Evaluation and Rehabilitation Options for Orthopedic Disorders of the Pelvic Limb



Summary

A comprehensive evaluation from a physical therapy perspective requires keen observational and manual skills. Assessment of the pelvic limb entails careful examination of the toes, tarsus, stifle, and hip as well as a scan of the spine to rule out referred pain. Elements of the exam include postural evaluation, functional assessment, gait analysis, strength testing, passive range of motion (PROM), flexibility testing, soft tissue palpation, joint play assessment, and special tests. Abnormal findings are used to create a problem list. Interpretation of the history and objective exam are considered in developing an assessment and physical therapy working diagnosis. Functional and measurable goals are established and are used as benchmarks of progress. Finally, a treatment plan is formulated to addresses the stated abnormal findings relative to the preset goals. The plan will include frequency and duration of treatment as well as the specific elements of the treatments. Treatment may include manual techniques such as soft tissue techniques and joint mobilization, modalities such as laser and electrical stimulation, and therapeutic exercise such as proprioceptive and strengthening exercises. Frequent reassessment is necessary in order to determine the effectiveness of the plan.





Evaluation of the Pelvic Limb


A rehabilitation orthopedic assessment includes a thorough patient history and a detailed examination. The examiner must be aware of the patient’s past medical history, results of imaging, current medications, and treatment to date. Subjectively, the owner provides information regarding the mechanism of injury (MOI) if applicable, aggravating or relieving activities and observed functional deficits.


Achieving an accurate diagnosis requires a strong knowledge of anatomy, fine-tuned manual skills, keen observational skills, and a good understanding of biomechanics. When examining the pelvic limb, it is important to scan the spine and pelvis to rule out referred pain from these proximal segments. A brief scan will include spinal AROM, assessment of pelvic alignment, soft tissue palpation, and joint provocation testing. Additionally, conscious proprioception is tested, and gait is observed for possible neurologic signs.


Elements of an Orthopedic Exam of the Pelvic Limb


Organizing the Exam


Sequencing of the exam is driven by patient comfort. At the first appointment, building trust is essential. Relaxed, friendly communication with the owner will help put the patient at ease. The patient is free to explore the new surroundings while the therapist obtains historical information from the owner. This author prefers to begin the exam with the hands-off elements of the evaluation, allowing the patient additional time to gain trust of the examiner. These elements in­­clude observation of posture, functional transfers, strength, and gaiting (see Chapter 2). The hands-on elements of the exam are performed next and include passive range of motion (PROM), flexibility, palpation, joint play, and special tests. The exam can be performed with the patient in lateral recumbency or in standing depending on patient preference. Ideally, the involved limb is evalu­­ated last.


Posture


Posture is observed in standing and sitting positions. Observing the patient in standing position, the therapist should note foot placement, top line (lordosis or kyphosis), head and tail position, balance of weight bearing (WB) (weight shift forward or backward, left or right), and any off-weighting of a limb (Figure 15.1). WB can be classified as nonweight bearing (NWB), toe-touch weight bearing (TTWB), partial weight bearing (PWB), or full weight bearing (FWB). Amount of WB can also be documented with an approximate percentage (e.g., PWB, approximately 60%). The patient is observed for the symmetry of the sitting posture, with a normal sit considered “square.” Positioning of all limbs, range of motion (ROM) of the pelvic limbs and WB are noted. For example, a patient with a stifle injury will commonly sit with the involved limb in hip abduction and external rotation, and decreased stifle and/or tarsal flexion (Figure 15.2).



Figure 15.1 Abnormal weight bearing. Dog is off-loading the right pelvic limb.


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Figure 15.2 Abnormal sitting posture. Dog is sitting with left stifle extended and abducted.


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Function


A functional assessment examines the patient’s activities of daily living. The assessment will depend on the patient’s job and condition. Therefore, the components included in assessment of a tetraparetic patient will be quite different than those of a postsurgical cranial cruciate ligament (CCL) patient or an agility patient with postevent lameness. Function is assessed by observation of specific activities. Analysis of the movement re­­quires a good understanding of functional anatomy and biomechanics. Elements of a functional exam may include stand-to-sit, sit-to-down, and sternal-to-lateral recumbency transfers as well as the reverse of each. Proper sequencing, timing, ROM, and strength are required to complete each transition appropriately. Pain and weakness will be reflected in compensations.


Gait Analysis


The difference between a lameness exam and gait analysis should be noted. The physical therapist evaluates gait with an eye for functional impairments and compensatory movement. The patient is observed in each gait (as appropriate for their current condition), as well as on stairs, inclines, declines, and while moving in circles in both directions. The patient is viewed from the front, the back, and each side. The stance and swing phases of gate are observed for appropriate ROM at each joint, proper muscle firing, and for compensatory movement. For example, if a patient is limited in stifle extension on the right pelvic limb, the ipsilateral swing phase of gait will be decreased. The examiner may note compensatory excessive lumbar side bending to the right in the patient’s attempt to lengthen the swing phase. Further evaluation is necessary to determine if the stifle is limited by swelling, muscle, joint capsule, or nerve.


Strength


Strength testing in humans is performed by asking the patient to hold a limb in a specific position against manual resistance. Isolating specific mus­cles, as done in the human assessment, is not possible with the canine patient; however, specific groups of muscles can be assessed. Canine strength is tested by placing the patient in specific test positions of varying difficulty. Grading the test depends on the patient’s ability to maintain a static, symmetric posture. The therapist makes note of compensatory movement related to weakness or pain. Information regarding specific muscle function is obtained by palpating individual muscle groups for intensity of contraction while the test is being performed. Strength tests are performed bilaterally for comparison. For accurate, reproducible testing, it is essential that the patient’s head be positioned appropriately. In the case of pelvic limb testing, treats are offered such that the head is elevated and the weight is shifted to the hindquarters. Strength can be graded and documented as poor (inability to maintain the standard test position), fair (ability to maintain the standard test position), and good (ability to maintain the advanced test position).


One example is the three-leg stand (Figure 15.3). To test the general strength of the right pelvic limb, the therapist unweights the left pelvic limb by holding the dorsal surface of the pes. The patient’s head must be elevated to insure WB in the hindquarters. The therapist will observe for the patient’s ability to maintain normal alignment of the standing leg. Specific muscles are palpated, such as hamstrings, quadriceps, and gluteals, noting the extent of contraction.



Figure 15.3 Three-legged standing test for general strength of the right pelvic limb.


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Diagonal leg standing is a more challenging test for the patient who demonstrates good strength on the three-leg stand. The assistant unweights a diagonal pair of legs, encouraging the patient to support full body weight through the standing limbs (Figure 15.4). To ensure that the pelvic limbs specifically are being assessed, the patient is offered a treat to elevate the head and shift the weight to the pelvic limbs. The therapist observes alignment, palpates each muscle group, and documents findings as above. With different head positioning (head pointing down), this test can also be used to assess front limb strength and core stability.



Figure 15.4 Diagonal leg standing test.


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Because atrophy may be associated with weakness, additional information regarding strength can be obtained with girth measurements. A Gulick is used to measure the circumference of both thighs (Figure 15.5). This baseline information provides the therapist with a means of monitoring progress. Gulick measurements can be performed in a weight-bearing or non-weight-bearing position. Because thigh circumference measurements vary according to the test position, the therapist must use the same test position for follow-up measurements.



Figure 15.5 Measuring the circumference of the thigh using a Gulick tape.


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PROM


Restricted ROM at one segment often leads to compensatory increased ROM at a related segment. As discussed in Chapter 6, the options for treating hypermobility are fewer and less desirable than the options for treating hypomobility. Therefore, it is important to identify hypomobility in its early stages before resulting compensatory hypermobility occurs. This is accomplished by assessing PROM.


PROM is performed by moving the joint through its available ROM, adding overpressure and determining the end-feel. If a restriction is noted, ROM is measured with a goniometer and compared to the contralateral side. The measurement of the uninjured limb is used as normal for that patient. The end-feel of the restricted joint is determined. This information is used to identify the limiting structure. The therapist can then choose the proper treatment to affect that particular structure. PROM is assessed throughout the toes, tarsus, stifle, and hip. Except for the hip, flexion and extension are the primary motions to be evaluated. At the hip, internal and external rotation and abduction and adduction can be examined. For more detailed descriptions of assessment of PROM, refer to Chapter 5 and Chapter 6.


Flexibility


Movement can be limited by muscle tightness; therefore, it is important to assess flexibility and determine whether it is contributing to the loss of motion. Muscle flexibility is assessed by placing the limb in the position opposite to the action(s) of the muscle being tested. Results are documented as normal or minimally, moderately, or severely restricted. A goniometer can be used to quantitate. This technique is described in detail in Chapter 6. Pelvic limb muscles that should be evaluated include the gluteals, iliopsoas, sarto­­rius, hamstring group (biceps femoris, semi­membranosus, semitendinosus, gracilis), sartorius, quadriceps, adductor, pectineus, gastrocnemius/calcanean tendon, and superficial digital flexor muscle (Table 15.1).


Table 15.1 Flexibility testing





































Muscle(s) Stretched position
Gluteal Hip and stifle flexion
Iliopsoas Hip extension and internal rotation
Biceps femoris Hip flexion and adduction, stifle extension, tarsal flexion
Semimembranosus/semitendinosus Hip flexion with slight abduction, stifle extension
Gracilis Hip flexion with abduction, stifle extension
Sartorius/rectus femoris Hip extension, stifle flexion
Adductor/pectineus Hip abduction
Quadriceps Stifle flexion
Gastrocnemius/calcaneal tendon Stifle extension, tarsal flexion
Superficial digital flexor Stifle extension, tarsal flexion, digital extension

Palpation


Palpating for abnormal or painful tissues is performed after PROM and flexibility testing have been completed. For patient comfort, it is important to palpate with the pads rather than the tip of the fingers. In a thorough palpation exam, the therapist assesses muscles, ligaments, tendons, and joint lines for pain, heat, swelling, tone, texture, and trigger points (see Chapter 6). Any abnormality is compared to the contralateral side. Important structures to assess include the gluteal, piriformis, tensor fascia latae, iliopsoas, sartorius, quadriceps, hamstring, gracilis, adductor, pectineus, gastrocnemius, superficial digital flexor, deep digital flexor, and cranial tibial muscles, as well as the sacrotuberous ligament, stifle medial collateral ligament (MCL) and lateral collateral ligament (LCL), popliteal lymph node, patellar ligament, parapatellar region, stifle joint line, possible medial buttress, calcaneal tendon, long digital extensor tendon, tarsal MCL and LCL, sesamoids, and digital joints.


Joint Play


It is beyond the scope of this chapter to train the reader to perform arthrokinematic assessment glides, as they require hands-on training. These glides are used to assess for normal joint play movement at each joint. Normal arthrokinematic motion is required for normal osteokinematic motion to occur. If a restriction is noted, it is documented on a 0–6 scale. The reader is referred to Chapter 6 for a detailed description of joint play assessment. Table 15.2 provides a list of the most commonly used assessment glides for the pelvic limb. Figure 15.6 shows an example of a cranial glide of tibia on stabilized femur.


Table 15.2 Hind limb joint play assessment



















Joint Assessment glides/traction
Coxofemoral joint Distraction
Stifle: Tibiofemoral joint Caudal, cranial, distraction
Tarsus: Talocrural joint Caudal, cranial, distraction
Pes: Phalangeal joints Dorsal, ventral, distraction


Figure 15.6 Cranial glide of the tibia on a stabilized femur.


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Special Tests


In addition to the special tests described for each joint in Chapter 14, the physical therapist may use the following tests.


The McMurray Test


The McMurray test is a human evaluative technique used to assess for meniscal tears. The action of this test is designed to compress a potential meniscal tear, with a positive result indicated by pain, a springy end-feel, and/or an audible clunk. To test the medial meniscus, the therapist starts with the stifle in flexion. The stabilizing hand is on the stifle, palpating the joint line, and the other hand grasps the tarsal-metatarsal region. The distal hand is used to externally rotate the tibia. While maintaining tibial external rotation, the proximal hand applies a valgus stress to the stifle as the joint is moved into extension. This can be reversed to test the lateral meniscus.


Long Digital Extensor Subluxation


Long digital extensor subluxation is tested by palpating the tendon of origin while flexing and extending the stifle. This disorder can be mistaken for patellar luxation, as the patient will present with an intermittent skipping gait.


Superficial Digital Flexor Tendon Luxation


Superficial digital flexor tendon luxation is tested by flexing the tarsus while palpating the tuber calcaneus. A positive test reveals a popping or sliding of the tendon to the medial or lateral aspect of the tuber depending upon which retinaculum has been stretched or ruptured.


Treatment Options for Disorders of the Pelvic Limb


This section will describe the physical therapist’s approach to treating commonly diagnosed pelvic limb disorders in canine patients. The goal of physical therapy is to maximize function. Normal musculoskeletal function requires normal ROM, flexibility, strength, and muscle recruitment in the absence of pain. Rehabilitation treatment techniques address one or more of the following conditions: pain (inflammation), hypomobility, hypermobility, and weakness or altered muscle recruitment. There are many options for addressing each of these conditions; thus, skilled treatment lies in the nuance of introducing and discharging the most efficient treatment techniques according to the stage of recovery and the individual response. Keys to successful outcomes are


Jul 9, 2017 | Posted by in EQUINE MEDICINE | Comments Off on Evaluation and Rehabilitation Options for Orthopedic Disorders of the Pelvic Limb
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