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Notes
DIAGNOSING the cause of lameness or weakness in dogs is not always straightforward. Although
orthopaedic conditions are the most common cause of thoracic and pelvic limb lameness and
neurological disorders the most common cause of weakness, occasionally neurological cases may
be presented due to lameness and orthopaedic cases due to weakness. Diagnosing orthopaedic
and neurological disorders as causes of weakness and lameness, respectively, can be challenging. A
detailed history and thorough clinical examination, with emphasis on the orthopaedic and neurological
components, is essential. This article describes the orthopaedic and neurological causes of lameness,
and weakness and incoordination, and highlights the specific investigations that can be carried out
Malcolm McKee to differentiate between the two.
graduated from
Glasgow in 1983.
He is a partner LAMENESS – IS IT ORTHOPAEDIC? It is important to consider that many orthopaedic
in the Willows
Referral Service conditions such as elbow dysplasia, hip dysplasia, cra-
in Solihull, and an Lameness is a common presentation in small animal nial cruciate ligament rupture and osteoarthritis can be
RCVS specialist in
small animal surgery practice and is usually due to orthopaedic conditions subclinical and, hence, not cause lameness. Evidence of
(orthopaedics). His involving joints or bones, such as osteochondrosis, hip pain is thus a critical feature. However, diagnosis is fur-
particular interests
are complex fracture
dysplasia, cranial cruciate ligament rupture, patellar lux- ther complicated by the fact that some conditions may
management, joint ation, osteoarthritis, fractures, panosteitis and neoplasia. result in chronic lameness without a focus of pain being
replacement and
spinal surgery in
Signalment, particularly with regard to age and breed, detectable on examination. Soft tissue conditions in the
the dog. He is past and history are useful aids to diagnosis. For example, region of the shoulder (eg, glenohumeral ligament rup-
chairman of the osteochondrosis is primarily a condition of immature, ture) and fragmented coronoid process are examples of
British Veterinary
Orthopaedic large-breed dogs and there is often a history of stiffness occult causes of lameness.
Association. after rest. Conversely, primary bone tumours are over- Radiography, synovial fluid analysis, arthroscopy,
represented in middle-aged to old large- and giant-breed computed tomography (CT), ultrasonography, scintigra-
dogs and lameness is usually insidious in onset and pro- phy, fine needle aspirates and biopsy can all be used to
gressive. Some historical features are highly suggestive investigate lameness.
of an orthopaedic condition (eg, paw problems often
result in excessive licking of the area and lameness that
is exacerbated on hard surfaces).
A thorough and complete orthopaedic exami- Historical features suggestive
nation should follow a general physical examina- of spinal pain
tion (see Houlton 2006). Gait should be analysed,
■ Yelping (unprovoked or when handled)
and conformation and posture studied. All limbs
■ Reluctance to jump or climb
should be examined systematically from the digits
■ Arching of the back
to the proximal aspect of each limb. Particular atten-
■ Low head carriage
tion should be paid to muscle atrophy and contralat-
■ Reluctance to lower the head to eat from the floor
eral limbs should be compared, bearing in mind that
■ Reluctance to look upwards
conditions may be bilateral. Individual bones should
■ Reluctance to turn in tight circles
be carefully palpated for evidence of pain, thicken-
■ Tense neck, back and/or abdomen
ing and deformity. All joints should be evaluated
■ Restlessness
In Practice (2007)
for pain, range of motion, thickening, crepitus and
■ Panting
29, 434-444 instability.
A B
Lateral (A), ventrodorsal (B), right lateroventral–left laterodorsal oblique (C) and left lateroventral–right laterodorsal
oblique (D) cisternal myelograms from a 7·5-year-old cocker spaniel with neck pain and left thoracic limb lameness,
showing no evidence of extradural spinal cord compression. Note the mineralised material within the C6-C7 intervertebral
disc and the left C6-C7 intervertebral foramen (arrow). The latter is extruded nuclear disc material that is compressing the
regional (C7) spinal nerve and causing the clinical signs
C D
Sagittal (left) and transverse (right) magnetic resonance images from a 10-year-old German shepherd dog with neck
pain and left thoracic limb lameness showing degeneration of the C5-C6 intervertebral disc and left ventrolateral spinal
cord compression (arrow). The latter is caused by extruded disc material that has migrated caudally from C5-C6. It is
compressing the ipsilateral spinal nerve
Degenerative disc disease intervertebral disc space narrowing. When the nucleus
Intervertebral discs that undergo degenerative chondroid pulposus is mineralised, extruded material may be vis-
or fibroid metaplasia may cause clinical signs in one of ible overlying the vertebral canal on a lateral view.
two ways: extrusion of the nucleus pulposus or protru- Oblique views may reveal mineralised disc material
sion of the annulus fibrosus. These are referred to as within the intervertebral foramen. Myelographic contrast
Hansen type I and II lesions, respectively. With annular studies may show extradural spinal cord compression.
protrusions there may be concomitant vertebral deformi- Oblique views may be necessary to detect ventrolateral
ty (eg, cervical spondylopathy-associated disc protrusion extrusions. Myelography is insensitive for diagnosing
or so-called wobbler syndrome). foraminal extrusions since the subarachnoid space is not
compressed. Magnetic resonance imaging (MRI) is the
CERVICAL DISC EXTRUSION preferred diagnostic test in these cases.
The nucleus pulposus may extrude dorsolaterally through
the annulus fibrosus and occupy the ventrolateral ver- CERVICAL DISC PROTRUSION
tebral canal or intervertebral foramen. Compression of The annulus fibrosus may protrude dorsolaterally into
the regional spinal nerve can result in pain and thoracic the vertebral canal and compress the regional spinal
limb lameness. Spaniels, terriers and chondrodystrophoid nerve, which may result in chronic thoracic limb lame-
breeds are most often affected. Thoracic limb lameness ness. Large-breed dogs, such as dalmatians and standard
is often associated with marked neck pain, which is typi- poodles, are over-represented. Neck pain is variable and
fied by spontaneous yelping and a low head carriage. muscle atrophy of the affected limb is often palpable.
Cervical muscle spasm and exacerbation of pain when
the neck is manipulated are common clinical features.
The affected thoracic limb is often held off the ground in
a flexed position.
Survey radiographs of the cervical spine may reveal
A
Eight-year-old dobermann with right thoracic limb
lameness and paraparesis (A), and resting (B) and traction
(C) cisternal myelograms from the same animal. Note the
spinal cord compression due to protrusion of the C6-C7
intervertebral disc, which is relieved with traction. The
split ventral contrast column (arrow) is consistent with
asymmetrical dorsolateral protrusion of the disc and
regional spinal nerve compression. There is vertebral
malformation and malarticulation (cervical spondylopathy) C
and spondylosis deformans
Survey radiographs of the cervical spine may reveal Lateral (A), ventrodorsal
(B), right lateroventral–left
intervertebral disc space narrowing. Mineralisation of laterodorsal oblique (C)
the affected disc is rare. Myelography with oblique views and left lateroventral–right
laterodorsal oblique (D)
may show ventrolateral extradural spinal cord compres- cisternal myelograms from
sion. The degree of compression is often reduced when a 7·5-year-old Yorkshire
traction is applied to the neck. It is probable that the terrier with left thoracic
limb lameness due to a
associated spinal nerve compression is also reduced or nerve sheath tumour.
eliminated as the intervertebral foramen is enlarged. The Note the left ventrolateral
C5-C6 extradural spinal cord
favourable response to vertebral distraction–stabilisation compression (white arrow)
surgery in these cases supports this hypothesis. MRI and the enlarged left
A C5-C6 intervertebral
is an excellent alternative imaging modality. Traction foramen (yellow arrow)
images may be obtained to assess the effect on spinal
cord and spinal nerve compression.
CERVICAL SPONDYLOPATHY-ASSOCIATED
DISC PROTRUSION
Caudal cervical vertebral malformation and associated
protrusion of the annulus fibrosus may compress the
spinal cord and regional spinal nerves. Middle-aged
dobermanns and great danes are over-represented. Neck
pain is variable, while muscle atrophy of the affected
limb is often marked.
Survey radiographs of the cervical spine may reveal
vertebral malformation, abnormal vertebral alignment
and intervertebral disc space narrowing. Myelography
with oblique views may show ventrolateral extradural B C D
spinal cord compression. As with other cervical disc pro-
trusions, the degree of cord compression is often reduced
with traction. MRI with traction views is increasingly deficits are often only evident when the condition is
used in the diagnosis of this condition. advanced. Muscle atrophy is often marked. Careful
palpation of the axilla may reveal a mass. Pain is
Neoplasia generally exacerbated when these tumours are manip-
Tumours arising from nerve sheaths or the caudal ulated and this may even be evident when the dog
cervical spine may cause progressive thoracic limb is sedated or anaesthetised. Brachial plexus tumours
lameness. may invade along one or more spinal nerves and enter
the vertebral canal and spinal cord. Electromyographic
NERVE SHEATH TUMOURS tests may reveal spontaneous electrical activity in
Malignant peripheral nerve sheath tumours (previously affected muscles and reduced nerve conduction veloci-
referred to as neurofibromas, neurofibrosarcomas or ties. MRI and ultrasonography may enable detection
schwannomas) may involve spinal nerves, the brachial of a mass. Some of these tumours are extremely small,
plexus or peripheral nerves. even after many months of progressive thoracic limb
Nerve sheath tumours arising from spinal nerves lameness, and false negative findings are therefore
within the vertebral canal may cause spinal cord com- possible.
pression. Neck pain is a common feature and neurologi-
cal deficits may be detected in other limbs, especially the CERVICAL SPINAL NEOPLASIA
ipsilateral pelvic limb. Oblique view survey radiographs Extradural tumours (eg, fibrosarcomas) and vertebral
may show enlargement of the intervertebral foramen tumours (eg, osteosarcomas) may cause spinal nerve
containing the affected spinal nerve. Myelography or compression and associated thoracic limb lameness.
MRI may reveal a lateralised extradural or intradural– Survey radiographs may reveal osteolysis or abnormal
extramedullary space-occupying lesion. new bone formation. Myelography may show evidence
Nerve sheath tumours arising from the brachial of concomitant spinal cord compression. MRI or CT
plexus generally do not cause neck pain. Neurological may also be useful diagnostic aids.
(left) Eleven-year-old labrador retriever with right thoracic limb lameness due to a brachial plexus
nerve sheath tumour. (middle) Transverse magnetic resonance image showing right C8 spinal nerve
enlargement (arrow). (right) Brachial plexus mass (arrow) on postmortem examination
A B
A B C
(A) Five-and-a-half-year-
old cocker spaniel with
back pain and left pelvic
limb lameness. Lateral
(B), ventrodorsal (C),
right laterodorsal–left
lateroventral oblique (D)
and left laterodorsal–right
lateroventral oblique (E)
myelograms show left
ventrolateral extradural
spinal cord compression
at L5-L6. The intervertebral
disc space is narrow and
the disc is mineralised.
Extruded nuclear disc
material is compressing the
L5 spinal nerve and causing D E
the clinical signs
Radiograph showing a vertebral osteosarcoma in an Lateral (above) and flexed ventrodorsal (below) radiographs
8·5-year-old mixed breed dog with back pain and left showing extensive vertebral end-plate osteolysis in a 4·5-
pelvic limb lameness. Note the osteolysis affecting the year-old boxer with back pain and left pelvic limb lameness
L5 vertebral body and regional extradural cauda equina due to lumbosacral discospondylitis
compression
Lumbosacral discospondylitis
Infection of the lumbosacral disc and adjacent vertebral
endplates may result in compression of the seventh lumbar
spinal nerve. This scenario is most likely in advanced cases
where marked destruction of the vertebral bodies results in
stenosis of the intervertebral foramina. Back pain and pel-
vic limb lameness can be severe. Survey radiographs show
osteolysis of vertebral endplates and irregular new bone
formation. MRI enables detection of early discospondyli-
tis prior to radiographic changes, but pelvic limb lameness
is not generally a feature in these cases. The infected disc WEAKNESS AND INCOORDINATION
space may be aspirated and material submitted for culture. – IS IT ORTHOPAEDIC?
Blood and urine may also be cultured.
Orthopaedic conditions may also cause weakness and
hence mimic neurological conditions. Furthermore, they
WEAKNESS AND INCOORDINATION may occasionally cause apparent incoordination and thus
In addition to – IS IT NEUROLOGICAL? further mimic neurological disorders.
neurological and An abnormal increase in flexion or extension of a
orthopaedic Weakness is a common presentation in small animal joint when weightbearing is the main reason orthopaedic
conditions, there are practice and neurological conditions are some of the conditions cause weakness. This is due to a lack of pas-
many other causes of most common causes. Diseases of the central nerv- sive or active joint support. Passive support depends on
weakness including ous system (brain and spinal cord), peripheral nervous joints being reduced and stable. It is reduced or absent
cardiovascular and system, neuromuscular junction and muscles may all when joints luxate or ligaments rupture. Active joint
metabolic disorders, cause weakness and/or incoordination. Spinal cord dis- support depends on intact, functioning musculotendi-
such as shock and orders are the most common and, of these, degenerative nous units. Rupture or avulsion of these units reduces
hypoadrenocorticism. intervertebral disc disease (cervical and thoracolumbar) or prevents active joint support. Orthopaedic conditions
is the most frequently diagnosed. cause apparent incoordination as a result of abnormal
The signalment may be useful as specific conditions limb movement during the gait cycle. Muscle contrac-
are over-represented in certain breeds (eg, thoracolumbar tures and limb deformities can have profound effects on
disc disease in dachshunds). Historical features may be limb movement.
suggestive of particular conditions (eg, exercise-induced Examination of dogs with orthopaedic causes of
weakness is typical of myasthenia gravis and some poly- weakness and incoordination will often reveal abnormal
myopathies). Spontaneous yelping is characteristic of joint movement, muscle contracture or limb deformity.
spinal pain. Neurological examination will generally be unremarkable.
Neurological examination should be thorough and
complete following a general physical examination (see THORACIC LIMB WEAKNESS
Garosi 2004). Gait analysis, proprioception tests, assess- Glenohumeral (shoulder) luxation may cause apparent
ment of segmental spinal and cranial nerve reflexes, and weakness, especially if it is developmental in nature
evidence of spinal pain may enable neurolocalisation. and bilateral. Triceps tendon rupture or avulsion, and
Neurological causes of weakness and incoordination olecranon fractures may result in an inability to extend
can be investigated using radiography, MRI, CT, mye- the elbow and bear weight. Carpal hyperextension with
lography, cerebrospinal fluid analysis, electrophysiologi- a palmigrade stance is not uncommon, especially in col-
cal testing, biopsy and blood tests. lie breeds, where the aetiology tends to be degenerative.
THORACIC LIMB
INCOORDINATION
Contracture of the infra-
Straight patellar tendon
spinatus muscle and, less rupture in a 4·5-year-old
Degenerative bilateral
carpal hyperextension in commonly, the supraspina- Border terrier with right
a seven-year-old Shetland tus muscle results in a pelvic limb weakness.
sheepdog with thoracic limb Bilateral cranial cruciate ligament rupture in a 2·5-year-old Note the increased distance
weakness and lameness characteristic thoracic limb golden retriever, which presented with arching of the back between the patella and
posture and gait abnormal- and apparent pelvic limb weakness the tibial tuberosity
Infraspinatus contracture
in a three-year-old springer
spaniel with apparent left
thoracic limb incoordination.
This was due, in part, to the Bilateral gracilis muscle contracture in a 4·5-year-
contracture causing external old German shepherd dog, which presented with
rotation of the humerus and apparent pelvic limb incoordination. This was
abduction of the distal limb due, in part, to the contracture causing internal
with flipping of the paw as rotation of the tibia as the hip flexed and the
the shoulder joint flexed stifle extended
Acknowledgements
The author is grateful to Toby Gemmill for his assistance
in the final preparation of this paper, Ruth Dennis
for magnetic resonance imaging and the veterinary
surgeons who referred the cases.
Further reading
BAGLEY, R. S., TUCKER, R. & HARRINGTON, M. L.
(1996) Lateral and foraminal disk extrusion in dogs.
Compendium on Continuing Education for the
Practicing Veterinarian 18, 795-804
BREHM, D. M., VITE, C. H., STEINBERG, H. S., HAVILAND,
J. & VAN WINKLE, T. V. (1995) A retrospective study of
51 cases of peripheral nerve sheath tumors in the dog.
Journal of the American Animal Hospital Association
31, 349-359
CHAMBERS, J. & HARDIE, E. (1986) Localization and
management of sciatic nerve injury due to ischial or
acetabular fracture. Journal of the American Animal
Hospital Association 22, 539-544
COCKSHUTT, J. R. & SMITH-MAXIE, L. L. (1993) Delayed
onset sciatic impairment following triple pelvic
osteotomy. Progress in Veterinary Neurology 4, 60-63
FANTON, J., BLASS, C. & WITHROW, S. (1983) Sciatic
nerve injury as a complication of intramedullary pin
fixation of femoral fractures. Journal of the American
Animal Hospital Association 19, 687-694
FELTS, J. F. & PRATA, R. G. (1983) Cervical disc disease in
the dog: intraforaminal and lateral extrusions. Journal
of the American Animal Hospital Association 19, 755-760
Bilateral proximal tibial valgus deformity in a 16-month- GAROSI, L. (2004) The neurological examination. In
old great dane, which presented with apparent pelvic limb Canine and Feline Neurology. Eds S. R. Platt and N. J.
incoordination Olby. Quedgeley, BSAVA. pp 1-23
GILMORE, D. R. (1987) Lumbosacral discospondylitis
in 21 dogs. Journal of the American Animal Hospital
Association 23, 57-61
SUMMARY
HOULTON, J. E. F. (2006) An approach to the lame dog
or cat. In Canine and Feline Musculoskeletal Disorders.
Neurological disease, such as foraminal disc extrusion Eds J. E. F. Houlton, J. L. Cook, J. F. Innes and S. J.
Langley-Hobbs. Quedgeley, BSAVA. pp 1-7
with spinal nerve compression and nerve sheath neopla- JEFFERY, N. D. (1993) Femoral head and neck excision
sia, can cause lameness and mimic orthopaedic disease. complicated by ischiatic nerve entrapment in two
dogs. Veterinary and Comparative Orthopaedics
Conversely, orthopaedic disease, such as hip dysplasia and Traumatology 6, 215-218
and infraspinatus muscle contracture, can cause weak- LEWIS, D. D., SHELTON, G. D., PIRAS, A., DEE, J. F.,
ROBINS, G. M., HERRON, A. J., FRIES, C., GINN, P. E.,
ness and incoordination, respectively, and mimic neu- HULSE, D. A., SIMPSON, D. L. & ALLEN, D. A. (1997)
rological disease. It is important to distinguish between Gracilis or semitendinosus myopathy in 18 dogs. Journal
orthopaedic and neurological causes of lameness, weak- of the American Animal Hospital Association 33, 177-188
McKEE, W. M. (2000) Intervertebral disc disease in the
ness and incoordination as the investigative approach and dog 1. Pathophysiology and diagnosis. In Practice 22,
prognosis can be quite different. Differentiation neces- 355-369
REINKE, J., MUGHANNAM, A. J. & OWENS, J. M. (1993)
sitates a detailed history and thorough clinical examina- Avulsion of the gastrocnemius tendon in 11 dogs.
tion, with emphasis on the neurological and orthopaedic Journal of the American Animal Hospital Association
29, 410-418
components. These are prerequisites to specific investi- VAUGHAN, L. C. (1979) Muscle and tendon injuries in
gations when assessing these often challenging cases. dogs. Journal of Small Animal Practice 20, 711-736
CLARIFICATION
Emergency care of the cat with multi-trauma (In Practice, July/August 2007, volume 29, pp 388-396)
The paragraph on ‘Analgesia’ on page 395 stated that meloxicam (Metacam Oral Suspension; Boehringer Ingelheim)
had been recently licensed for long-term use in cats at a dose of 0·05 mg/kg orally, once daily, for up to 14 days.
Boehringer Ingelheim points out that Metacam Oral Suspension for Cats has been granted a long-term licence in
which there is no restriction on the duration of use, thus allowing, where indicated, the product to be continued beyond
the 14-day period stated. It says that a loading dose of 0·1 mg/kg should be administered on the first day of treatment
to ensure that stable, therapeutic plasma levels are reached quickly, within the 48-hour period stated on the licence.
The authors add that Metacam injection is currently licensed as a single subcutaneous injection, at a dose of 0·3
mg/kg, for preoperative use in cats for pain related to minor surgical trauma. It may therefore be used off label for
pain related to trauma according to the same dosing regimen; owners should obviously be appraised of the off-label
use of this product before treatment. If Metacam therapy is continued orally after this time it should be used at a
dose of 0·05 mg/kg. If no improvement is seen in seven to 14 days, the authors suggest that Metacam therapy should
be discontinued.
CORRECTION
Total intravenous techniques for anaesthesia (In Practice, July/August 2007, volume 29, pp 410-413)
In the table of ‘TIVA protocols’ on page 413, the doses for propofol induction and maintenance in horses were incorrect.
The induction dose should have read 2 mg/kg and the maintenance dose 0·1 mg/kg/minute. The author regrets the error.