PATIENT SIGNALMENT: Canine. Yorkshire terrier. 1yr old. Male, castrated.
HISTORY / CLINICAL SIGNS: 1 mo Hx of intermittent yet progressive left forelimb lameness. Occasionally non-weightbearing. No known inciting cause or injury. Lameness unchanged with activity vs. rest. Some improvement with NSAIDs (meloxicam). UTD vaccines and HW/flea/tick preventives.
PHYSICAL EXAM FINDINGS: BAR, excitable temperament. BCS 5/9. MCS 2-3/3 left shoulder; otherwise 3/3. PE unremarkable besides LF lameness.
NEURO EXAM FINDINGS: Unremarkable. Exhibits circling behavior to the left when excited, but thought to be behavioral, not neurologic.
ORTHOPEDIC EXAM FINDINGS: LF lameness (score 3-5/5) & pain localized to shoulder. Minimal muscle atrophy of LF. Symmetry between forelimbs. Awake exam limited due to excitable temperament. Sedated exam yielded decreased ROM of LF & repeatable discomfort upon shoulder abduction & LF extension, especially upon palpation of biceps, infraspinatus, & supraspinatus. No crepitus. No gross structural instability.
What is on your differential diagnosis list? What diagnostic tests would you order? Any other questions?
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DIAGNOSTIC TESTS & RESULTS:
- CT scan: Small osteophyte along caudal margin of left humeral head (see IMAGE 1 below). Otherwise unremarkable, including normal right shoulder, both elbows, & cervical spine.
- Ultrasound (left shoulder):
- Infraspinatus tendon: mildly thickened at level of insertion with well-defined rounded hypoechocic region & heterogenous fibers (see IMAGE 2 below).
- Biceps tendon: mildly thickened; heterogenous fibers; sheath moderately distended by anechocic fluid; moderate osteophyte at intertubercular groove (see IMAGE 3 below).
- Supraspinatus tendon: mildly thickened & hypoechoic. Infraspinatus & supraspinatus muscles: unremarkable.
- Glenoid cavity: small well-defined round hyperechoic focus (see IMAGE 4 below).
- Ultrasound (right shoulder): unremarkable
IMAGE 1 – CT scan – left humerus
IMAGE 2 – ultrasound – left infraspinatus tendon
IMAGE 3 – ultrasound – left biceps tendon
IMAGE 4 – ultrasound – left glenoid cavity
Based on this patientโs signalment, clinical signs, physical exam findings, and test results, what is your diagnosis, recommended treatment, and prognostic outlook?
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DIAGNOSIS: Supraspinatus & Infraspinatus Tendinopathy (mild), Bicipital Tenosynovitus (moderate, chronic), & Osteoarthrosis (mild) of the Left Shoulder
A definitive inciting cause of this soft tissue injury cannot be proven, but the patientโs compulsive tendency to spin rapidly to the left when excited is thought to exacerbate or be the initial cause of the injury.
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TREATMENT:
- NSAIDs: Continue meloxicam daily for anti-inflammatory effects & pain relief.
- Autologous Conditioned Plasma (ACP) injections: To promote soft tissue healing, blood from the patient was drawn to harvest ACP to be injected into the left glenohumeral joint & around the left infraspinatus & supraspinatus tendons q 3 weeks X 3 sessions.
- Shockwave therapy: To promote healing & minimize pain, shockwave therapy was performed over the left infraspinatus, supraspinatus, & biceps tendons q 3 weeks X 3 sessions.
- Behavioral modification: Control spinning behavior with positive reinforcement to prevent worsening tendon strain. Start fluoxetine (Prozacยฎ).
- Exercise restriction/rest
- Considerations if the above therapies fail: Acupuncture. Additional psychopharmaceutical(s). Hobble system for front limbs.
PROGNOSIS: 4 months following the start of treatment, the patient has markedly improved and only requires meloxicam occasionally. Fortunately, additional therapy considerations were not needed. The patient has been recently weaned off fluoxetine (it only had a mild subjective effect in decreasing spinning behavior). Daily use of Purinaยฎ Calming Care probiotic supplement is being considered. He now only occasionally limps on the LF due to overuse and is monitored to prevent re-injury.
Who knew a Yorkie would develop a โsports injuryโ from hyperactive spinning?!
Any other questions, comments, or suggestions?
Unless otherwise stated, these clinical cases are real-life cases that I have managed as a veterinarian in general small animal veterinary practice or else assisted with as a student in vet school. These cases are a great real-world learning tool for vet students and other veterinary professionals. They shall be used for learning purposes and collaboration of knowledge only. These cases are not intended to diagnose or treat any disease by pet owners. – Maranda Elswick, DVM
