Introduction

The Efficient Canine Orthopedic Examination

The objective of this session is to provide the veterinarian with some practical tips on how to perform an efficient but thorough orthopedic exam. We recommend you practice this examination on as many normal candidates as you can get your hands on, so that when you then get your hands on an abnormal patient you will appreciate the difference! Try to develop a consistent approach to this exam every time you perform it to help ensure you are not missing steps. Look for a consistently repeatable response from your patient that fits with the signalment and history, then use this information to guide further investigation.

Gait Observation/Ambulatory Exam

The purpose of this portion of the evaluation is to help decide if the dog’s gait is sound (normal), lame (orthopedic), or ataxic (neurologic). Localize the lameness to a particular limb or limbs. Grade the lameness severity as a reference to others, and to assess the success of treatments.

CSU small animal orthopedic lameness grading scale

Tips for Success

• Use an assistant to lead the patient whilst you observe, a quiet area (with few distractions), and good footing is ideal.
• Video the patient and replay in slow motion (use of a smart phone on a selfie stick can be particularly handy!)

What You Are Looking for When You Compare the Right and Left Sides of the Patient

• Head or hip “bobbing”—rise and fall.
• Pets lift their head/hip as the paw of the painful limb strikes the ground—in order to “un-weight” the limb.
• Some people prefer to watch for dropping of the head/hip when the normal limb strikes the ground—”Down on sound”.
• It is best to look for forelimb lameness as the dog walks towards you and hind limb lameness as the dog walks away.
• Stride length may be shortened in the affected limb.
• Straight vs. circular advancement of the limb.
• Abduction or adduction of the affected limb may also be noted.
• If you do not note a lameness at a walk, observe the dog walking at a faster pace or ascending and descending stairs.
• More weight is carried by the hind limbs when ascending and the fore limbs when descending.
• Watch which limb the dog may preferentially lead with, or whether it “bunny hops” both limbs together.

Sit Test

• Observe the patient as they are asked to sit on command.
• Forcing the patient to sit by pushing on their hind end may result in false positive or negative.
• A positive sit test is when the patient sits with the leg held out to the side, underneath the body or behind the body.
• In order to sit normally (negative sit test), dogs need to comfortably fully flex the stifle and tarsal joints.
• A positive sit test may indicate lameness related to the stifle or the tarsal joint (e.g., cranial cruciate ligament disease.

Standing Exam

• The goal of this portion of the exam is to further localize the lameness to a specific joint/bone/muscle or tendon.
• Use both hands simultaneously to note asymmetry in muscle mass, joint effusion, tissue warmth, bony landmarks, etc.
• Allow pet to familiarize with examiner!
• Stand animal symmetrically.
• Most dogs shift their sore limb(s) away from the center of their body weight.
• Be systematic—work from rostral to caudal, and from proximal to distal on the patient.
• “Eyes in your fingertips”
• Pelvic limb—can usually evaluate entire limb while standing behind patient.
• Thoracic limb—stand in front or beside patient to examine limb (use muzzle and avoid eye contact if patient feels threatened).
• Effusion readily detected in elbow, stifle, carpus and tarsus.
• Correlate findings with previous clinical findings from signalment, history and gait observation.

Joint Manipulation

• The goal of this portion of the exam is to further confirm your localization of the lameness to a specific joint/bone/muscle or tendon.
• Whether you localize more with the standing or recumbent portion of your physical exam may be dictated by temperament of patient. Some animals are better evaluated with secure restraint in lateral recumbency, whilst other patients will “tense up” making interpretation of pain and/or instability difficult.
• Comfort the pet to aid in relaxation.
• Usually begin with “normal” limb first.
• Usually start at toes and move proximally on the limb.
• What to look for when manipulating the joints (CREPI).
• Crepitus.
• Range of motion.
• Effusion.
• Pain.

Instability

• Don’t forget to palpate the bones in-between the joints and the axillary and inguinal regions!
• Look for a consistent, repeatable response from the patient that fits with the rest of the previous exam findings!

Specific Manipulations for Specific Joints

• Elbow
• Supination/pronation (with carpus and elbow held at 90 degrees).
• Direct palpation of medial compartment of the elbow (just distal to prominent medial epicondyle).
• Shoulder
• Biceps traction test (biceps tenosynovitis—flex shoulder, extend distal limb, palpate bicipital groove).
• Abduction angles (shoulder in extension not flexion).
• Stifle
• Cranial drawer (landmarks—patella, lateral fabella, tibial tuberosity and fibular head).
• Tibial thrust (index finger over patella and patella tendon onto tibial tuberosity, flex tarsus and compress tibia).
• Ensure the tibia is not already cranially translated by pinching between your proximal hand’s index finger and thumb.
• Patella luxation (if present, it is usually easiest to luxate and reduce the patella with the stifle in extension—patella will be proximal in the groove).
• Hip
• Landmarks (hip luxation—triangle, thumb-pinch).
• Ortolani (support pelvis, push dorsally with leg in neutral position to subluxate, then abduct the limb to feel for “clunk” of reduction=Ortolani sign).
• Other
• Lumbosacral disease (direct palpation, extension of the hind limbs).
• Iliopsoas muscle strain (traction with extension of hip and internal rotation of femur).