Downloaded from inpractice.bmj.com on June 29, 2012 - Published by group.bmj.
com
Companion animal practice
Andy Moores graduated from
Bristol in 1996, and spent five
years in small animal practice
before returning to Bristol to
complete a residency in small
animal surgery. He subsequently
spent three years as a lecturer in
small animal surgery at the Royal
Veterinary College. He is currently
head of the orthopaedic service
at Anderson Moores Veterinary
Specialists. He holds the RCVS
diploma in small animal surgery
(orthopaedics), is a diplomate of
the European College of Veterinary
Surgeons and an RCVS recognised
specialist in small animal surgery
(orthopaedics).
doi:10.1136/inp.d8267
22 In Practice January 2012 | Volume 34 | 2226
Muscle and tendon disorders in small
animals 1. General management and
conditions affecting the forelimb
Andy Moores
Muscle and tendon injuries and diseases are common causes of lameness
in dogs and occasional causes of lameness in cats. This article reviews
the general management of these disorders and provides an overview of
specific conditions affecting the forelimb (thoracic limb). A second article,
to be published in the February issue of In Practice, will consider conditions
affecting the hindlimb (pelvic limb) and digital flexor tendon injuries.
General management fibrous scar tissue. When the entire muscle is affected,
the result is a contracted and inelastic muscle referred
Presentation to as fibrotic myopathy or muscle contracture. The
Muscle and tendon disorders can present in a variety most common examples of this are discussed later.
of ways. Completely ruptured or avulsed tendons are Indirect muscle injuries result from excessive
associated with complete dysfunction of that muscle force or stress on a muscle without direct trauma.
tendon unit, but may not necessarily be unduly pain- They are often referred to as muscle strains. Strains
ful. Dysfunction of the extensor muscletendon units may vary from clinically mild and self-limiting inju-
of the elbow, stifle and hock will be more obvious ries to complete muscle tears. The weak-point in the
than that of the corresponding flexor units due to muscletendon unit is the myotendinous junction
their greater role in weightbearing. Tendinopathies or and complete tears are most often seen in this area.
incomplete tendon injuries or avulsions are more likely In the acute period, mild to moderate muscle strains
to result in pain due to forces being applied across the are treated by topical cold therapy and non-steroidal
injured or diseased area. These injuries may not be anti-inflammatory drugs (NSAIDs) to limit inflamma-
associated with dysfunction of the muscletendon unit tion followed by a period of rest for one to three weeks
other than that related to the pain component of the and then a gradual return to normal activity. Severe
condition. strains with partial or complete rupture of a muscle
Muscle injuries are generally very painful in the may require surgical repair. They are uncommon in
acute phase but, with time, will become less so, and pet dogs, but more common in racing greyhounds.
usually there are no long-term consequences. The Many muscles or groups of muscles are enclosed
exception to this is if the injury leads to muscle fibro- within a defined anatomical compartment by bone
sis, which is non-painful but will result in a character- and inelastic fascial sheaths. Consequently, injury to
istic dysfunction, depending on the muscle involved. such a compartment resulting in swelling and/or arte-
rial haemorrhage will lead to an increase in pressure
Muscle injuries within the compartment that can cause local neuro
Muscles can be injured by a variety of mechanisms muscular ischaemia due to vascular compromise, a
including ischaemia, and direct (contusions or lacera process known as compartment syndrome (Box 1).
tion) and indirect injuries. Complete muscle lacera-
tions repaired surgically will primarily heal with a Muscle and tendon surgery
connective tissue scar. Functional recovery after such Severe muscle tears/ruptures should be debrided of
injuries is rarely complete but partial recovery can be haematoma and repaired with long-lasting, mono-
expected. Recovery after partial lacerations depends filament absorbable sutures such as polydioxanone
on the degree of laceration. (PDSII; Ethicon). Muscle does not hold sutures well
Muscle contusion is followed by haematoma and and so tension-relieving patterns such as horizontal
an inflammatory reaction with later scar tissue forma- and vertical mattress sutures should be used, incor-
tion and variable muscle regeneration, depending on porating strong fascial sheaths wherever possible.
the degree of injury. Severe contusion, particularly if Repaired complete ruptures are unlikely to be able to
recurrent, may result in heterotopic bone formation withstand physiological forces in the immediate post-
or myositis ossificans, which may or may not cause a operative period and so a strategy to protect the repair
clinical problem. This can occur in any location and and prevent gap formation at the repair is important.
may be more common in dogs with von Willebrands Tendons can be anatomically classified as those
disease. Severe or repeated contusion may also lead to with a synovial sheath, such as digital flexor ten-
the replacement of normal muscle architecture with dons, or those that move in a straight line and are
 Downloaded from inpractice.bmj.com on June 29, 2012 - Published by group.bmj.com
Box 1: Compartment syndrome
Four compartments have been identified in the limbs
of dogs (Basinger and others 1987):
The craniolateral compartment of the crus
(proximal tibia);
The caudal compartment of the crus;
The femoral compartment;
The caudal compartment of the antebrachium.
Compartment syndrome is most often associated
with blunt trauma and recognised by tense swelling
of the osteofascial compartment, as well as with
pain and potential dysfunction of the nerves passing
through the compartment. The author has seen the
syndrome most often in the femoral compartment of
dogs, in association with complex femoral fractures.
Compartment pressures can be measured with an
arterial manometer attached to a split or wick catheter.
Standard hypodermic needles tend to overestimate
pressures. The normal compartment pressure in dogs
is 2 to 8 mmHg. Surgical fasciotomy is warranted if
the pressure exceeds 30 mmHg.
surrounded by loose areolar connective tissue called
the paratenon. The paratenon contains a rich vascu-
lar network that supplies the tendon whereas sheathed
tendons take their vascular supply from the musculo
tendinous junction, the periosteal attachment and
from a few discrete bands, known as vincula, which
originate from the synovial sheath.
In humans, in order to maintain good hand func-
tion, it is important that strategies are employed to
avoid the formation of adhesions between the ten-
don and its sheath in the repair of digital flexor and
extensor tendons. These strategies include the use of
intratendinous tendon suture patterns and early post-
operative controlled passive motion, but are of much
less importance in canine patients, in which functional
deficits associated with adhesions of flexor tendons
are not readily recognised. Repair strategies for canine
tendons should concentrate on restoring functional
tendon length and minimising gap formation during
healing, as gap formation results in delayed healing,
scar formation and tendon lengthening, which will all
affect function. Gap formation is minimised by using
an appropriate tendon suture pattern and by protect-
ing the repair from excessive forces for the first four
to six weeks after surgery. Numerous suture patterns
have been described for tendon repair, many of which
are of purely historical interest.
The three-loop pulley pattern (Fig 1) is favoured
for round tendons, such as those of the Achilles mecha-
nism, and such repairs are stronger and less susceptible
to gap formation than those with one or more locking-
loop sutures (Moores and others 2004). Repair of large
round tendons can be augmented with circumferential
epitenon sutures. A continuous cruciate pattern is pre-
ferred for flat tendons (Renberg and Radlinsky 2001),
such as the gluteal tendons. Monofilament suture
materials should be used to allow the suture to glide
through the tendon substance. Polypropylene (Prolene;
Ethicon) is often used in round tendons due to its low
drag and permanent nature, which is an advantage as
tendons heal slowly. Long-lasting absorbable sutures
such as polydioxanone are used more often in flat ten-
dons such as the gluteal tendons following tenotomy
as part of a surgical approach. Repairs of the large
Companion animal practice
Fig 1: Three-loop pulley suture pattern. Reproduced
with permission from Moores and others (2004)
weightbearing tendons such as the triceps tendon or
the Achilles tendon will not initially be strong enough
to resist weightbearing forces. Protecting the repair
will require immobilisation of the neighbouring joint
via external coaptation or by surgical means (eg, trans
articular external skeletal fixation). Immobilisation is
usually maintained for four to six weeks.
Conditions affecting the forelimb
Bicipital tenosynovitis/tendinopathy
Although bicipital tenosynovitis or tendinopathy is
still commonly referred to as bicipital tenosynovitis,
the name is misleading in that it is rarely associated
with an inflammatory infiltrate. The term bicipital
tendinopathy provides a more accurate description of
the condition.
Before the advent of arthroscopy most dogs with
shoulder lameness were considered to have bicipital
tendinopathy. However, arthroscopy has shown that
biceps tendon disease is not as common as previously
thought. Bicipital tendinopathy primarily occurs in
medium- to large-breed dogs in middle to old age, and
causes chronic lameness, probably due to repetitive
Fig 2: Positive contrast
trauma. There is often pain on point palpation of the arthrogram of the shoulder
tendon on the craniomedial aspect of the joint and on of a dog. Irregular filling of
shoulder flexion with simultaneous elbow extension. the bicipital tendon sheath
is consistent with bicipital
Plain radiography may reveal osteophytes in the region
tendinopathy. The contrast
of the bicipital groove. Contrast arthrography may distal to the tendon sheath
reveal irregular filling of the bicipital groove due to indicates tendon sheath
adhesions between the tendon and the tendon sheath rupture (arrow)
(Fig2). Ultrasound examination may show an inhomo
geneous tendon, mild swelling of the tendon, effusion
of the tendon sheath and a hyperechoic tendon sheath
wall (Kramer and others 2001). Arthroscopy is a very
useful diagnostic tool, allowing visual examination
of the tendon and its sheath for adhesions, tears and
hyperaemia. However, occasionally, it is the extra-
articular part of the tendon that is affected, in which
case arthrography and arthroscopy can be unremark-
able. Bicipital tendinopathy is occasionally associated
with rupture of the bicipital sheath, recognised as
In Practice January 2012 | Volume 34 | 2226 23
 Downloaded from inpractice.bmj.com on June 29, 2012 - Published by group.bmj.com
Companion animal practice

contrastleakage from the distal part of the sheath on

an arthrogram (Fig 2).
Treatment in the first instance is generally strict
rest for four to six weeks. Some clinicians addition-
ally use intra-articular methylprednisolone (Depo-
Medrone V; Pfizer), which is associated with clinical
improvement in about 50 per cent of cases. If admin-
istered, it is important that the steroid is not inadvert-
ently injected into the tendon itself, which could result
in further tendon injury.
Surgical management can be via tenodesis or
tenotomy. Tenodesis is performed via a craniomedial
approach to the shoulder. The transverse humeral liga-
ment is incised to allow mobilisation of the tendon,
which is detached from the supraglenoid tuberosity and
fixed to the proximal humerus with the elbow joint in Fig 3: Characteristic posture of a dog with infraspinatus
extension. Tenodesis can be performed with a screw muscle contracture
and spiked washer. More recently, tenotomy has been
described, which has the advantage that it is minimally and haemorrhage, progressing to fibrosis. By the time
invasive and can be performed under arthroscopic guid- contracture has developed, manipulation of the shoul-
ance. The tendon is cut and allowed to retract into the der is non-painful and the dog has a characteristic
bicipital groove where it remains tethered and presum- gait with obvious circumduction of the limb during
ably eventually fibroses to the proximal humerus. This protraction. The limb may be held up with the elbow
technique has been reported in humans and a small series flexed and the lower limb externally rotated (Fig 3).
of dogs with good results (Wall and Taylor 2002). Surgical transection of the tendon of insertion corrects
the condition and is associated with a good prognosis.
Biceps tendon ruptures The tendon should be approached over the cranio
Complete rupture of either the tendon of origin or inser- lateral aspect of the shoulder and greater tubercle.
tion of the biceps is recognised by a lack of resistance to Caudal retraction of the acromial head of the deltoid is
shoulder flexion with the elbow extended. Complete required to expose and section the tendon. On cutting
rupture of the tendon of origin can be confirmed with the tendon the joint should be extended fully to break
arthrography, ultrasonography or arthroscopy. The down any adhesions and an immediate improvement
tendon should be repaired if there is concurrent insta- in the joint range of motion should become obvious.
bility of the shoulder, but repair or reattachment of the The gait abnormality described above can, less
tendon to its origin may be problematic due to the large commonly, be due to contracture of the supraspina-
forces the repair will be subjected to. In the absence tus muscle. This is also treated by tenotomy, and good
of shoulder instability, conservative management or results have been reported.
tenodesis to the proximal humerus may be preferred.
Incomplete ruptures/avulsions at the origin on the Infraspinatus bursa ossification
supraglenoid tubercle are not uncommon and can cause Infraspinatus bursa ossification is most often seen in
lameness. These are managed by tenotomy or release labrador retrievers (McKee and others 2007). Small
and tenodesis. Rupture of the tendon of insertion has opacities can be observed between the acromion and
also been reported, with a good response seen follow- the humeral tubercle on the craniocaudal view of the
ing conservative management (Guilliard 2001). shoulder (Fig4). If the lameness does not improve fol-
lowing a period of rest and administration of NSAIDs,
Medial displacement of the biceps tendon
Medial displacement of the biceps tendon is most com-
monly associated with racing greyhounds. Rupture of
the transverse ligament of the humerus allows the ten-
don of origin to displace medially out of the bicipital
groove. This can often be palpated as the shoulder is
flexed. It may be possible to repair the torn ligament
but, if this is not feasible, efforts should be made to pre-
vent displacement. One method is to place a partially-
threaded cancellous screw just medial to the tendon
to physically prevent its movement. Some greyhounds
will return to racing although the general prognosis is
guarded.

Infraspinatus contracture Fig 4: Craniocaudal

Contracture of the infraspinatus muscle is most com- radiograph of the
monly seen in working dogs, particularly working shoulder in a labrador
spaniels, although it can occur in any breed. The con- retriever with
ossification of the
dition is probably associated with chronic repetitive infrapsinatus bursa
trauma to the muscle, which results in inflammation (arrow)

24 In Practice January 2012 | Volume 34 | 2226

 Downloaded from inpractice.bmj.com on June 29, 2012 - Published by group.bmj.com
Fig 5: Bone opacities superimposed on the humeral
tubercle in a dog with mineralisation of the
supraspinatus tendon
the tendon sheath should be explored surgically and
the osseous bodies removed.
Mineralisation of the
supraspinatus tendon
Mineralisation of the supraspinatus tendon may be
seen as an incidental finding in dogs, but has also
been reported as a cause of chronic lameness (Flo and
Middleton 1990, Laitinen and Flo 2000). The condi-
tion is diagnosed by radiography. Mineralisation just
proximal to or superimposed on the greater tubercle
may be seen on a lateral view (Fig 5). The mineral-
isation can be seen cranial or slightly medial to the
tubercle on a cranioproximal-craniodistal skyline
view (Figs 6, 7). In the first instance, the condition
is treated with rest and NSAIDs. A failure to respond
warrants surgical investigation. Since this condition
can be asymptomatic, investigation would ideally
include shoulder arthroscopy to rule out other condi-
tions of the shoulder. Surgical investigation reveals a
grossly normal tendon, which, when incised longitudi-
nally, contains multiple pockets of pastey mineralised
debris. Removal of this debris results in a reasonable
response, with most dogs improving, although recur-
rence, which may not always be symptomatic, is not
uncommon.
Medial epicondyle bone spurs
Bone spurs within the flexor tendons arising from the
medial epicondyle of the elbow may cause lameness and
elbow pain (Fig 8). There may be pain on direct palpa-
tion of the bone spur. Bone spurs are readily identifiable
Fig 8: 3-D reconstruction
computed tomography
scan from a dog,
showing a flexor tendon
bone spur distal to the
medial epicondyle of
the humerus
Companion animal practice
Fig 6: Positioning for cranioproximal-craniodistal skyline view of the humeral tubercle
(Flo and Middleton 1990). The red arrow shows the direction of the x-ray beam and the
red box shows the position of the radiographic cassette
Medial Lateral
Fig 7: Cranioproximal-
craniodistal skyline view
of the humeral tubercle in a
dog with mineralisation of the
supraspinatus tendon (arrow)
on a flexed mediolateral radiograph. Symptomatic cases
are managed with surgical excision of the bone spur.
Avulsion of the origin of the
extensor carpi radialis
Avulsion of the origin of the extensor carpi radialis is
an uncommon traumatic injury, which causes pain and
swelling at the origin of the muscle on the craniolateral
aspect of the distal humerus. In chronic cases, perio-
steal new bone is seen (Fig 9). Surgical reattachment to
the humerus can be performed, but there may also be a
good response to conservative management (Anderson
and others 1993).
Stenosing tendinopathy of the
abductor pollicis longus tendon
The abductor pollicis longus (APL) tendon passes
through the medial sulcus of the distal radius. Tendin
opathy and/or new bone formation on the borders of Fig 9: 3-D reconstruction
computed tomography
the sulcus can cause lameness and impinge the tendon scan from a dog, showing
(Fig 10a) (Grundmann and Montavon 2001). Firm periosteal new bone along
swelling over the medial aspect of the antibrachio- the craniolateral humerus
distally due to avulsion of
carpal joint and pain on full flexion of the carpus are
the extensor carpi radialis
consistent clinical findings. Acute cases may respond tendon
to local injection of 20 mg methylprednisolone acetate
along the tendon sheath combined with a three-week
period of external coaptation. Chronic cases with
impingement of the tendon by osteophytes respond
better to surgery. The osteophytes can be debrided
(although they may recur) or managed by tenotomy
(Fig 10b). Resected tendon may show chondroid meta-
plasia on histological examination.
Flexural deformity of the carpus
in puppies
Occasionally, puppies aged two to three months will
present with an inability to fully extend the carpus,
In Practice January 2012 | Volume 34 | 2226 25
 Downloaded from inpractice.bmj.com on June 29, 2012 - Published by group.bmj.com
Companion animal practice

Fig 10: (a) Close-up

dorsopalmar radiograph of
the carpus of a dog. New bone
(arrows) at the medial sulcus is
causing stenosing
tendinopathy of the abductor
pollicis longus tendon.
(b) Intraoperative photograph
of the same dog. The abductor
pollicis longus tendon has
been displaced medially from
its sulcus
B
which bows or knuckles dorsally (Fig 11). This has been
called a flexor tendon contracture, although, in fact, it
is overgrowth of the skeleton rather than contracture
of the tendons or muscles that is the likely cause. The
condition is most often seen in dobermanns. A good
history should be obtained from owners to ensure the
puppy is on an appropriate diet and exercise should
be restricted for several weeks, but most dogs make a
spontaneous recovery within a month. Those that do
not can be managed via tenotomy of the insertion of
the flexor carpii ulnaris tendon on the accessory carpal
bone. Sectioning of other carpal and digital flexor ten-
dons may be required in rare cases.
References and further reading
Anderson, A., Stead, A. C. & Coughlan, A. R. (1993)
Unusual muscle and tendon disorders of the forelimb in the dog.
Journal of Small Animal Practice 34, 313-318
Basinger, R. R., Aron, D. N., Crowe, D. T. &
Purinton, P.T. (1987) Osteofascial compartment syndrome
in the dog. Veterinary Surgery 16, 427-434
Flo, G. L. & Middleton, D. (1990) Mineralization of
the supraspinatus tendon in dogs. Journal of the American
Veterinary Medical Association 197, 95-97
Grundmann, S. & Montavon, P. M. (2001) Stenosing
tenosynovitis of the abductor pollicis longus muscle in dogs.
Veterinary and Comparative Orthopaedics and Traumatology
14, 95-100
Guilliard, M. J. (2001) What is your diagnosis? Rupture
Fig 11: Carpal flexor tendon deformity in a dobermann
puppy
of the insertion of the biceps brachii from the radial
tuberosity. Journal of Small Animal Practice 42, 375,
418
Kramer, M., Gerwing, M., Sheppard, C. &
Schimke, E. (2001) Ultrasonography for the diagnosis
of diseases of the tendon and tendon sheath of the biceps
brachii muscle. Veterinary Surgery 30, 64-71
Laitinen, O. M. & Flo, G. L. (2000) Mineralization
of the supraspinatus tendon in dogs: a long-term follow-
up. Journal of the American Animal Hospital Association
36, 262-267
McKee, W. M., Macias, C., May, C. & Scurrell,
E.J. (2007) Ossification of the infraspinatus tendon-
bursa in 13 dogs. Veterinary Record 161, 846-852
Moores, A. P., Owen, M. R. & Tarlton, J. F.
(2004) The three-loop pulley suture versus two locking-
loop sutures for the repair of canine achilles tendons.
Veterinary Surgery 33, 131-137
Renberg, W. C. & Radlinsky, M. G. (2001) In
vitro comparison of the locking loop and continuous
cruciate suture patterns. Veterinary and Comparative
Orthopaedics and Traumatology 14, 15-18
Wall, C. R. & Taylor, R. (2002) Arthroscopic
biceps brachii tenotomy as a treatment for canine
bicipital tenosynovitis. Journal of the American Animal
Hospital Association 38, 169-175

Self-assessment test: Muscle and tendon disorders in small animals

1. General management and conditions affecting the forelimb
1.Which of the following represents the most suitable suture pattern for c. Bunnel pattern
the repair of a mid-body, complete gastrocnemius tendon of insertion d. Continuous cruciate or baseball stitch pattern
rupture?
3.In dogs, compartment syndrome may be seen in:
a. Locking-loop pattern
a. The upper forelimb and the caudal antebrachium
b. Three-loop pulley pattern
b. The upper hindlimb and the cranial antebrachium
c. Bunnel pattern
c. The cranial thigh and the cranioproximal tibia
d. Continuous cruciate or baseball stitch pattern
d. The caudal tibia and the cranial antebrachium
2.Which of the following represents the most suitable suture pattern for
the repair of a middle gluteal tendon of insertion repair?
a. Locking-loop pattern Answers
1. b, 2. d, 3. c
b. Three-loop pulley pattern

26 In Practice January 2012 | Volume 34 | 2226

 Downloaded from inpractice.bmj.com on June 29, 2012 - Published by group.bmj.com

Muscle and tendon disorders in small

animals 1. General management and
conditions affecting the forelimb
Andy Moores

In Practice 2012 34: 22-26

doi: 10.1136/inp.d8267

Updated information and services can be found at:

http://inpractice.bmj.com/content/34/1/22.full.html

These include:
References This article cites 10 articles, 3 of which can be accessed free at:
http://inpractice.bmj.com/content/34/1/22.full.html#ref-list-1

Article cited in:

http://inpractice.bmj.com/content/34/1/22.full.html#related-urls

Email alerting Receive free email alerts when new articles cite this article. Sign up in
service the box at the top right corner of the online article.

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/