difficult case

[Guest guest]

Hi everyone,

Wondering if anyone has suggestions for me on a problem case.

Zack is a 4 year old sheltie who does agility. He came to me in

October with a history of chronic intermittent LF lameness. Exam

revealed no changes on shoulder, elbow and carpal radiographs. There

was pain on palpation over the entire biceps tendon and muscle and

there was also some medial shoulder instability with abduction of 50

degrees on the left and 30 degrees on the right. I have ultrasounded

the biceps, cross friction massage, stretching. Exercises to rehab

have included stability exercises, theraband, stretches, underwater

treadmill, wheelbarrow on flat and down a hill etc. etc. Zack seemed

to be doing well but after one session of the treadmill with

resistance jets he came up lame again in December, the pain was

focused over the biceps insertion this time. We re-radiographed the

elbow and saw no changes. I used the laser this time on the biceps -

we backed off on exercise and he improved again.

Over the holidays his owner has been walking and trotting him and he

has come up lame again. After 3 months of rehab she is really

frustrated and so am I!

I talked to her about surgical options for the biceps and about shock

wave which I do not have. His shoulder instability is improved to 40

degrees of abduction and there has never been any pain there.

Suggestions? - his owner will not use medications unless they are

herbal and Zack has been on Traumeel.

Thanks

[Guest guest]

Hi , From a musculo-skeletal point, I have seen these cases all the time with agility dogs and the problem could be, and most of the time it is, in the diaphragm. If the diaphragm is in contracted mode ( look over the dog and see if one side of the chest is flat compared to the other side) the dog can't extend more than 50% approximately (caused by C5-6-7 phrenic nerve irritation from a neck injury). The dog will use the biceps extensively for trying to get more extension in the shoulder for jumping over the jumps. This is the start of chronic biceps irritation what only gets worse with more jumping and only temporarily relieve with modalities and rehab. Surgery of cutting the biceps tendon is totally not solving the problem but only creating more shoulder instability. Treatment: Fix the alignment of the cervical and thoracic spine, Cranio sacral techniques as needed, release the diaphragm with manual therapy and let the biceps tendon heal finally with or without modalities. If you are interested, I will help you as best as I can with the treatment protocol. My two cents if they have any value, Sincerely, kortekaas PT www.fullspectrumcaninetherapy.com difficult case Hi everyone, Wondering if anyone has suggestions for me on a problem case. Zack is a 4 year old sheltie who does agility. He came to me in October with a history of chronic intermittent LF lameness. Exam revealed no changes on shoulder, elbow and carpal radiographs. There was pain on palpation over the entire biceps tendon and muscle and there was also some medial shoulder instability with abduction of 50 degrees on the left and 30 degrees on the right. I have ultrasounded the biceps, cross friction massage, stretching. Exercises to rehab have included stability exercises, theraband, stretches, underwater treadmill, wheelbarrow on flat and down a hill etc. etc. Zack seemed to be doing well but after one session of the treadmill with resistance jets he came up lame again in December, the pain was focused over the biceps insertion this time. We re-radiographed the elbow and saw no changes. I used the laser this time on the biceps - we backed off on exercise and he improved again. Over the holidays his owner has been walking and trotting him and he has come up lame again. After 3 months of rehab she is really frustrated and so am I! I talked to her about surgical options for the biceps and about shock wave which I do not have. His shoulder instability is improved to 40 degrees of abduction and there has never been any pain there. Suggestions? - his owner will not use medications unless they are herbal and Zack has been on Traumeel. Thanks

[Guest guest]

Hi and .Interesting discussion, though I'm trying to understand the relationship of the biceps with the diaphragm...The biceps is innervated by the musculocutaneous nerve (C6-8) and the diaphragm by the phrenic nerve (C5-7).  I can understand assessment of the cervical spine accessory motion as potential for involvement in the biceps issue and I can also see that the diaphragm might be "involved" but secondary to a cervical spine issue as well.  , maybe I misunderstand, but you're suggesting that the diaphragm issue is primary with the cervical spine and biceps issue as secondary.  I know it's pointless (sometimes) to argue over the chicken and the egg question, but...  If we suggest (rather directly) that the cervical spine should be examined when the biceps is our clinical issue, then we might be indirectly treating the diaphragm?Trying to see outside of the box...Amie Amie Lamoreaux Hesbach, MSPT, CCRP, CCRTDirector of RehabilitationNext Step Animal Rehabilitation & FitnessThe Mid-Atlantic Animal Specialty Hospital (MASH)Huntingtown, land, USAwww.vetmash.comOwnerFor Paws Rehabilitation, LLCwww.forpawsrehabilitation.comFaculty MemberThe Canine Rehabilitation InstituteWellington, FloridaSnowmass, Coloradowww.caninerehabinstitute.comPresidentAnimal Rehabilitation Special Interest GroupOrthopaedic SectionAmerican Physical Therapy Association (APTA)www.orthopt.orgwww.apta.org Hi , From a musculo-skeletal point, I have seen these cases all the time with agility dogs and the problem could be, and most of the time it is, in the diaphragm. If the diaphragm is in contracted mode ( look over the dog and see if one side of the chest is flat compared to the other side) the dog can't extend more than 50% approximately (caused by C5-6-7 phrenic nerve irritation from a neck injury). The dog will use the biceps extensively for trying to get more extension in the shoulder for jumping over the jumps. This is the start of chronic biceps irritation what only gets worse with more jumping and only temporarily relieve with modalities and rehab. Surgery of cutting the biceps tendon is totally not solving the problem but only creating more shoulder instability.Treatment: Fix the alignment of the cervical and thoracic spine, Cranio sacral techniques as needed, release the diaphragm with manual therapy and let the biceps tendon heal finally with or without modalities. If you are interested, I will help you as best as I can with the treatment protocol. My two cents if they have any value,Sincerely, kortekaas PTwww.fullspectrumcaninetherapy.com  difficult case Hi everyone, Wondering if anyone has suggestions for me on a problem case. Zack is a 4 year old sheltie who does agility. He came to me in October with a history of chronic intermittent LF lameness. Exam revealed no changes on shoulder, elbow and carpal radiographs. There was pain on palpation over the entire biceps tendon and muscle and there was also some medial shoulder instability with abduction of 50 degrees on the left and 30 degrees on the right. I have ultrasounded the biceps, cross friction massage, stretching. Exercises to rehab have included stability exercises, theraband, stretches, underwater treadmill, wheelbarrow on flat and down a hill etc. etc. Zack seemed to be doing well but after one session of the treadmill with resistance jets he came up lame again in December, the pain was focused over the biceps insertion this time. We re-radiographed the elbow and saw no changes. I used the laser this time on the biceps - we backed off on exercise and he improved again. Over the holidays his owner has been walking and trotting him and he has come up lame again. After 3 months of rehab she is really frustrated and so am I! I talked to her about surgical options for the biceps and about shock wave which I do not have. His shoulder instability is improved to 40 degrees of abduction and there has never been any pain there. Suggestions? - his owner will not use medications unless they are herbal and Zack has been on Traumeel. Thanks

[Guest guest]

Hi Amie and , Thanks for thinking out the box. Use all your knowledge in the box and put it in a functional light. Lots of dogs hurt their necks running into things and get facet dysfunctions in C5-7 nerve roots. This can give a diaphragm restriction on that side of the body. If you think in osteopathic concepts, the body will protect itself in an hierarchy of importance: 1. The vascular system, 2. the Nervous system, 3. the motility of the organs, 4. the Lymphatic system, 5. the endocrine system and last, but not least, the musculoskeletal system. So, with chronic, not wanting to get better biceps tendonitis, the problem might be, 1. in overstretching of the carotids, vertebral artery, and/or jugulars at injury. The neck will go in spasm to protect around it (means continuation of compression on the nerve roots C6-8 (biceps) and phrenic nerve, what the body will protect around than in second place) 3. the lung/heart motility might be off so the body will protect around it. Again the muscles around the neck and shoulder will be tight, and can continue a chronic biceps tendonitis. 4. and 5. I don't see often in this case but can be there. But, when the diaphragm is in spasm, the shoulder muscles will be pulled back (serratus/latissismus dorsi etc) and the dogs will only have approximately 50% extension and internal rotation in the shoulder. If they are agility dogs, they need to have the extension to clear the bars. This will over use the biceps and, wala, the shoulder doesn't want to get better. So moral of the story: Check and manipulate cervical, thoracic and lumber spine (crura's from the diaphragm on L3 and L4) and check the diaphragm of each dog. I have gotten many dogs better with releasing the diaphragm after fixing C5-6-7 facet joint dysfunctions. After restoring normal mobility and motility in diaphragm and lung/heart tissues, the biceps tendonitis went away. Dogs return to agility with no returning tendonitis. Hope this helps. It is hard to explain in proper English and the right order in a short story. Sincerely, Kortekaas PT www.fullspectrumcaninetherapy.com difficult case Hi everyone, Wondering if anyone has suggestions for me on a problem case. Zack is a 4 year old sheltie who does agility. He came to me in October with a history of chronic intermittent LF lameness. Exam revealed no changes on shoulder, elbow and carpal radiographs. There was pain on palpation over the entire biceps tendon and muscle and there was also some medial shoulder instability with abduction of 50 degrees on the left and 30 degrees on the right. I have ultrasounded the biceps, cross friction massage, stretching. Exercises to rehab have included stability exercises, theraband, stretches, underwater treadmill, wheelbarrow on flat and down a hill etc. etc. Zack seemed to be doing well but after one session of the treadmill with resistance jets he came up lame again in December, the pain was focused over the biceps insertion this time. We re-radiographed the elbow and saw no changes. I used the laser this time on the biceps - we backed off on exercise and he improved again. Over the holidays his owner has been walking and trotting him and he has come up lame again. After 3 months of rehab she is really frustrated and so am I! I talked to her about surgical options for the biceps and about shock wave which I do not have. His shoulder instability is improved to 40 degrees of abduction and there has never been any pain there. Suggestions? - his owner will not use medications unless they are herbal and Zack has been on Traumeel. Thanks