Surgery STAT: Rehabilitation therapy of the elbow in dogs

EDITOR'S NOTE: SurgerySTAT is a collaborative column between the American College of Veterinary Surgeons (ACVS) and DVM Newsmagazine.

Next month, Dr. Canapp finishes his three-part series on elbow dysplasia in dogs by discussing medical management.

Last month, I discussed a new subset of elbow dysplasia known as traumatic fragmented medial coronoid process (TFMCP). In this second part of a three-part series, I cover rehabilitation therapy for the elbow after surgery.

Rehabilitation after elbow arthroscopy follows a sequential and progressive multiphased approach to return the patient to its previous functional level as quickly and safely as possible. Key principles (Table 1) and a combination of techniques are used to decrease postoperative pain and inflammation, restore range of motion and improve muscle strength and condition. This provides long-term pain relief, facilitates better overall limb function and improves quality of life.

Table 1 Key Principles of Rehabilitation

The following information and Table 2, provide the basics of a rehabilitation program (goals, modalities, manual treatments and therapeutic exercises) and serve as a general guideline that can be tailored to fit each patient's individual needs through the healing process.

Table 2

Rehabilitation modalities

• Cryotherapy — Cooling causes vasoconstriction, reduced cellular metabolism and permeability, decreased motor and sensory nerve conduction velocity, analgesia and decreased muscle spasm. Apply ice around the entire elbow joint for 15 to 20 minutes three to six times daily.

• Cryotherapy and intermittent compression — Both the rate and magnitude of tissue cooling are increased with this combined therapy (Photo 1). Cold reaches deeper into tissues, providing longer-lasting therapy, and the intermittent compression mimics natural muscle contractions, pumping fluids and cellular debris out of the injured area. This cyclical action reduces swelling, encouraging lymphatic return and improved blood flow.

Photo 1: A dog undergoing cryotherapy and intermittent compression after a bilateral elbow arthroscopy.

• Laser therapy — Laser irradiation enhances production of cellular ATP, thus mediating release of growth factors, cytokine reactions and cell replication and resulting in an acceleration of delayed tissue healing. Apply 4 to 6 joules per spot, covering the entire treatment area, daily for the first week, every other day during week two and then as needed (Photo 2).

Photo 2: Laser therapy in a dog after an elbow arthroscopy.

• Transcutaneous electrical nerve stimulation (TENS) — This modality provides pain relief through inhibition of the pain-gait theory and via descending inhibitory mechanisms (release of endogenous opiate-like substances). Apply treatments three to seven times a week, and decrease the frequency as pain and lameness subside (Photo 3).

Photo 3: Transcutaneous electrical nerve stimulation (TENS) in a dog after an elbow arthroscopy.

Manual treatments

• Passive range of motion (PROM) — Perform this slow, controlled movement with slight overpressure at the end range on each joint of the forelimb two to three times daily.

• Joint mobilization — Perform these slow manipulations to improve joint play on the carpus, elbow and shoulder to increase circulation, proprioception and healing while decreasing inflammation.

• Massage and stretching — Soft tissue massage or mobilization and stretching of the surgical forelimb, nonsurgical forelimb, cervical spine and hindlimbs minimize the effects of compensations that occur prior to or secondary to surgery.

Therapeutic exercises

Leash walking may be initiated after surgery. Start with five to 10 minutes three times daily, increasing the duration to 20 minutes as tolerated by the end of the acute phase. Weight-bearing exercises are then gradually introduced and performed on a daily basis:

• Three-leg standing — Lift the nonsurgical forelimb, and shift the weight onto surgical limb (Photo 4).

Photo 4: The three-leg standing technique.

• Down to stand — Ask patient to lie down and then stand.

• Rocking on all fours — While the dog stands on all four limbs, gently rock the dog from side to side and diagonally with 3-cm perturbations in each direction, promoting weight bearing and proprioception to the affected limb.

• Ladder — Using Cavaletti rails or an extension ladder on a level floor, walk the dog slowly through the ladder rungs or rails to ensure individual weight bearing on all limbs.

• Wheelbarrow exercises — Hold both rear legs and have the dog walk on its forelimbs only. Begin with a short distance, and increase it as tolerated.

• Hydrotherapy — Have the dog swim or walk on an underwater treadmill (Photo 5). Before initiating hydrotherapy, full range of motion of the elbow should be present, and there should be no palpable tenderness or inflammation of the elbow or shoulder. Perform the hydrotherapy sessions two to three times a week, and start slowly at five minutes, increasing one to two minutes per session, as tolerated.

Photo 5: A dog undergoing hydrotherapy with an underwater treadmill.

• Wobble board, BOSU or therapeutic ball — Implement these exercises to improve coordination, balance and strength (Photo 6).

Photo 6: A dog balancing on a wobble board.

This series on elbow disease in dogs will conclude with Part 3 next month and discuss medical management.

Dr. Canapp is an ACVS board-certified surgeon who practices orthopedic surgery and sports medicine at the Veterinary Orthopedic & Sports Medicine Group in Annapolis Junction, Md.

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