Re: forelimb flexor tendon repair rehab - questions

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Real quick note Pam....I had a dog a few years ago with a similar scenario. The one owner was a brilliant human cardiologist that challenged me every step of the way. We would play 'paper citation' everytime his dog came in. I am attaching a few abstracts that I pulled for him dating back to that time. (I've not updated it and I've not translated the information... but as I said, this is just a quick note...) You'll notice that I have only looked at human papers (i.e. where the rehab evidence lies) as it pertains to the achilles tendon - as that is the only structure that is similar enough in function to the SDFT & DDFT in us to make a comparison with.I'm a bit of an evidence-based geek - and instructor for CRI... and feel that I bring a good deal of evidence-based application to the CRI program (just my 2 cents! Please note the smiley winking face!)We used the therapaw carpoflex for our dog that we rehabbed - as it allowed for many variations of support.For example we started using it with a rigid support - thermoplastic - at the beginning. As the dog improved we had the dog walk without the thermoplastic.When it came time to adding some faster speeds; trotting etc, we used the thermoplastic, but had it off for normal walking.We then reduced from thermopastics to the velcro piece up the back for slightly more support than brace alone... as well the amount of foam insert is a level of support as well that we could alter.The dog graduated to no brace in the house, but brace for walks... the amount of support for the walks went from additional velcro strip, to no velcro strip.The dog then graduated to no brace for house and walks. Off leash activity was started with the brace again... short periods, then gradually longer periods.I'm finding it hard to remember but somewhere early on (I think just before the in house no-brace time, we used an air-splint - child's arm size) to allow for very mild support. It was hard to control & manage however... and required duct tape protection on the bottom.The flat toes are not a good sign. I'd be worried that they perhaps already blew it by letting the dog run free.I'd also be rather blunt with them that by allowing free running now, they should kiss her agility aspirations goodbye. Sometimes it needs to be more than a 'suggestion'! :)These are good ones for UWT - higher water for increased buoyancy.You could try testing the integrity of the SFDT by individually stretching each toe with the elbow and carpus in extension. 1st extend a toe from the middle phalanx (testing SDFT) and then from the distal phalanx (testing DDFT). Assess for extensibility as well as pain... you may answer you own questions about the flat toes by doing this and comparing all toes as well as the other side.Cheers,Laurie

Hi All,I've just seen a dog for a lacerated, surgically repaired tendon injury; I've not rehabbed such a thing before and am searching for suggestions. Zara is a 5 yr old Pointer agility dog who lacerated her right front distal flexor tendons in January while running in a field. They were surgically repaired. I'm not sure of exactly which tendons and how badly injured because I did not get much history from the surgeon, just a referral form that said "flexor tendon laceration /repair with degloving wound of entire carpus/metacarpal area". I plan to try and talk to him for more info. The dog was in a rigid splint for 8 wks then soft bandage for 4 weeks with EOD bandage changes and somewhere in there she had some kind of severe infection that required amikacin dosing. During this time the owner let her run free (and apparently run crazy) in large fields .She put the leg to the ground only intermittantly. Bandage came off today. She is NWB most of the time whether standing, sitting or walking. She has significantly reduced carpal flexion, slightly reduced carpal extension, and a firm swelling on the lateral aspect of the carpus. She has severe hyperextension of the digits,giving her a very flat foot on this leg (the other paw is a tight cat foot). The owner is intending to let the dog run free in the fields again. I told her this was a bad idea but I don't know how restricted she will keep the dog. I have a video but it will take me some time to figure out how to post it (it's still in the camera)

My questions:1. Would a carpal support be the right thing now, I am thinking yes, I am thinking the Thera Paw Carpo Flex X OR Carpo flex sports wrap (I've never used these but am just looking on their web site)

2. the flat foot (hyperextended toes) -- is this typical from disuse and will it resolve with strengthening?3.I would welcome suggestions for appropriate exercises. Today I did laser of the area, ultrasound of the carpus (because I don't like the firm swelling, don't know what it is), carpal ROM and joint mobs and some light exercises like cavalettis and standing on a trampoline to encourage her to put her foot down. Owner is to do range of motion, weight shifting and some leash walking (ha ha, probably some field running too).

4. Timeline for recovery - I know studies show tendons have only 79% of original strength even at 1 yr. I am thinking she needs 2 to 3 months of intensive rehab followed by another 3 to 4 months for return to sport. Does that sound realistic? The owner told me she was #2 Pointer in akc agility last year and she is really hoping to go back to claim that spot again.

thanksPam Mueller PhD DVM CCRT still pending

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And then I forgot to attach the abstracts!!!;( (frustrated winking face!)Laurie

Hi All,I've just seen a dog for a lacerated, surgically repaired tendon injury; I've not rehabbed such a thing before and am searching for suggestions. Zara is a 5 yr old Pointer agility dog who lacerated her right front distal flexor tendons in January while running in a field. They were surgically repaired. I'm not sure of exactly which tendons and how badly injured because I did not get much history from the surgeon, just a referral form that said "flexor tendon laceration /repair with degloving wound of entire carpus/metacarpal area". I plan to try and talk to him for more info. The dog was in a rigid splint for 8 wks then soft bandage for 4 weeks with EOD bandage changes and somewhere in there she had some kind of severe infection that required amikacin dosing. During this time the owner let her run free (and apparently run crazy) in large fields .She put the leg to the ground only intermittantly. Bandage came off today. She is NWB most of the time whether standing, sitting or walking. She has significantly reduced carpal flexion, slightly reduced carpal extension, and a firm swelling on the lateral aspect of the carpus. She has severe hyperextension of the digits,giving her a very flat foot on this leg (the other paw is a tight cat foot). The owner is intending to let the dog run free in the fields again. I told her this was a bad idea but I don't know how restricted she will keep the dog. I have a video but it will take me some time to figure out how to post it (it's still in the camera)

My questions:1. Would a carpal support be the right thing now, I am thinking yes, I am thinking the Thera Paw Carpo Flex X OR Carpo flex sports wrap (I've never used these but am just looking on their web site)

2. the flat foot (hyperextended toes) -- is this typical from disuse and will it resolve with strengthening?3.I would welcome suggestions for appropriate exercises. Today I did laser of the area, ultrasound of the carpus (because I don't like the firm swelling, don't know what it is), carpal ROM and joint mobs and some light exercises like cavalettis and standing on a trampoline to encourage her to put her foot down. Owner is to do range of motion, weight shifting and some leash walking (ha ha, probably some field running too).

4. Timeline for recovery - I know studies show tendons have only 79% of original strength even at 1 yr. I am thinking she needs 2 to 3 months of intensive rehab followed by another 3 to 4 months for return to sport. Does that sound realistic? The owner told me she was #2 Pointer in akc agility last year and she is really hoping to go back to claim that spot again.

thanksPam Mueller PhD DVM CCRT still pending

Laurie Edge-, BScPT, MAnimSt(Animal Physio), CAFCI, CCRTCo-Owner,The Canine Fitness Centre Ltd.Calgary, AB, Canadawww.caninefitness.comCEO,Four Leg Rehab Inc.www.fourleg.comPast-Chair,The Animal Rehab DivisionThe Canadian Physiotherapy Associationwww.animalptcanada.comInstructor,The Canine Rehab Institutewww.caninerehabinstitute.comGuest Lecturer,Faculty of Veterinary MedicineThe University of Calgarywww.vet.ucalgary.caVice-President,International Association of Physical Therapists in Animal PracticeWorld Confederation for Physical Therapywww.wcpt.org

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Tendon repairs and rehab.docx

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Thanks Laurie for all the info. We have ordered the carpal flex splint kit from Therapaw and will fit it tommorrow. They said you like to get a custom splint made -- but they couldn't do that until next week so we went with the kit. Until the splint is on we are restricting activity severely. I read the owner the riot act several times re letting the dog run free and I think she has come around.

 I tried as you suggested to test the SDF and DDF. When testing an individual toe on the right (injured leg) and comparing it to the left I didn't feel like I had a big difference in pain or extensibility. She is painful on extension of digit V but there is a lot of scar tissue there on the lateral edge presumably from the very bad infection she had post op. However, when I try to extend the whole foot as one there is clearly much greater extension on the right vs the left. I have attached a picture here to try and show that. I am pressing up on both feet they are both extended as far as they will go you can see the difference. Do you think this means the tendon repair is shot or just that the collagen is soft at this point and it can improve?

 I have also put up a video at :http://youtu.be/VIlVabJyWak  -- is this the right way to do it??? Anyone who wishes to view the video and comment with suggestions they would be appreciated.

 She reduced carpal and digit flexion of course -- but no ROM was done over 12 wks of coaptation so that is not surprising and I am hoping that we can get that back without too much trouble. But will her tendons (ever) be strong enough to support her in the activities of agility?

 I talked to the surgeon, who told me that in normal cases of tendon repair (without the complications this dog had) he coapts for 12 weeks then they are " good to go " back to whatever they want. Huh? That doesn't sound right to me. From a splint/bandage to running and jumping with nothing in between? Surgeons out there, would this be your normal plan?

 Pamela Mueller PhD DVM

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