1: Musculoskeletal physiotherapy

Musculoskeletal physiotherapy


Gait analysis or assessment is a skill that requires close observation of the patient at walk and trot, to determine the cause and location of the lameness. A start point is to become familiar with a normal gait pattern, taking into account breed variations (i.e. dachshund vs bull mastiff). Once you are familiar with normal gait pattern, any deviation from this can be recognised.

Animals should be on a loose lead at walk and trot to observe for anatomical symmetry (normal gait pattern). Animals should be observed in a straight line towards, and then a straight line away from the observer. Pay particular attention to how the animal turns to both the left and right side – this may show reluctance to transfer weight onto the affected limb, or that the animal has issues with balance. The observer should then view the animal moving from both left and right sides. Subtle lameness may not readily be observed at walking pace; however, at trot the animal will only have one thoracic limb and one pelvic limb in contact with the ground, and these limbs will be placed under greater pressure meaning a lameness may be easier to detect.

Videoing the gait pattern, then slowing it down on playback, may be a useful way to detect lameness.

Gait analysis

Observe muscle symmetry, weight-bearing (paw and toe position) and conformation at rest.

Observe gait in a quiet area at walk and trot; thoracic limb lameness is often associated with head bobbing. When the animal takes its bodyweight through the painful thoracic limb the head will bob upwards in an attempt to unload the ground reaction force passing through the limb.

Pelvic limb lameness can be observed by a hiking up in the gluteal region in an attempt to offload or shift weight from the painful limb; this may be towards the contralateral pelvic limb, or forwards usually towards the contralateral thoracic limb. Lameness in pelvic limbs may also present with a bunnyhopping gait pattern. This may be related to a reduction in pelvic limb power, often observed with stair climbing or running. The bunnyhopping gait pattern may also be related to a reduced range of motion within the coxofemoral joint, which would be confirmed on physical examination.

Lameness is a general term used to describe an abnormal gait pattern; it may be:

  • Congenital – chondrodystrophic abnormalities, i.e. valgus (lateral deviation of the distal limb), often seen in dachshunds.


  • Pathological – related to a disease process such as osteoarthritis, which can affect any breed but is often seen in larger breeds.

Scoring systems are often used to grade the degree of lameness, and in veterinary practice a typical 1–10 scale is used where 1/10 would indicate barely lame, whereas 10/10 would indicate non-weight-bearing lameness. The scale is very subjective, as only descriptive terms are allocated to the very mildest and most severe lameness. If one observer rated lameness as 4/10, then a second observer may rate the same lameness as 6/10; does this indicate the lameness is progressing? This is why it is important to obtain a full and accurate history from the owner, who will probably observe the animal’s gait every day and be able to state if the lameness is improving, staying the same, or deteriorating. A simpler alternative scoring 0–5 system is available (Table 1.1).

Table 1.1 Lameness scoring scale.

From Summer-Smith (1993). Reproduced with permission from Elsevier.

Score Description
0 Normal
1 Reduced weight-bearing through affected limb in stance
2 Mild lameness at trot
3 Moderate lameness at walk and trot
4 Intermittently carries limb, lame in trot
5 Non-weight-bearing lameness

Elbow dysplasia gait analysis findings include abduction of the affected limb in an attempt by the patient to reduce the amount of bodyweight passing through the elbow joint. This will be most evident when the animal is ambulating on hard ground as the concussive forces passing through the elbow joint will be greater.

Flicking of the carpal joints is also evident with elbow dysplasia; this is a compensatory mechanism for the reduced range of motion, especially elbow flexion, that is characteristic of advanced elbow dysplasia. The condition is often bilateral, so it is important to observe how the animal turns (weight transfer) and observe (or ask the owner about) functional activities such as how or if the animal is able to descend stairs or jump from the car; this will increase load on the elbow joint and will be uncomfortable for the animal so he may avoid these functional activities.

Hip dysplasia gait analysis findings may include a short stride length; this is usually shown as reduced hip extension and can be readily observed as the animal climbs stairs as a weak or short hip extension/push-off. The reduction in hip extension is a characteristic of hip dysplasia, with associated osteoarthritis and joint remodelling.

Adduction of the affected limb is also evident. This can be due to weakness in the hip flexor muscle groups, and may also be associated with secondary osteoarthritic changes and compensatory coxofemoral joint remodelling. As discussed earlier hiking up of the gluteals to shift bodyweight from the affected limb, and bunnyhopping with bilateral hip dysplasia are also gait characteristics observed with this disease.

Cruciate rupture patients usually present with an abnormal gait pattern. Lameness can vary from mild 1/5 (usually chronic) to 5/5 (usually acute). The degree of lameness often correlates with the level of pain the animal is experiencing. A short stride length, especially reduced extension, is evident; also the animal will tend to limit stifle flexion. The animal will usually guard or resent stifle end-of-range flexion. Clicking of the joint may be evident and may indicate associated meniscal damage; this may be evident when the animal flexes the stifle joint, and loads the joint with bodyweight, such as in stair climbing. In acute presentation a joint effusion may be present. In chronic presentations thickening of the joint on the medial surface often with a tibial buttress is common. Stifle range of motion (ROM) is reduced as a result of scar tissue formation and secondary osteoarthritic changes.

The animal may abduct the limb to alter the direction of ground reaction forces passing through the joint, and if there is fatigue or weakness in the hip flexor muscle groups.

The animal will be reluctant to fully weight-bear through the affected limb; at rest, toe touch weight-bearing is often evident; the animal may also adopt various strategies to reduce weight-bearing in stance and will often position the affected limb in a cranio-medial plane.

The long-term muscle changes associated with pelvic limb lameness are short, tight hip flexor muscles, with, weak hamstring muscles. The goal for the physiotherapist is to stretch the short, tight muscles, whilst strengthening the weak, muscles.

History taking

This should include:

  1. Age – Young dogs: When taking a history consider hip dysplasia, elbow dysplasia, oesteochondrosis dissecans (OCD).

               Adult dogs: Consider osteoarthritis, cruciate disease and neoplasia.

  2. Breed – Toy breed: Often show patella luxation, Legg–Calvé–Perthes disease.

                   Large breed: May present with cruciate disease, elbow dysplasia, neoplasia.

  3. Onset of lameness:

    1. May be sudden or subtle or traumatic.
    2. Can be episodic or cyclic.
    3. Is it consistently the same limb or a shifting lameness?

  4. Duration of lameness:

    1. Can be continuous or intermittent.
    2. Is the patient’s condition deteriorating, remaining static or improving?

  5. Association:

    1. Does exercise or rest effect the condition?
    2. Does the patient appear worse in the morning or night?
    3. Is there a seasonal pattern when symptoms are seen in summer or winter?
    4. Does soft or hard ground affect the severity of symptoms?

  6. Behavioural changes:

    1. Is the patient showing aggression?
    2. Does the patient have sleep disturbance?
    3. Is the patient reluctant to play/jump?

  7. Exercise – Ask about type, frequency and duration.
  8. Response to treatment:

    1. Is the patient on any medication, has this made any difference?
    2. Has the patient had any previous physiotherapy treatment? If so what was the response or outcome?
    3. Explore the owner’s expectations of physiotherapy.

Physical examination

When assisting with a physical examination try to find a quiet area. Adopt a systematic anatomical approach each and every time. With the animal standing each limb will be lifted in turn to gauge weight-bearing through the limbs. Obviously the animal will be taking least weight through the affected limb, but lifting each limb in turn may give an indication of where the animal is shifting his bodyweight as a compensatory measure. Compensatory measures can often lead to secondary musculoskeletal issues so these should be noted during the physical exam and addressed later.

When assessing muscle mass compare with the unaffected contralateral limb for muscle mass symmetry. A standard tape measure can be used to measure the circumference of muscle bulk. Again, try to be systematic to ensure accuracy. For example, when measuring pelvic limb muscle bulk try to measure in standing, measure at the thickest point – this usually corresponds to the level of the muscle belly. Try to have a landmark – say in the pelvic limb the greater trochanter of the femur – where the two ends of the tape measure should meet and record the measurement. A difference of more than 1 cm would be considered significant. It is good practice to measure three times and take the average measure from the three readings and record this average reading in the notes.

Conscious proprioception may be delayed or absent in the presence of a joint effusion, which is often evident in acute cranial cruciate ligament injury.

Exercise plans

Exercise plans are designed to rehabilitate patients back to their highest level of function; they can be staged and should be progressive:

  • Early phase (approximately 0–2 weeks): this time scale will depend on the patient’s condition. The aims will be to control inflammation, maintain joint ROM and muscle length.
  • Mid-phase (approximately 2–6 weeks): during this phase the patient should be progressing. The aims are to build on the progress from the early phase and also to improve strength, balance and proprioception.
  • Late phase (approximately 6–12 weeks): this stage is when the patient will continue to gain strength, regain balance and improve stamina.

Early stage post-surgical rehabilitation will begin on day 1 postoperatively. Aim to minimise pain and inflammation, ensure non-weight-bearing (NWB) status on affected limb, maintain joint ROM and muscle length.

Mid-stage rehabilitation can commence 14 days postoperatively, following a satisfactory check-up from the veterinary surgeon and suture removal. The aims are to begin to increase joint ROM of the affected limb, and increase muscle length and mass on the affected limb. Begin gentle partial weight-bearing (PWB) exercises to increase function and strength, and prevent secondary compensatory postures and complications from developing.

Late-stage rehabilitation can commence at 6 weeks postoperatively following a satisfactory check-up from the veterinary surgeon, who may take survey radiographs at this stage to check healing. Rehabilitation goals will be to continue to strengthen the muscles of the affected limb. The patient may be full weight-bearing (FWB) on the affected limb at this stage.

Commence balance and proprioceptive exercise training using wobble cushions, wobble boards and cavaletti pole work. Address compensatory postures, which may be associated with trigger points.

Address secondary complications such as muscle imbalances (tight in flexor muscle groups, weak in extensor muscle groups, which is a common finding in animals with long-term lameness). Finally, the aim of the rehabilitation programme is to return the patient back to the highest level of function, so late-stage rehabilitation will address cardiovascular fitness or stamina, which will have been effected by the graded return to function rehabilitation programme.

Also consider the owner’s ability and commitment to carry out the rehabilitation programme, plus environmental factors. The owner may work full time and have other family commitments. The rehabilitation home exercise programme should fit in with the animal’s needs and the owner’s time restrictions. Do not advise a rehabilitation home exercise programme that takes any more than 30 minutes twice daily to ensure owner compliance. Environmental factors to consider would include: are there other animals in the house, and are there stairs in the house that the patient needs to use?

Physiotherapy treatment techniques and modalities

Cold therapy

Cold therapy aims to control and minimise inflammation postoperatively or following acute injury. The body responds to injury by triggering an inflammatory reaction in the cells. The normal inflammatory phase in healthy tissues is approximately 72 hours. This is the period of time when cold therapy is recommended to minimise the inflammatory response.

Signs of inflammation

  • Pain – from swollen or damaged nerve endings.
  • Redness – from damage of local tissues.
  • Heat – from dilation of local blood vessels.
  • Swelling – from the associated capillaries becoming more permeable resulting in oedema of the local area.

Cold can be applied to the affected area in several ways. Broken ice chippings wrapped in a plastic zip-lock bag covered by a damp cloth, applied to the affected area for 10–20 minutes can be effective. This treatment can be repeated every 4–6 hours as required.

Usually begin the treatment early to minimise the inflammatory response. If an animal is recovering from surgery and is hypothermic, treatment may be postponed until the patient’s body temperate returns to normal.

Cold therapy works by causing vasoconstriction of the local damaged blood vessels, thereby reducing swelling, damage to local tissues, and oedema.


  • Cold hypersensitivity.
  • Altered skin sensation.


  • Cardiac conditions.
  • High blood pressure.
  • Open healing wounds.
  • Areas over superficial nerves.

Heat therapy

Various methods can be used to apply heat to the superficial tissues, such as wheat bags and heat discs that can be warmed in the microwave. Alternatively a damp towel can be microwaved, placed in a zip-lock bag and applied to the affected area for 10–20 minutes. This can be repeated every 4–6 hours.

Heat therapy can commence once the inflammatory phase has passed (usually 72 hours post-injury).

The principle of heat therapy is to vasodilate local blood vessels thus increasing blood flow to the local area to promote healing. Increased cellular activity results in an increase of oxygen and nutrients delivered to the cells.

Heat therapy can be used to reduce pain, stiffness and muscle spasm. Heat improves the elasticity of tissues and can be use prior to stretching.


  • Sensory changes.
  • Burns/scalds.
  • Thrombus/embolism.
  • Hyper- or hypo-sensitivity to heat.
  • Infections.
  • Malignant tumours.

Positioning and supports

Positioning aids and supports are used to maintain muscle length and support the weight of the affected limb. The animal may not have full function or control of the affected limb postoperatively. This may be exacerbated by factors such as pain or discomfort, bulky dressings or external fixators.

The animal will usually choose not to lie on the same side as the affected limb. However, the animal may find it difficult to find a comfortable position in which to rest. In most circumstances the animal will be more comfortable if the affected limb is supported in a neutral position, or slightly elevated in the early stages of recovery, and this will also prevent any muscle imbalances from developing. Folded beds, towels and pillows can be used to maintain the required position. Gentle handling and support of the affected limb and reassuring the animal are essential to aid compliance.

If a patient is placed with the injured limb uppermost and appears uncomfortable, or if the animal continually changes his position to lie on the injured limb, leave the animal in this position as he obviously finds it more comfortable. However, it is preferable not to allow the animal always to lie on one side, so attempt to gently reposition the animal on his non-affected side even if he only tolerates this position for a short period.

Ensure that if the patient’s trunk is positioned in sternal recumbency and the patient has a support at his lateral thorax so he is not weight-bearing excessively or unevenly through his elbow joints. Ensure the elbows are equally abducted to prevent uneven weight-bearing, which could result in pressure sores. If the affected limb is positioned uppermost an adductor wedge or internal rotator wedge should be placed between the limbs to prevent muscle imbalance – for instance, weak gluteals versus tight adductors. Aim to use the adductor wedge to place the affected limb in a neutral position as this will be most likely tolerated by the patient.

Many waterproof animal mattresses are available to assist in preventing pressure sores. However, this will create an unstable surface when the animal is standing, and walking in and out of the kennel. Position yourself on the opposite side of the affected limb when assisting the patient to stand and walk in and out of the kennel. When positioned on the unaffected side you are able to assist the animal to shift his weight onto his unaffected limb to ensure he does not lose his balance.

Manual aids


Slings are used to assist the animal when he is mobilising. A variety of slings are available for veterinary use, most commonly used with orthopaedic patients is The Soft Quick Lift™ (Four Flags Over Aspen, Inc.) abdominal sling. This type of sling is useful following pelvic limb surgery, is easy to use, and is usually well tolerated by the patient. If you are using a sling to assist the patient to mobilise, position yourself on the same side as the unaffected limb in line with the pelvic limb. In this position you can tilt the patient slightly onto his unaffected limb and assist with balance if necessary and prevent him from falling.

In the early stages following orthopaedic surgery it is not desirable for a patient to weight-bear on the affected limb. This is because the soft tissues and bones are still healing, stabilising and remodelling. Early weight-bearing is not a sign of successful surgery. The sling is used in much the same way that a human would use crutches following surgery to a pelvic limb. The crutches are used to protect the limb whist healing takes place until a bony callus forms; the implant used to stabilise the joint is not strong enough to allow the individual to bear full weight through the affected limb.

A Helping Hand pelvic support sling (Mikki, Dorking, Surrey, UK) is sometimes used to support orthopaedic patients postoperatively when they are mobilising. A Helping Hand can be more difficult to place on the patient, it may be easier to assist the patient to stand, then whilst supporting him, position his feet in the limb holes of the Helping Hand and then pull them up, secure with Velcro and fasten the clips.

A Helping Hand sling is preferred to The Soft Quick Lift™ sling for animals undergoing pelvic or hip surgery as it gives added support to the pelvis and does not block hip flexion movements. A Helping Hand sling would also be the support aid of choice for thoracic limb post-surgical support. Given that the dog bears 60% of his bodyweight through the thoracic limbs support of the thoracic limbs to allow healing to take place is even more crucial.

For animals with multiple trauma to several limbs a fully body sling and mobile hoist may be necessary to assist mobilisation. The body sling supports the animal’s trunk, whereas the hoist supports the animal’s bodyweight; the hoist is slowly moved forwards and the animal can move his limbs without taking very much of his body weight.


Electrotherapy can be a useful modality when used in conjunction with therapeutic rehabilitation exercises.

Pulsed electromagnetic energy (PEME; Biomag® therapy)

The unit consists of a control panel and an electronic waterproof pad that can be placed under the affected area to be treated. It is a non-invasive treatment and as such is usually well tolerated by the patient. It is especially useful for treatment in arthritic patients and uses pulsed magnetic therapy to reduce pain and inflammation. PEME can be used in both the acute and chronic phases of disease. Pulsed magnetic therapy has been used in the assistance of bone healing.

Class IV laser

This can be used to treat wounds, for chronic and acute musculoskeletal conditions, for soft tissue injures, for pain and to control oedema (Figure 1.1). Power settings and the duration of treatment are calculated according to species, skin colour, bodyweight, area to be treated and the stage of the condition (acute or chronic). N.B. Eyes must be protected with dark-green lens glasses.


Figure 1.1 The K-Laser™ programmed and ready to use on a patient.

Contraindications of laser therapy

  • Do not use laser therapy in pregnant animals.
  • Do not use laser therapy to treat animals’ eyes.
  • Do not use laser therapy in animals with neoplasia.
  • Do not use laser therapy over the thyroid area.

Transcutaneous electrical nerve stimulation (TENS)

This consists of a small control box, with wires leading to electrode pads. It is used to reduce pain by transmitting small electrical pulses to the affected area via the electrode pads.

The transcutaneous electrical nerve stimulation (TENS) machine can be used at a frequency of 90–130 Hz to stimulate large nerve fibres that activate the inhibitory interneurons that block the signal in the projection neurons that connect to the brain, and thereby blocking pain perception. If small nerve fibres become active and stimulate the projection neurons, this blocks the inhibitory interneurons and pain will be perceived in the brain.

When the TENS machine is set at a frequency of 2–5 Hz this stimulates the body to produce its own pain-easing chemicals, endorphins, thereby blocking the pain signals.

Many research studies have investigated the positive effects of TENS in humans with orthopaedic and neurological conditions. One study (Mills & Levine, 2014) investigated the effect of TENS on osteoarthritic pain in the stifle of dogs. Five dogs with chronic mild osteoarthritis, induced by cranial cruciate ligament resection and stifle stabilisation, were treated with TENS stimulation (70 Hz) applied to the affected stifle. Pre-treatment ground reaction forces were determined using a force plate before electrical stimulation to assess the functional use of the limb.

Significant improvements in ground reaction forces were found 30 minutes after treatment. These differences persisted for 210 minutes after TENS application and were statistically significant 30, 60, 120 and 180 minutes after treatment.

Each dog was re-evaluated following a 4-day rest period and still exhibited a mild increase in weight-bearing on the affected limb, but these differences were not significant. The author concluded this preliminary study showed positive benefits of TENS application in dogs with osteoarthritic stifle joints.

Manual techniques

Passive range of motion exercises

Passive range of motion (PROM) exercises are movements usually of the limbs performed by an individual such as a physiotherapist. The joints of the limbs are moved passively, and the patient does not gain any strengthening benefits from passive movements of the limbs.

PROM exercises are performed to maintain or improve joint ROM, and to prevent joint inflammation and stiffness. PROM exercises are especially important in recumbent animals that may already have established osteoarthritis and associated pain, stiffness and reduced ROM in the affected joints.

If the patient has undergone joint surgery full ROM of the joint is neither desirable nor essential in the early stages. However, full ROM should be maintained in all the other joints of the affected limb.

PROM exercises can commence from day 1 postoperatively. Gentle PROM exercises within the pain-free range will assist with lymphatic drainage of the limb and limit oedema when used in conjunction with positioning. If the distal limb is oedematous, compression followed by release exercises can be performed: two sets of 50 repetitions appear to be effective.

As the inflammatory phase passes PROM exercise of the affected joint may be gradually increased within the pain-free range, and with consent from the veterinary surgeon.

The animal is usually recumbent for the PROM exercises with the affected limb(s) uppermost. (However, the exercises can be performed in standing with the patient supported.) If the animal has undergone joint surgery this joint should be isolated and gently moved through its pain-free range in all anatomical planes. This joint would then be supported and the other joints in the affected limb would be moved through full ROM in all anatomical planes. PROM exercise three sets of 10 repetitions for each joint twice a day is considered to be effective.

If the patient has not undergone joint surgery and the PROM exercises are being performed to reduce pain, inflammation and stiffness in the joint, all the joints in the limb can passively be moved together. Be aware that if the patient has established osteoarthritis, ROM in the joint may be reduced and at the end of range you will feel a bony block; do not force the joint beyond this point as it will cause the patient further discomfort.

When performing PROM exercises the movements of the operator will push the joints together and then push them apart. PROM exercises should never involve pulling a limb or joints. Do not grip the limb tightly. If all joints are to be moved together into flexion then extension the patient should be supported at the medial elbow for the thoracic limb, and at the medial stifle for the pelvic limb to prevent any rotation of the joints, which may be uncomfortable. The movements should be in line with normal anatomical planes of movement (Table 1.2).

Table 1.2 Normal canine joint range of motion.

Joint Degrees of movement
Carpus Flexion 20–35°

Extension 190–200°

Valgus 10–20°

Varus 5–15°
Elbow Flexion 20–40°

Extension 160–170°
Shoulder Flexion 20–40°

Extension 160–170°
Abduction 40–50°
Adduction 40–50°
Tarsus Flexion 40°

Extension 170°
Stifle Flexion 45°

Extension 160–170°
Hip Flexion 55°

Extension 160–165°


Stretches are performed to maintain or increase muscle length. These are usually performed passively by an operator for recumbent patients, or in patients that have undergone surgery.

If a muscle crosses two joints, such as the quadriceps, any shortening of this muscle group will affect the ROM of the hip and stifle joint. As the quadriceps muscle group shortens, the stifle and hip will be brought into flexion. If the quadriceps becomes shortened or contracted for a prolonged period of time the patient will be unable to extend the stifle and hip, and so weight-bearing through the limb will become problematic.

Changes in muscle length can occur quickly in: (i) recumbent animals; (ii) patients that have recently undergone surgery when they may not be moving limbs through their full ROM; or (iii) an animal that is non-weight-bearing for a period of time, when the flexor muscles will become short and tight, and the opposing extensor muscle groups will become weak.

In recumbent animals stretches should begin on day 1. Flexor, extensor and internal rotator muscle groups should be stretched at least twice daily. Each stretch is held for 15 seconds, the animal is given a few seconds to rest, then the stretch is repeated three times in total. Following stretches, if the patient is resting in lateral recumbency, a wedge should be placed between the thoracic and pelvic limbs to prevent adductor/abductor muscle imbalance. Recumbent animals tend to become tight in the adductor muscle groups, and weak in the abductor muscle groups. Correct positioning following stretches can help to prevent muscle imbalance from occurring.

Stretches can be performed with the patient lying laterally or in standing. If the stretches are performed in standing, the animal will need to be supported at the trunk. The operator will use one hand to support at the origin of the muscle being stretched; with other hand a pushing force will be applied at the insertion of the muscle. The muscle should be stretched until resistance is felt in the muscle, then at this point the stretch should be held for 15 seconds and repeated three times. Stretching should not be uncomfortable for the patient. As described earlier pre-warming a muscle will improve the elasticity of the tissues, thus improving the range of the stretch. This may be useful if the animal is cold, has muscle spasm or has developed muscle contractures.


Mobilisations are graded movements or manipulations of joints that are passive and usually performed by a physiotherapist.

The grade of movement delivered depends on the desired effect of the mobilisation or manipulation. For example, a grade II mobilisation would be a repetitive movement of a joint within its pain-free range with the aim of relieving pain within the joint. However, a grade III mobilisation would also be a repetitive movement of a joint but greater force would be applied with the aim of increasing ROM within that joint.

Mobilisations are treatments used to maintain ROM in painful joints; once the pain within the joint is manageable the grade of mobilisation can be increased to increase ROM within stiff joints.

The operator will be positioned close to the patient. If, for example, the joint mobilisation is to be applied to the spinal processes of the lumbar spine to increase extension the patient will preferably be lying in sternal recumbency. The operator will position her or his hands so that one thumb overlaps the other and using a pulsing motion pressure will be applied directly to the spinal process. The physiotherapist is aligned over the patient and the pressure transmits from the shoulders down the arms to the thumbs; if the pressure was generated from the thumbs alone the physiotherapist would fatigue quickly.

In conjunction with passive exercises to improve ROM and passive stretches to increase muscle length, progressive exercise programmes focused around the assessment findings can be useful adjuncts to achieve short- and long-term goals.

Progressive exercise programmes

  1. Begin with gentle passive and progressive PROM exercises; aim to work within the pain-free range. Repeat the PROM flexion/extension exercises for three sets of 10 repetitions.

    Consider the use of electrotherapy such as a class IV K-Laser™, if available, to reduce pain and inflammation within the joint and control scar tissue, which may reduce ROM.

    If available hydrotherapy using an underwater treadmill (UWT) would be an ideal active exercise for the patient to increase ROM of the joint. Use the buoyancy effect of the water and fill to the level of the patient’s mid-trunk. Start with slow speeds and short duration with plenty of rest breaks, then increase speed and time as the patient progresses.

  2. Stretch short/tight muscles into early resistance, and hold each stretch for 15 seconds, then allow the patient to relax and repeat the stretch, for a total of three stretches. As the patient progresses with his exercise programme he will be functionally stretching muscles as he ambulates and increases weight-bearing through the limb. Controlled stair climbing with support or ascending gentle slopes will all functionally stretch muscles.
  3. Gently start to gradually increase weight-bearing on the affected limb by using weaving exercises to encourage weight transfer onto the affected limb. Start with the cones wide apart; to progress the exercise over the 6-week period reduce the distance between the cones, increase the speed of the exercise (tempting the patient with a treat may help), and gradually towards the end of the 6-week period reduce the support given by the sling.

    Hydrotherapy using a UWT can also be used to strengthen the extensor muscles as the patient places his limb in the stance phase and pushes through the limb and enters the swing phase. As the patient progresses a faster belt speed will encourage longer strides and greater activity in the extensor muscle groups.

  4. Inflammation within the joint may affect conscious proprioception (CP). Stepping over cavaletti poles will challenge and improve CP as the patient will need to think about where he is placing his limb once he clears the pole. Start with the poles low and wide apart, progress by increasing the height and number of poles. Progress him further by altering the arrangement of poles (high, low, high, low).

    Exercising him on different surfaces will improve his CP, as on a slightly uneven surface he will receive increased afferent feedback from his foot to his brain signalling how he should place his foot. Start by exercising him on flat, firm, non-slip surfaces and progress him to grass, bark chippings and sand, which will be the most challenging surface.

    Practising functional activities in a controlled environment will boost the animal’s confidence to carry out these activities in the home environment. If the animal has stairs to negotiate in the home or other places he visits this activity should be practiced under supervision.

    Stair climbing is a functional activity that requires strength to ascend the stairs, and balance to descend the stairs (Figure 1.2).

    Another common functional activity that the animal may need to perform is getting in and out of the car. A ramp is recommended for medium to large dogs. If the animal has not used the ramp before he may be reluctant to use it. Always make sure the ramp is firmly secured to the car. Start by practising getting into the car first so he can gain confidence. Practice this several times before attempting using the ramp to exit the car. Like with stair practice he will feel most vulnerable on the descent. It may be useful to have an assistant at the opposite side of the ramp to yourself to give extra reassurance and to assist the patient should he lose his balance.

    Early gait re-education is vital to prevent any secondary complications or compensatory postures from developing. If the animal is holding the limb in extreme hip flexion most of the time he is at risk of developing muscle imbalance (tight in flexors vs weak in extensors). He is also at risk of developing severe muscle atrophy in the extensor muscle groups, and reduced joint ROM.

    Another point to note is the extra pressure placed on the other limbs, mainly the other pelvic limb and the contralateral thoracic limb. The joints and muscles in these limbs will be placed under greater stress so function in these limbs should also be assessed and treated as necessary. Also the lumbar spine should be assessed in pelvic limb chronically lame animals for any signs of stiffness, and for pain in the associated muscles, which may develop muscle tension or trigger points.

    Laser therapy can be useful in treating lumbar spine pain and inflammation associated with chronic pelvic limb lameness. Alternatively, or as an adjunct to laser therapy treatment, direct ischaemic pressure treatment can be used at the site of the trigger point. A gradual pressure equating to approximately 4 kg is applied until the trigger point or muscle spasm diminishes.

    Lumbar spine pain and stiffness can be treated with mobilisations. Start gently with grade II for pain relief, then progress to grade III to improve mobility and reduce stiffness.

    Active-assisted (using a sling) exercises in a controlled environment are an excellent way to reduce gait abnormalities. As the patient is challenged by the exercises (weaving cones/cavaletti poles) he will not be able to compensate by mobilising on three limbs and therefore will commence with gentle weight-bearing, which is desirable at this stage of the rehabilitation programme.

  5. Hydrotherapy using a UWT is another excellent exercise to improve gait abnormalities as the buoyancy of the water means the patient will have less weight and concussive forces passing through his joints so he will be more likely to use the limb. The warmth of the water will also assist in relaxing any muscle tension. The speed, duration (time), and level of the water (buoyancy effect) can all be controlled to suit the needs of the patient and the rehabilitation programme. Start with slow speeds and short duration; it is important that the patient gains confidence to begin with.

Figure 1.2 A patient ascending stairs. Note the reciprocal gait pattern: the right thoracic limb is flexed to step up, and the left pelvic limb is extended to push off onto the step. The right pelvic limb is flexed to place the limb on the stair, and the left thoracic limb is extended as weight is being taken through this limb.

The aim of the late-stage rehabilitation programme is to fine tune any minor discrepancies regarding joint ROM or muscle imbalances. The late-stage programme aims to improve strength of the affected limb, improve muscle bulk, improve CP and balance, and finally to improve stamina.

  1. Balance: simply start by testing the patient’s ability to resist perpetrations or ‘nudges’, forcing the patient to take weight through the affected limb(s). This exercise can be progressed to incorporate limb lifting. Start by lifting the affected limb, then progress to lifting the non-affected pelvic limb (support the patient as necessary with an arm under his abdomen at the start). Progress the exercise by lifting the contralateral thoracic limb (diagonal lifting). Hold each limb lift for 5 seconds and repeat five times.

    A wobble cushion can be placed under the patient’s limb. Perpetrations or nudges at the contralateral hip will force the patient’s limb onto the wobble cushion, which is an unstable surface so he will need to use stabilising muscles in the limb to maintain his balance. If this exercise is well tolerated, it can be progressed by incorporating limb lifting of the contralateral pelvic limb whilst the affected limb is balancing on the cushion. This will increase the stabilising muscle strength in the limb and also further challenge his ability to balance. Hold each limb lift for 5 seconds and repeat five times.

    Wobble boards can also be used to challenge balance and improve strength. The patient walks onto the board and faces forwards. Start by gently wobbling the board in an anterior/posterior motion. If the patient tolerates this progress to challenge the patient’s balance in the medial/lateral motion. Progress this exercise further to target a limb by incorporating limb lifting into the exercise; start by lifting a pelvic limb. This will force the patient to take more weight through the standing limb, thus increasing strength, and challenging balance. Because a dog takes 60% of his bodyweight through his thoracic limbs this exercise can be further progressed again by lifting the contralateral thoracic limb (diagonal limb lifting), forcing the patient to shift his weight back onto the pelvic limb to increase strength and balance. Hold each limb lift for 5 seconds and repeat five times.

    The owner can be taught how to carry out the limb-lifting exercises at home. The owner could also have the patient walk in figures-of-eight or in circles to challenge balance. Start with wide figures-of-eight and circles, and then progress by making them smaller.

  2. Stamina and cardiovascular (CV) fitness: will start to improve as the patient is allowed more lead exercise at this stage. Hydrotherapy can be useful in the late stages of rehabilitation as the speed of the belt can be increased to a fast walking pace or gentle trot; this will also improve joint ROM as the patient will take longer strides and improve extensor muscle strength as he propels himself forwards. The level of the water can also be adjusted to give a strengthening effect. The greatest resistance of the water is at the surface level so this level should correspond with the level of the muscle groups you are aiming to strengthen. Resistance can be added by using the UWT water jets; this will further increase strengthening. The work time can also be increased, and the rest time decreased to increase stamina and CV fitness.

Musculoskeletal presenting conditions

The coxofemoral joint

Common conditions associated with the coxofemoral joint, or hip joint as it is often referred to, include:

  • Hip dysplasia.
  • Legg–Calvé–Perthes disease.
  • Fractures.
  • Luxations.

The coxofemoral joint is stabilised by the:

  • Teres ligament.
  • Joint capsule.
  • Dorsal acetabular rim.
  • Surrounding muscles.

Hip dysplasia (HD)

Hip dysplasia is described as an abnormal development of the coxofemoral joint characterised by subluxation or complete luxation of the femoral head from the acetabulum in young animals (<1 year old) leading to degenerative joint disease in later life.

HD is thought to be a multifactorial disease process. The primary cause is thought to be hereditary, and the incidence of HD is highest in large breeds of dogs including Labradors and German shepherd dogs. Environmental factors cited include rapid weight gain, rapid growth and over-exercise.

Hip dysplasia is also seen in humans. However, this is not considered a hereditary condition and is not screened for. The primary cause in humans relates to the size (large) and presentation of the foetus. The incidence is highest in large female babies who develop in a confined space with the hip joint flexed and rotated. All babies are assessed for excessive hip laxity shortly after birth. If hip dysplasia is confirmed the baby is fitted with a special hip brace, which is worn for most of the day for a period of months to correct the hip deformity.

However, the disease process of HD in animals is described as:

  • Slackening of coxofemoral joint ligaments.
  • Subluxation of the femoral head from the acetabulum.
  • Destruction of cartilage surfaces.
  • A change in shape of joint surface, the femoral head becomes flattened, and the acetabulum becomes shallow.

Secondary osteoarthritis develops resulting in new bone growth at the destroyed cartilage sites, and the formation of fibrous tissue within the joint space as an attempt to provide joint stability.


  1. Joint instability/wobbly pelvic limb gait pattern.
  2. Pain, especially on end-of-range hip extension, and later abduction.
  3. Muscle atrophy, especially in gluteals.
  4. Difficulty rising, especially after lying for a long period of time, which is common in the morning, or following exercise.
  5. Exercise intolerance or reduced levels of exercise.

Physical examination

  1. Increased hip laxity caused by weakened ligaments and sub/luxation of the hip joint.
  2. Reduced ROM in the hip joint, caused by remodelling of the joint surfaces and associated joint fibrosis.
  3. Poor musculature; the animal will be reluctant to weight-bear through the affected limb and will attempt to shift weight onto other limbs, often most evident in stance.

Hip dysplasia – general management

Dietary management: control weight gain especially in immature animals that are still growing. Immature joints have a higher degree of mobility; increased weight gain will place further stress on these developing joints.

Exercise management: again in immature animals that are still growing excessive uncontrolled exercise can place the developing hip joint under increased stress, which may lead to an abnormally developing joint.

Pain control: short-term use of 1–3 weeks’ analgesia and strict rest may be prescribed by a veterinary surgeon if indicated.

Nutraceuticals: these may be considered as an adjunct to therapy. The aim of these natural products is to protect the cartilage surfaces and prevent the formation of new bone forming at these sites. Since the changes in cartilage occur early in the disease process the use of nutraceuticals should commence at an early stage also.

Chondroprotectants and nutraceuticals are compounds that are proposed to have a positive effect on the health and metabolism of chondrocytes and synoviocytes (Beal, 2004).

Chondroprotective agents have three main effects:

  1. To support or enhance metabolism of chondrocytes and synoviocytes (anabolic).
  2. To inhibit degradative enzymes in the synovial fluid and cartilage matrix (catabolic).
  3. To inhibit formation of thrombi in the small blood vessels supplying the joint (antithrombotic) (Beal, 2004).

A combination of glucosamine hydrochloride, chondroitin sulphate, manganese and ascorbate is a commonly used nutraceutical in osteoarthritic small animals (Hulse, 1998). The use of these nutritional supplements is supported by clinical studies investigating the treatment of osteoarthritis (Leeb et al., 2000).

Cosequin® has also been found to suppress the anti-inflammatory effects of acute synovitis and immune-mediated arthritis (Beren et al., 2001; Canapp et al., 1999).

Hip dysplasia – conservative versus invasive surgery

The surgical options for hip dysplasia include total hip replacement (THR) or femoral head and neck excision (FHNE) (Figure 1.3). However, when choosing between conservative therapy and surgery, one should take into account the animal’s age and current level of activity. The aim of the rehabilitation programme should be to return the animal to its highest level of function. A case study of a conservative rehabilitation programme illustrates a typical approach taken with a 12-month-old dog.


Figure 1.3 Severe hip dysplasia with a left femoral head and neck excision.

Stifle joint

The canine stifle is made up of bones that form joints, which are supported by ligaments and menisci.



  • Femur.
  • Tibia.
  • Patella.
  • Fabellae.
  • Popliteal sesamoid.


  • Femoral-tibial.
  • Patella-femoral.


  • Cranial cruciate ligament – stabilises the tibia relative to the femur to prevent hyperextension and also internal rotation of the tibia.
  • Caudal cruciate ligament – stabilises the tibia to prevent caudal displacement relative to the femur.
  • Medial and lateral collateral ligaments – prevent valgus and varus movement of the stifle joint.


  • Medial.
  • Lateral.

Cruciate ligament injury

Cruciate injury is a relatively common condition in small animals. It is typically seen in young active dogs. Presentation maybe seen as an acute, chronic or a partial tear.


Canine cruciate ligament (CCL) rupture may be acute and related to trauma, and seen in any breed. Chronic injury occurs over a period of time and may be multifactorial in nature. Obesity and muscle imbalances may contribute to chronic cruciate injury. Partial tears can cause pain and inflammation; if the tear is minor it may settle with rest and conservative treatment. However, major partial tears may require a more invasive approach (surgery) (Figure 1.5).


Figure 1.5 Sequence of cranial cruciate ligament disease events.

It may be worth noting that not all humans or indeed animals undergo surgical procedures to stabilise a ruptured cruciate ligament. Over time capsular fibrosis occurs and this scar tissue stabilises the joint to some degree. However, a trade-off may be some loss of ROM in the stifle, but the limb will be functional. If the patient goes on to develop a meniscal injury this will require surgical intervention as pain will be present when the animal flexes and loads the joint, resulting in chronic lameness. Secondary osteoarthritis of the stifle joint will occur as a consequence of CCL injury.

Clinical signs

  • Lameness – non-weight bearing if acute, subtle lameness associated with exercise in early partial tears.
  • Joint effusion – seen in the acute stage, and is part of the normal injury inflammatory process.
  • Fibrosis – (medial buttress), palpate medial aspect of stifle joint and compare with the contralateral stifle.
  • Muscle atrophy – (indicates its not an acute injury).
  • Decreased ROM of the affected stifle.
  • Crepitus or meniscal clicking of the stifle during passive flexion and extension may be evident.

Conservative treatment

  • Rest.
  • Non-steroidal anti-inflammatory drugs (NSAIDs) for 6 weeks.
  • Weight reduction (if appropriate).
  • Controlled exercise to strengthen the hamstring muscle group to stabilise the tibia and prevent forward draw of the tibia.

Surgical treatment


  • Lateral fabellar suture.


  • Over-the-top technique (OTT).
  • Tibial plateau levelling osteotomy (TPLO).
  • Tibial tuberosity advancement (TTA).
  • Tibial wedge osteotomy (TWO).
  • Triple tibial osteotomy (TTO).

Tibial osteotomies all aim to eliminate cranial tibial thrust, and provide long-term stability of the stifle joint. Long-term studies are required to provide evidence of each technique’s effectiveness.


  • Infection.
  • Implant failure.
  • Late meniscal injury.
  • Persistent lameness.
  • Osteoarthritis.
  • Rupture of contralateral cruciate ligament.
Jul 18, 2021 | Posted by in NURSING & ANIMAL CARE | Comments Off on 1: Musculoskeletal physiotherapy

Full access? Get Clinical Tree

Get Clinical Tree app for offline access