Sunday, August 12, 2012

This Little Piggy Cried Whaa! Whaa! Whaa!, All the Way Home.

The lifeline of equine medicine is foot problems. Actually I should re-state that the demise of racing horses are foot problems. And did you know that one of the largest chapters in the textbooks for both ruminants and equids is on foot problems? And, there are quite a few foot ailments chickens get, too. Okay, I suppose that the point is that many, many, species are afflicted with foot problems.

For a little anatomy review I will remind everyone that dogs and cats have four feet. We still call them wrists and ankles, or to be anatomically specific; meta-carpals (wrist) and meta-tarsals (ankle). Our pets fingers and toes are called phalanges. And, just in case you didn't take human anatomy there are a lot of bones in your hands and feet. (I should know how many off the top of my head, but to try to recall at this point would require a pad, pen, and stick drawings, and I would still forget a few ones in that muddle of upper wrist. Remembering those freshmen anatomy pop-quiz questions for me at this point requires walking to the shelf an opening a book).

In dog and cat veterinary medicine we see a fair share of limping pets. The first thing we try to do when we see a limping patient is to try to identify where in the leg the problem is.

We start with a general overview of the pet walking and ask ourselves the following questions;
First we decide how bad the lameness is? We grade lameness on a 1 to 5 scale. 1 being the mildest and 5 being non-weight bearing. A 5 means that the pet refuses to put the foot down to ambulate. This implies that the foot is so painful they won't use it, or so unstable (fracture) that they can't use it. Any and all grade 4 and 5 lameness's need a vet ASAP.

The second thing we do is palpate the entire leg. Here is where the experience comes into play. We all have our own methods of palpation. I tend to start in the area that I don't think has the problem. So if I think the problem is in the foot as I watch the pet walk I will start palpating high on the leg. As a good rule we also look at both legs from the back and front to check for symmetry. We look to see if the legs are different sizes/shapes and that helps us identify chronicity of the disease, or aggressiveness of the disease, if bones and/or muscles are involved, swelling of tissue. In general, there are a ton of clues very good observation will give you. And then we palpate everything.

Palpation helps to identify the source of the pain, and the source of the problem. If we feel a swelling of the bone we worry about bone cancer, or bone diseases. If we feel a incongruity of the bones we think fracture or dislocation. A loss of muscle indicates chronic disuse of the muscle to the point of atrophy. We also check for lymph node enlargement.

There is certainly an art to good palpation. Every vet has had the dog who has an obvious limp and yet refuses to show any sign of pain no matter how hard you try to identify the source of their lameness. I call these guys the "stoic" dogs. There are also many many dogs who will bite you if you even approach their feet on a good day when everything seems normal. Try to  identify a foot problem in a foot phobic fear's not fun, and it is frustrating I promise.

Oddly, (although I shouldn't say that, because "oddly = normal" in my life), I saw three foot dogs in an afternoon. 

The first was a young sweet Boston Terrier. She was an easy one because her owners had witnessed her jump on their porch and then slide across the deck where they saw and heard her drive her foot into a very long wooden splinter. She immediately yelped! and then lifted her foot. They could see the splinter in her foot so they tried to pull it out. Unfortunately only half of it could be extracted. It broke under the skin and left a large piece behind. When I say "thankfully they saw it," I say it because as big as that piece of wood was you could barely feel it, and you couldn't see it at all. If they hadn't been there to point it out I would have missed it on her physical exam. It took two vets, three technicians, and a muzzle to remove it. When we finally got a forcep on it it came out easily and measured about an inch long. OUCH!

The second was a Bernese Mountain dog. He came in limping and with a large red wound on the top part of his foot, (we call it dorsal). Where some pets who have what we call a "lick granuloma" this dog seemed to be excessively licking her foot because it hurt. It took a few minutes to find the source of her pain. She had a small black pinpoint wound between her toes. She was licking the top of her foot to try to tell us that she had a wound on the bottom of her foot. Thank goodness we didn't write her off as "another dog licking for some unknown reason" and just put an e-collar on her. I have a serious pet peeve about e-collars. They only get used when you are sure of the reason and and you are treating the cause. They are otherwise torture devices. Not being allowed to scratch or lick a boo-boo is torture if you aren't treating the boo-boo.

My last dog of the day had a laceration to her foot pad. We see this a lot. They bleed like crazy, send owners into a panic attack, and often somewhat limiting in our ability to treat. Luckily foot pads heal very quickly if kept clean, dry and protected. Often after a few hours they don't seem to hurt so bad and most pets go back to walking almost normally. The real trick is to keep them from opening back up and bleeding. Now IF you have a deep laceration to the foot pad that can be a different story. keeping a deep laceration clean and allowing it time to heal, (usually this means you try to keep the pet from walking too much on it, because all that motion on the foot means the wound can't close). Some of these deep lacerations require surgery, long term antibiotics, and strict cage rest. And another concern is that many of the foots tendons live under the foot pads, we need to insure they are still intact or the foot will not function properly.

For many of the foot pad lacerations I see they are usually just the most superficial layer of the pad, so I often place a temporary foot bandage on it with lots of antibiotic cream, (after I have soaked the foot in another antimicrobial foot bath), and then re-check them in 24 hours. Usually 24 hours later the bandage can be removed and the skin/foot pad has already started to heal.

For those limping, lame dogs that we cannot find a wound on, we try to use our hands, the history from the owner and our experience to try to identify whether an x-ray will help identify the source of the problem. I have to admit and warn you that there are times when we take an x-ray and still we don't find our answer. Without being able to identify an obvious cause we often recommend rest and an anti-inflammatory. This is also the time that I tell my clients to come back and let me re-check if the problem persists or worsens. Sometimes it takes a few visits for us to figure out the cause for lameness. But I always promise that I won't give up on you if you don't give up on me. Diagnosing and treating any disease is a process and sometimes we all get stumped. When this happens, or when we feel the problem is beyond our abilities, we will refer you to orthopedic, neurology, or radiology experts.

If your pet is lame, painful, or not getting better, keep looking for answers, and don't give up. There is always a reason, and it is very difficult to provide a treatment plan when you don't have a diagnosis.

1 comment:

  1. There can be so many reasons for limping it's wild. We always do start by checking out the feet, quite rarely the problem is there.

    Our vet has quite a magical diagnostic touch, so he can usually figure out what the source of the problem is. Which may be easy or hard to treat. For example, Jasmine's angry iliopsoas take forever to get happy.