Pain Management Case of the Month: Kent—Bicipital Tenosynovitis and Supraspinatus Insertional Tendinopathy

Kent doing his land rehab exercises, including shake-a-paw to work the biceps muscle.

by Heather Owen, DVM

Signalment and History

A nine-year-old male neutered Labrador retriever, Kent, presented with acute pain on the left front shoulder after slipping on the owner’s hardwood floors while playing with their other two dogs. The patient yelped and then started favoring his left front limb. The primary veterinarian started the patient on gabapentin, nonsteroidal anti-inflammatory drugs (NSAIDs), and tramadol. The patient had an Assisi Loop from a previous tibial plateau leveling osteotomy (TPLO), as well as disease-modifying nutraceuticals two years previously.

Presenting Signs

Pain was identified with left shoulder extension as well as with biceps tendon pressure. Biceps tendon thickening and supraspinatus tendon pressure pain were also present. The patient’s lameness score was 3/5 on the left front limb. Objective pain assessment was 3/4 on the Colorado State University (CSU) Pain Scale. Owing to the patient’s history of TPLO on the right hind limb, we chose to be aggressive on therapy to prevent more off-loading of left front weight to the left hind side and increasing risk of another cranial cruciate ligament injury. Reducing slipping at home was crucial not only to healing but in preventing further injury. A musculoskeletal ultrasound of both shoulders was performed and revealed bicipital tenosynovitis and supraspinatus insertional tendinopathy of the left front limb.

The patient was taken off NSAIDs and amantadine was initiated, as were cross-fiber bicipital tendon massage, shake-a-paw, and high-fives to help with pain before regenerative medicine scheduling.

Choice of Therapy

Regenerative medicine, photobiomodulation, and rehabilitation were used. A targeted pulsed electromagnetic field (Assisi Loop) was also applied. Platelet-rich plasma (PRP) was performed on the left biceps and left supraspinatus tendon with musculoskeletal ultrasound guidance followed by photobiomodulation at 1,800 Joules over the left shoulder joint after PRP and one week later.

Formal in-clinic rehabilitation was initiated one week after PRP injection. At that time, our patient was a 2/4 on the CSU Pain Scale with a 2/5 lameness score on the left front limb.

Kent doing his land rehab exercises, including shake-a-paw to work the biceps muscle.

Photobiomodulation was continued the first week of rehabilitation to promote healing and decrease adhesion formation. Deep-friction cross-fiber massage to the left bicep tendon was continued to prevent adhesions for five minutes once daily. An underwater treadmill was not able to be used by this patient because of the patient’s fear of water. Both in-clinic and at-home exercises were initiated and maintained to optimize patient outcome. Controlled, slow leash walks were performed to warm up our patient before rehabilitation exercises. In-clinic rehabilitation for weeks one through four consisted of passive range of motion to both front limbs and hind limbs. A rocker board in flexion and extension plane was utilized, as were three-legged lifts with the pet initially on the ground and then while standing on the giant fit bone. Wheelbarrowing was initiated. Home exercises during the first four weeks consisted of passive range of motion, slow, controlled leash walks, shake-a-paw, and high-five exercises. Slow hill walking both up- and downhill was initiated. Week four after PRP, our patient had a pain score of 1/4 on the CSU Pain Scale and was 1/5 lame on the left front limb. The biceps tendon swelling had resolved and there was no pain elicited with shoulder extension or biceps/supraspinatus tendon pressure. For rehabilitation exercises, the wobble board was initiated, as was the rocker board in both flexion/extension planes and abduction/adduction planes. Lateral hill walking was initiated. Stand-to-down on land and on the fitness equipment was started, as was decline standing with the hind limbs elevated on a fitness step with front limbs down, in addition to Cavaletti walking, circle walking, and figure-eight walking. On week eight, our patient had a 0/4 pain score on the CSU Pain Scale and was 0/5 lame on the left front. Normal shoulder extension and flexion had returned. Rehabilitation exercises were continued with the addition of stand-to-down on decline and walking-to-trotting activities on flat ground in addition to decline. The patient was discharged to maintenance on week ten.

Outcome and Conclusion

At the time of discharge, the patient’s pain score was a 0/4 on the CSU Pain Scale and the patient remained 0/5 lame on the left front and right hind. This patient has an active lifestyle living and playing in the Rocky Mountains, on beaches, and on our flat terrain. Continuing with secure footing has aided in the outcome of the patient’s success. The patient has continued on his disease-modifying nutraceuticals and is currently only needing the Assisi Loop intermittently.

One of the many reasons that this patient responded so quickly and completely to regenerative medicine, photobiomodulation, and rehabilitation was the quick thinking of the primary veterinarian for referral. Knowing this patient had a previous TPLO on the right hind complicated issues, and his primary veterinarian knew that the pet was at increased risk of tearing the left hind cruciate if strength and function were not addressed in addition to pain. The collaboration of work performed by the primary veterinarian and rehabilitation veterinarian was crucial to the quick resolution and increased healing of this patient.

Discussion by Mike Petty, DVM, CCRT, CVPP, DAAPM

In the past few years, I have been utilizing PRP injections for all sorts of joint issues. My own dog had the same shoulder issue as this Lab, and two injections fixed the problem and it remains fixed more than one year later. I also give PRP injections in conjunction with custom bracing for cruciate disease, to treat elbow osteoarthritis and any osteoarthritis that is refractory to more mainstream treatments. Although the procedure does take a bit of time, the results are more often than not satisfactory and it is one more treatment you can offer your clients.

Rehabilitation therapy is an important part of any recovery, not only to reduce the pain and inflammation but to restore muscle mass. Many of the therapies employed here are considered advanced, and if you are not comfortable performing them, you should develop a relationship with a rehabilitation therapist in your area. You can look here: caninerehabinstitute.com/find_a_therapist.html, or here: utvetce.com/canine-rehab-ccrp/ccrp-practitioners.

Michael C. Petty, DVM, CCRT, CVPP, DAAPM, is in private practice in Canton, Michigan. He is a frequent national and international lecturer on topics related to pain management. Petty offers commentary on each Pain Case of the Month (and occasionally writes one himself). He was also a member of the task force for the 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats.

Heather Owen, DVM, is the owner of Animal Acupuncture and Canine Sports Medicine Facility in Tulsa, Oklahoma. She is a certified medical acupuncturist, certified canine rehabilitation practitioner, certified canine fitness practitioner, and certified master trainer.

Photo credits: Photos courtesy of Heather Owen