The classification of canine
Achilles tendon lesions. Veterinary and Comparative
Orthopaedics and Traumatology 6, 53-55
MOORES, A. (2012) Muscle and tendon disorders in small
animals 1. General management and conditions affecting
the forelimb. In Practice 34, 22-26
Moores, A. P., Comerford, E. J., Tarlton, J.F.
& Owen, M. R. (2004a) Biomechanical and clinical
evaluation of a modified 3-loop pulley suture pattern for
reattachment of canine tendons to bone. Veterinary Surgery
33, 391-397
Moores, A. P., Owen, M. R. & Tarlton, J. F. (2004b)
The three-loop pulley suture versus two locking-loop
sutures for the repair of canine achilles tendons. Veterinary
Surgery 33, 131-137
Moores, A. P. & Sutton, A. (2009) Management
of quadriceps contracture in a dog using a static flexion
apparatus and physiotherapy. Journal of Small Animal
Practice 50, 251-254
Reinke, J. (1998) Treatment of joint mice in the deep
digital flexor tendon sheath. In Current Techniques in Small
Animal Surgery, 4th edn. Eds G. W. Ellison and B.Slocum.
Williams & Wilkins. p 1260
Shires, P. K., Braund, K. G., Milton, J. L. & Liu,
W. (1982) Effect of localized trauma and temporary
splinting on immature skeletal muscle and mobility of the
femorotibial joint in the dog. American Journal of Veterinary
Research 43, 454-460

Self-assessment test: Muscle and tendon disorders in small animals

2. Conditions affecting the hindlimb and digital flexor tendons
1. W
 hich of the following is correct? 3.Which of the following is true?
a.The DDFT sheath inserts on the caudoproximal aspect of the a. The DDFT sheath communicates with the tibiotarsal joint
calcaneus b. SDFT displacement at the calcaneus is usually medial
b. The SDFT sheath communicates with the tibiotarsal joint c.Gracilis rupture is most often associated with German shepherd
c. Each DDFT splits into two distally and encircles its associated SDFT dogs
d. The DDFT inserts on the third phalanx d.Myectomy or myotomy carries a good prognosis for gracilis
contracture
2.Which of the following is false?
a. Type 1 Achilles tendon lesions present with a plantigrade stance
b.Type 2 Achilles tendon lesions present with a normal posture but
swelling at the calcaneus
c.Type 3 Achilles tendon lesions are treated by immobilisation of the
hock in extension
d.Achilles tendon repairs in dogs require protection from Answers
1. d, 2. b, 3. a
weightbearing forces postoperatively

In Practice February 2012 | Volume 34 | 7477 77

 Downloaded from inpractice.bmj.com on June 29, 2012 - Published by group.bmj.com

Muscle and tendon disorders in small

animals 2. Conditions affecting the hindlimb
and digital flexor tendons
Andy Moores

In Practice 2012 34: 74-77

doi: 10.1136/inp.e747

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