MLS Master Class - Veterinary Imaging Presented by CelticSMR Ltd Free Phone (UK): 0800 279 9050 International: +44 (0) 1646 603150 AUTHOR DETAILS Carl Gorman BVSc MRCVS PUBLISHER DETAILS Mike Howe B Vet Med MRCVS celticsmr.co.uk Key words : Laser, therapeutic, hip, stifle, hock Practical treatment 2: The Hindlimb Overview As for the forelimb, treatment of condition of the hindlimb may be treated by both localised therapy, applying the laser directly to affected joints and tissues, or by globalised therapy, stimulating acupuncture or myofascial trigger points. The muscles surrounding an affected joint should be palpated for taut bands and then hypersensitive trigger points may be detected along these bands. These can be directly treated to relieve the pain and referred signs associated with them. The hip The hip or coxo-femoral joint is an enarthrosis connecting the pelvis and the femur. This ball and socket joint is very robust. It is surrounded by a joint capsule forming a robust sleeve. An intra-articular ligament, the teres ligament of the hip, provides additional stability. Strong muscle masses add to the strength of the joint. These are the pelvic muscles, the iliopsoas and the thigh muscles. The joint capsule is associated with the following structures; Cranially with the head of the quadriceps femoris Dorsally with the deep gluteal Caudally with the gemelli Medially with the adductor muscles
Treatment of the hip The aim of conservative treatment with the laser is to reduce pain and inflammation in the periarticular soft tissues, whilst post-surgery treatment aims to reduce pain and oedema and to accelerate scarring of the tissues. During treatment, apply the laser to the lateral and medial surfaces of the joint. Access the medial surface via the inguinal area. Concentrate on those areas that are painful on palpation, and otherwise administering energy in a uniform way over the whole joint. (Fig 1,2, 3, 4) Fig 1Treatment points on the lateral hip Fig 2 Treatment points on the medial hip Fig 3 Lateral hip anatomy
Fig 4 Area of medial hip to aim the laser If the patient will allow, treatment of the hip joint from the medial side (the groin area) allows better access to the hip itself. Point treatment is suitable for the hip itself, while scanning mode should be used to treat discomfort in associated hip and paravertebral muscles. (Fig 5). Fig 5 Areas associated with the hip which may be affected by muscle contracture The following muscles should be checked for contractures when assessing the hip: (Table 1) Gluteals Quadriceps femoris Biceps femoris Gracilis Semimembranosus Semitendinosus
Muscle Origin Insertion Biceps femoris Ischial tuber Patella, tibial crest and calcaneus Gluteals Ilium Greater trochanter Quadriceps (vastus medialis, Proximal femur lateralis and intermedius) Quadriceps (rectus femoris) Ilium just cranial to acetabulum Tibial tuberosity via the patella and patellar tendon Gracilis Pubic symphysis Medial aspect of the stifle and calcaneus Semimembranosis Ventral aspect of ischial tuber Medial aspect of the femur and tibia Semitendinosis Ventral aspect of ischial tuber Tibial crest and calcaneus Table 1 - Origins and insertions of some hindlimb muscles The paravertebral muscles in the lumbar and sacral areas should also be checked. Treatment of these muscles will often help in treating hip pain and should be included. Trigger points may be found in the quadriceps femoris and the middle gluteal. Examples of conditions of the hip Hip dysplasia (Fig 6, 7) Legg-Calvé-Perthes disease (Fig 8) Dislocation Gracilis and semitendinosus myopathy Fig 6 Osteoarthritis associated with hip dysplasia
Fig 7 Radiograph of a severe case of hip dysplasia Fig 8 Radiograph of a case of Legg-Calve-Perthes disease The Stifle The joint between the femur and tibia is a condyloid composite articulation. The articular surfaces are the femoral condyles, the articular surface of the patella, and the articular surface of the tibia (the tibial plane). Because these articular surfaces do not come into direct contact with each other the joint depends on accessory structures to complete the articulation, in particular the lateral and medial menisci. There is a large joint capsule connecting the bones, reinforced by several strong ligaments, notably the straight patellar ligament and the medial and lateral collateral ligaments. As well as the ligaments, several tendons are associated with the stifle: Cranially, the distal end of the quadriceps femoris Laterally, the biceps femoris Medially, the adductors of the thigh and the fasciae latae Caudally, the two ends of the gastrocnemius
Treatment of the stifle For conservative management of conditions of the stifle, the aim of treatment with the laser is to reduce inflammation and pain in the periarticular structures. Post-operatively the aim of treatment is to reduce pain and oedema and to accelerate scarring. Include all articular surfaces when administering treatment, concentrating on areas which are painful on palpation, while also administering energy in an even manner over both the lateral and medial sides of the joint. (Fig 9,10,11,12). Fig 9 Treatment points on the lateral stifle Fig 10 Treatment points on the medial stifle
Fig 11 Treatment points on the lateral stifle (skeletal) Fig 12 Treatment points on the medial stifle (skeletal) Point treatment is suitable for the lateral and medial stifle itself, while scanning mode should be used when treating discomfort and contracture in the associated muscles. Look for contracture in the associated muscles, particularly the quadriceps femoris and biceps femoris. Active trigger points may be found in the quadriceps femoris.
Examples of conditions of the stifle Cranial cruciate ligament rupture Patella luxation Osteochondritis dissecans Quadriceps contracture (Fig 13, 14, 15). Fig 13 Treating a stifle injury Fig 14 Ensure all surfaces of a joint are treated
Fig 15 Quadriceps contracture in an American Bulldog (photo Kimberley DiMaio) The hock The hock is a complex joint containing articulations between the bones of the tarsus as well as connecting the tarsus to the distal metatarsus. The joint is the equivalent of the ankle in humans. There are several joints involved and all are diarthroses. The joint is surrounded by a large joint capsule, which is reinforced by Long and short lateral collateral ligaments Long and short medial collateral ligaments Dorsal tarsal ligament Long plantar ligament Treatment of the hock Following surgery, MLS laser therapy is used to reduce pain and oedema and to accelerate scarring. In conservative management of hock injuries, the laser is used to reduce inflammation of the periarticular tissues and so reduce pain. The laser should be applied to both medial and lateral surfaces of the joint to try to reach all articular surfaces. Concentrate on any areas which are painful on palpation, and otherwise try to deliver and even amount of energy over the whole joint. Point treatment is suitable for treating the hock itself. It is important to treat the associated muscle groups as contracture is common in these tissues, affecting joint mobility and causing pain. Remember that the main muscle bodies of these muscles may be located proximally, nearer to the stifle joint. Scanning mode should be used on the muscles.
Examples of conditions of the hock Osteochonditis dissecans (OCD), mainly on the medial ridge of the talar trochlea Tendon and ligament injuries, e.g. luxation and subluxation, and Achilles tendon rupture Practical laser treatment of hindlimb conditions Frequency of treatment Treatments should be administered two or three times weekly depending on the clinical condition. Programmes recommended 1) Post surgery or for acute pain: 'Post surgery', 'Acute inflammation' or 'Acute pain' Normally use point mode. Consider reducing intensity during the first 2 or 3 treatments (use 50% intensity rather than 100%) 2) Conservative treatment of chronic conditions: 'Chronic inflammation', 'Arthrosis' or 'Chronic pain' Use point mode over joints 3) Muscle contractures For acute cases use 'Acute pain'. For chronic cases use 'Sprain/strain' or 'Muscle contracture'. Use scan mode to cover the contracted area and surrounding tissue.