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The General Practitioner’s Orthopedic Exam
Debra Weisman, DVM, MS, Dipl ACVS
Newtown Veterinary Specialists, Newtown, CT
A complete orthopedic exam consists of observing an animal at rest, in motion
and palpation of the animal at rest and in lateral recumbency. As with the physical exam,
the orthopedic exam should be performed the same way every time to assure that the
practitioner does not miss the actual problem, due to clinical suspicion of another disease
process. Additionally, the examiner must determine if the gait abnormality is orthopedic
in origin or from another cause (i.e. neurologic or oncologic).
History is a vital part of establishing a differential diagnosis. In addition to
signalment, the examiner should know how long the owner has had the pet, the use or
function of the animal, the chief complaint, whether or not a known traumatic event has
occurred, the duration of the problem, any treatments that have been tried, and their
response. A complete physical exam and medical history should also be performed to rule
out any systemic abnormalities. The examiner should also be prepared to perform a
complete neurologic exam based on the results of the orthopedic exam.
HINDLIMB ANALYSIS
At rest: Animals with rear limb lameness will often shift weight forward or will shift
weight to the non-painful rear limb in a effort to unload the painful limb when standing.
Dogs with cranial cruciate ligament are often reluctant to sit normally. They will sit with
one or both stifles extended. Animal with painful hip may set abnormally or be reluctant
to sit at all and prefer to lie down. Some postures or stances are associated with a specific
disease process. For example animals with Achilles tendon ruptures will have a
plantigrade stance. This stance is occasionally seen in cats with diabetic neuropathy (and
intact Achilles mechanisms). Dogs with severe hip dysplasia and muscle atrophy may
have hyperextension of the hocks.
Standing Palpation: Specific landmarks to evaluate include iliac crest, ischiatic
tuberosity, greater trochanter, stifle, quadriceps, patella, patellar tendon, tibial tuberosity,
hamstring muscles, femoral condyles, distal tibia, calcaneus and tarsal joint and digits.
The stifle joint should be carefully palpated for effusion. The examiner should be able to
define the cranial aspect of the patellar tendon easily. If the tendon is indistinct, there is
joint effusion. In normal animals, the tibial tuberosity is located 90 degrees to the greater
trochanter and the quadriceps mechanism will line up along the long axis of the femur.
Any deviation of the tibial tuberosity should be noted. In some dogs with a grade 3-4
medial patellar luxation, the first notable finding may be the ability to palpate the femoral
trochlea. The examiner should flex and extend the stifle and hip in a standing position. In
some animals this may be the most sensitive position to detect patellar luxation.
Lateral Recumbency: A complete orthopedic exam cannot be performed without the help
of an assistant. Starting at the toe nails; examine for evidence of abnormal wear or
damage, saliva staining or swelling at the nail bed. The area between the toes and pads
should be closely examined for foreign bodies, draining tracts and skin lesions. Each digit
should be individually flexed and extended.
The tarsus inherently has a fair amount of medial and lateral laxity that varies
depending on the position of the joint. Effusion of the tarsus is usually readily palpable.
Collateral ligament injuries to the hock are frequently seen therefore palpation should be
palpated as stress is applied medially and laterally. Palpation of the Achilles tendon is
preformed and compared to the findings in the standing animal.
The tibial shaft should be palpated for pain and irregularity. The muscles should
be palpated for pain, swelling or atrophy. The tibial crest should be located and firmly
palpated as avulsions are often difficult to identify. The patellar tendon should be
identified and followed to the patella. If the patellar tendon is difficult to identify or feels
surrounded by soft tissue swelling, joint effusion is likely present.
The stifle should be flexed and extended. Attention should be paid to the position
of the patella and evidence of crepitus as the patella tracks within the trochlear groove.
With the stifle in full extension, pressure should be applied medially and laterally while
the distal limb is internally and externally rotated.
Assessment for cranial cruciate insufficiency is performed by either checking for
cranial drawer motion or the tibial compression test (or both). Collateral ligament injury
to the stifle can also occur and the clinician should routinely assess medial to lateral
stability of the joint and attempt to “open” the joint from either side. The femur is then
palpated along the shaft and the major muscle groups palpated individually up to the hip.
Animals with degenerative joint disease of the hip generally resent extension and
abduction more than flexion. Some normal animal and those with lower back pain may
also object to full hip extension. Normal abduction should be at least 90 degrees. Internal
and external rotation of the hip should also be assessed. Crepitus should be noted.
Assessment of hip joint laxity via the Ortolani maneuver should be performed in younger
dogs. Hip luxation can be detected by a combination of assessment of bony landmarks
and finding on the direct palpation. Craniodorsal hip luxations can be assessed by
palpating the greater trochanter in line with, not ventral to, a line from the proximal iliac
crest to the ischiatic tuberosity. Abduction of the limb will be limited.
Vertebral and rectal palpation should be part of every orthopedic exam. The dorsal
spinous processes of each vertebra should be palpated for alignment and to detect pain.
The cervical spine should be evaluated with lateral palpation. The normal dog and cat
should be able to point their nose straight up in the air, completely flex ventrally and
touch the lateral aspect of the thorax on either side. The tail should be extended dorsally,
and flexed laterally and along the length. Rectal exams should always be performed in
dogs with rear limb lameness to assess for lumbosacral pain and for caudal abdominal or
pelvic canal masses.
FORELIMB ANALYSIS
At rest: Animals with forelimb lameness may shift weight back to the rear limbs, or may
off load the painful limb. Muscle atrophy may be visible in animals with short coats, as
may carpal or elbow joint effusion. Observe at the loading of the digits and whether or
not there are any toenails misaligned or pads that are more or less visible.
Standing: With the animal standing, the examiner should carefully palpate and examine
all of the major muscle masses in the forelimbs, in addition to the bones and joints.
Specific landmarks that should be evaluated include the spine and vertebral boarder of
the scapula, the acromion process, the greater tubercle of the humerus, humeral
epicondyles, olecranon, and accessory carpal bone. Muscle atrophy is easiest to detect
when comparing the infra- and supraspinatous muscles along the scapular spine. The
triceps muscles should be compared, as should the muscles of the antebrachii. Palpate for
effusion over the caudal compartment of the elbow joints and the carpal joints, then
compare for symmetry. Evaluation of range of motion and palpation of the long bones
can be performed in the standing position in dogs that are fractious or resist lateral
recumbency. Test for knuckling and hopping (in small dogs and cats) during this portion
of the exam.
Lateral Recumbency: With the help of an assistant, start by examining the toenails and
digits. Observe for wear, damage, and saliva staining around the nail beds. The area
between the toes and pads should be examined for foreign bodies, draining tracts, skin
lesions and thickening. Each interphalangeal joint should be palpated individually
through full flexion and extension. Each metacarpal should be palpated individually up to
the carpus. For each joint, the examiner should observe and record crepitus, range of
motion, presence of effusion, pain response and instability.
The carpus should be flexed and extended. In most dogs and cats, the carpal pad
can touch the caudal aspect of the antebrachium. The carpus can extend past 1800 .
Always compare both limbs to determine what may be normal for each animal.
The radius and ulna should be palpated separately. Moving from distal to
proximal, the examiner should look for boney changes or pain. The elbow should be fully
extended, flexed, internally and externally rotated. The joint capsule should be palpated
medially and laterally for evidence of thickness or effusion. The humeral shaft should be
palpated and evaluated for muscle and bone pain.
The shoulder has a very wide range of motion. If is important to manipulate in
flexion, extension, abduction, adduction, internal and external rotation. If shoulder
instability is suspected, hold the scapula fixed and attempt to move the proximal humerus
in a “drawer” type motion cranially and caudally. Palpate the biceps tendon with the
shoulder in both extension and flexion with the limb pulled parallel to the trunk. Deeply
palpate the axilla to check for pain and masses.