A Fresh Look at an Old Problem: How to Best Manage Limping Dogs?
Denis Marcellin-Little, DEDV
Synopsis
There is no standardized method used by all clinicians to diagnose the source of lameness in dogs.
Clinicians are left to pick and chose what they do and when. The result is less than ideal. Many
orthopedic problems in dogs stay undiagnosed for long periods of time. Also, the conservative or surgical
management of orthopedic problems is not always commensurate with its severity: many therapies have
minimal effectiveness and many effective therapies are not routinely implemented. It is in everyone’s best
interest (the patient, the owner, and the veterinarian) to adopt a more proactive approach to the
identification and management of orthopedic problems in dogs. That proactive approach includes owner
education (hint: a handful of deeply rooted myths must be debunked), the development of more accurate
palpation skills, and the establishment of convenient and sustainable long-term management programs
for orthopedic problems that are managed conservatively. This presentation sets up the stage for
successful early identification and long-term management of orthopedic problems in dogs.
Introduction
Too often, osteoarthritis (OA) is diagnosed when middle-aged dogs become exercise-intolerant or have
difficulties performing their activities of daily living. Yet, most dogs with OA live with the disease for years
before they are identified. The lengthy delay in the identification OA is a glaring sign that we need to
rethink our approach to the identification of orthopedic problems in dogs.
Owner education
A clear lack of knowledge regarding orthopedic diseases in dogs combined with a number of orthopedic
myths complicate the identification and management of orthopedic problems in dogs. Many owners are
unfamiliar with basic dog anatomy and joint physiology and with concepts such as polygenic
developmental orthopedic diseases, the phenotypic expression of faulty genes, the influence of external
factors such as growth rate on the phenotypic expression of a polygenic disease, the idea of screening to
detect a disease because it becomes visibly obvious, the concept of treating joint disease very promptly
to avoid irreversible negative consequences, the impact of specific nutrients (protein, energy, calcium) on
growth, the impact of having a lean body weight over a lifetime, the use of exercise to strengthen or
stretch, etc. These facts influence the evolution and the management of orthopedic problems. They can
be discussed at a level that can be understood by all dog owners.
Also, several orthopedic myths are prevalent. For example, owners tend to think that orthopedic problems
tend to affect older dogs more than younger dogs (an anthropomorphic belief based on the fact that older
humans have more orthopedic problems such as osteoporosis and OA than younger humans), that
orthopedic problems in growing dog tends to be mild and self-correcting or self-limiting (another
anthropomorphic belief, based on the fact that most orthopedic injuries in children can be managed with
temporary protection [rest] or joint immobilization [cast or brace]), that catching a flying disc and retrieving
a tennis ball are healthy forms of exercise, that increased exercise can lead weight loss in dogs that are
overfed, that dogs left unsupervised in a fenced-in backyard exercise spontaneously, that adjunctive
therapies can ‘treat’ the late stages of OA, etc. Owner education is a lengthy process that requires
repeated interactions over time.
Screening patients
Veterinarians and owners must be aware of the risk of orthopedic disease in their dogs. A good first step
is to assess the reported prevalence of hip dysplasia, elbow dysplasia, and patellar luxation on the web
site of the Orthopedic Foundation for Animals (Table 1). From these data, 1 dog in 5 has hip dysplasia, 1
in 6 has elbow dysplasia, and one in sixteen has patellar luxation. Several breeds carry an extremely high
risk of hip or elbow dysplasia. Hip dysplasia can also be evaluated more proactively and accurately using
the PennHIP screening method (Table 2). Because of the biases and potential false negative results
present in databases such as OFA, it may be more scientifically valid to compare the relative risk of
orthopedic problem based on other sources, such as large review of patients treated by veterinarians. In
a report of > 1.2 million dogs available in the Veterinary Medical Database, Newfoundland was 5.77 times
more likely to have hip dysplasia and 3.77 times more likely to have a cranial cruciate ligament injury than
dogs as a whole.1
Table 1. Prevalence of hip dysplasia, elbow dysplasia, and patellar luxation among breeds screened by
the Orthopedic Foundation for Animals (source: OFA.org, accesses January 18, 2017).*
Rank
Breed
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Hip dysplasia
Prevalence (%)
Breed
Elbow dysplasia
Prevalence (%)
Breed
Patellar luxation
Prevalence (%)
Bulldog
Pug
Dogue de bordeaux
Neapolitan mastiff
Otterhound
St. Bernard
Brussels griffon
Clumber spaniel
Boerboel
Black russian terrier
Sussex spaniel
Basset hound
Cane corso
Perro de presa canario
Argentine dogo
Fila brasileiro
American bulldog
Norfolk terrier
Maine coon cat
Boykin spaniel
French bulldog
Glen of imaal terrier
Am. staffordshire terrier
Bloodhound
Newfoundland
Spanish water dog
Lagotto romagnolo
Bullmastiff
American pit bull terrier
English shepherd
Cardigan welsh corgi
Shiloh shepherd
Rottweiler
Chow chow
Louisiana catahoula leopard
Mastiff
Berger picard
Shih tzu
German shepherd dog
Chesapeake bay retriever
White shepherd
Norwegian elkhound
Golden retriever
Pembroke welsh corgi
Hybrid
Gordon setter
Old english sheepdog
Kuvasz
Greater swiss mountain dog
Affenpinscher
71.8
70.3
57.4
51.3
49.3
49.1
45.5
43.7
42.7
42.2
40.3
39.5
39.1
38.3
38.2
37.8
36.3
35.2
33.8
30.8
30
27.8
26.4
26.2
25.9
25.8
25.6
25.4
23.8
22.3
21.8
21.6
21.2
21.1
20.8
20.7
20.6
20.6
20.5
20.3
20.2
20.1
20.0
19.9
19.3
19.2
19.2
19.1
18.5
18.3
Chow chow
Pug
Rottweiler
Bulldog
Fila brasileiro
Boerboel
Otterhound
Bernese mountain dog7
Black russian terrier
Chinese shar-pei
Newfoundland
Dogue de bordeaux
American bulldog
Sussex spaniel
German shepherd dog
White shepherd
Am. staffordshire terrier
Staffordshire bull terrier
Cane corso
Bullmastiff
Irish water spaniel
St. Bernard
American pit bull terrier
English setter
Mastiff
Tibetan mastiff
Bloodhound
English springer spaniel
Gordon setter
Irish wolfhound
Glen of imaal terrier
Australian cattle dog
Golden retriever
Greater swiss mountain dog
Labrador retriever
Bouvier des flandres
Stabyhoun
Airedale terrier
Belgian malinois
Soft coated wheaten terrier
Clumber spaniel
Keeshond
Giant schnauzer
Shiloh shepherd
Spinone italiano
Afghan hound
Kuvasz
Kerry blue terrier
Standard schnauzer
Rhodesian ridgeback
47.8
43.6
38.9
34.7
32.4
31.7
28.7
27.6
20.0
25.2
23.7
20.6
20.4
20.0
19.3
18.7
16.8
16.5
16.3
15.8
15.7
15.7
15.6
15.6
15.4
14.8
14.6
14.5
13.6
12.9
12.3
11.4
11.2
11.1
10.5
9.6
9.5
9.4
9.3
8.8
8.6
8.3
8.2
7.0
6.8
6.7
6.4
6.3
6.2
6.2
Pomeranian
Yorkshire terrier**
Australian terrier
Tibetan spaniel
Cocker spaniel
English toy spaniel
Boykin spaniel
Mi-ki
Chow chow
Eurasier
Japanese chin
Bedlington terrier
Russian tsvetnaya bolonka
Lowchen
Portuguese podengo pequeno
Toy fox terrier
Chinese shar-pei
Shiba inu
Norwich terrier
Biewer terrier
Boston terrier
Chihuahua
Pug
Nederlandse kooikerhondje
Scottish terrier
French bulldog
Norfolk terrier
Coton de tulear
Brussels griffon
Tibetan terrier
Cardigan welsh corgi
Petit basset griffon vendéen
Lhasa apso
American eskimo dog
Bulldog
Bichon frise
Puli
Affenpinscher
Dachshund
Rat terrier
Miniature bull terrier
Schipperke
Poodle
West highland white terrier
Chinese crested
Cockapoo
Am. hairless terrier
Labrador retriever
Maltese
Papillon
Total : 107,256 of 497,515
21.6
Total : 42,413 of 263,993
16.1
Total: 2,303 od 35,938
* List limited to the 50 breeds with the highest prevalence, with > 100 dogs evaluated within each breed.
Breeds listed in all categories are in bold font. They include Bulldog, Pug, and Chow chow.
** Fourteen terrier breeds are included in the 50 breeds with highest prevalence of patellar luxation.
36.2
23.4
19.0
11.8
11.6
10.1
9.6
9.3
8.6
8.5
8.5
8.0
7.5
7.1
7.0
6.5
6.0
5.7
5.6
5.6
5.6
5.5
5.5
5.5
5.5
5.4
5.1
5.0
5.0
4.9
4.8
4.8
4.6
4.4
4.4
4.3
4.1
3.9
3.9
3.7
3.6
3.5
3.4
3.4
3.4
3.3
3.3
3.3
3.2
3.1
6.4
Table 2. Example of PennHIP report for a Lagotto Romagnolo dog.
The Lagotto Romagnolo dog in this report had a distraction index of 0.62. Sixty to seventy percent of
dogs within that breed had tighter hips and twenty to thirty percent had looser hips.
Assessing the true impact of orthopedic disease on dogs
The impact of orthopedic diseases on dogs vary greatly over time from a mild and intermittent lameness
to a complete loss of ability to stand or walk (Figure 1). Yet, we tend to treat dogs based on their disease
rather than the severity of their problem.
Figure 1. These two dogs have approximately the same age, the same size and are from comparable
breeds. They both have chronic orthopedic diseases. The Golden Retriever on the left is asymptomatic
and is shown trotting comfortably. The Labrador Retriever on the right perceives severe pain in both of
his pelvic limbs and is shifting most of his weight to his forelimbs. The Golden Retriever has hip
dysplasia and the Labrador Retriever has partial tears to both of his cranial cruciate ligaments.
Background information should include a report on the severity of the orthopedic problems. Questions
should include: How is the functioning? What are the dog’s limitations? What triggers the lameness? How
severe is it? How long does it last? The assessment of the severity of an orthopedic problem includes
observation of the dog resting, getting up, standing, walking, and trotting, palpation of the affected limbs,
and (radiographic) imaging. Is the dog demeanor altered: Is the dog unwilling or unable to perform
specific activities? Is the dog reluctant to play or exercise? Often, owners of dogs that have received a
total hip replacement prosthesis report that their dog is “acting like a puppy” because the dog had lost its
willingness to play as a result of chronic hip dysplasia and chronic pain.
Chronic orthopedic problems, particularly OA, have classic stages:
STAGE 1. Growing dogs or young adults show intermittent signs lasting a few seconds or a few minutes
Growing dogs with developmental orthopedic diseases may have hind limb lamenesses (with hip laxity,
patellar luxation) or forelimb lamenesses (with elbow subluxation, elbow dysplasia, OCD of the shoulder
joint). The lameness is often mild. It may be intermittent or constant. The clinical signs of early joint
disease, however, are often ill defined: being generally slower, clumsier, less playful, and having a “funny”
gait. Unfortunately, joint disease is often overlooked or missed at that stage in life. It is missed because
owners and clinicians often think of growing dogs as being very healthy. Also, they may falsely attribute
the lameness to “growing pains” or “pulling a muscle.” As OA enters its chronic phase, the clinical signs of
joint disease become more discrete and more intermittent. They may become bilateral, too, and bilateral
lameness is seemingly more difficult to detect than unilateral lameness. When signs subside, owners and
caregivers often forget the period of lameness and no longer worry about the potential presence of a
chronic orthopedic disease.
STAGE 2. Young adult dogs have intermittent signs lasting a few hours
Young adult dogs with joint disease often have intermittent signs that subside after a night of rest. These
signs are often associated with more intense periods of activity—for example, with a sudden burst of
activity (the “weekend warrior syndrome”). OA may or may not be diagnosed during this second stage.
The likelihood of diagnosing OA appears to vary between specific joints. Some diseases are much easier
to visualize than others. For example, it is easier to detect hip subluxation on ventrodorsal radiographs of
the pelvis than to detect humeroradial subluxation on radiographs of the elbow joint. Also, dog owners
and clinicians tend to be much more aware of hip dysplasia than elbow dysplasia. Surprisingly, there is
not a lot of difference between the number of dogs with hip dysplasia and elbow dysplasia (Table 1).
STAGE 3. Adult dogs become exercise intolerant and show difficulties performing activities of daily living
Middle-aged dogs with OA progressively become exercise intolerant. They may sit when taking a leash
walk. They hesitate or refuse to climb into a motor vehicle or to climb stairs. The changes present at that
stage of OA are more profound: Cartilage damage is major, the joint capsule is thickened and may restrict
the motion of the arthritic joint (i.e., hip extension is limited, elbow flexion is limited, stifle joint extension is
limited), and dogs often have lost muscle mass in affected limbs. A pain response to joint motion
(hyperflexion, hyperextension) or to joint loading (galloping, jumping) is much more likely to be present at
that stage. OA flares are easier to trigger, are more severe, last longer, and are harder to control with
therapy. OA is often diagnosed at that third stage because the clinical and radiographic signs are more
obvious, severe, and persistent.
STAGE 4. Older dogs lose the ability to walk
The fourth stage is the most severe OA stage. It most often involves geriatric dogs that are losing the
ability to walk and perform activities of daily living. The changes present in limbs with OA are similar to
changes present in the third stage: loss of articular cartilage, thickening of the joint capsule, and pain
present when joints are loaded or when joint capsules are stretched. The loss of muscle mass is more
severe. Dogs, particularly overweight dogs, progressively lose the ability to walk. Because most
households are not prepared or able to care for a dog with limited mobility, the loss of ability to walk
because of OA is one of the key causes of euthanasia in large dogs, if not the main cause of euthanasia.
In a lifelong study of seven litters of Labrador retrievers, the loss of ability to walk because of OA was the
leading cause of end of life.7 For some dogs, the loss of ability to walk occurs much earlier in life.
Setting up a management plan adapted to the situation
Owners’ expectations for the dog are a key to setting up an effective management program.
When is surgery needed?
Surgery is needed to relieve pain (that cannot be managed by non-surgical means) (THR), to restore a
functional limb (fracture, joint luxation, joint instability), or to positively impact the progression of a
disease. Few surgeries positively impact the course of orthopedic diseases. For example: a segmental
ulnar ostectomy can improve the congruity of the elbow joint in young growing dogs with elbow
subluxation as a result of a premature closure of the distal ulnar growth plate. The juvenile pubic
symphysiodesis can improve the stability of the hip joint in a young dog with hip laxity. Let’s face it, most
orthopedic surgical procedures not aimed at repairing long-bone fractures are not particularly effective or
are not proven to be effective over the long term. Let’s look at the four most common orthopedic diseases
for example. The scientific evidence that the surgical stabilization of cranial cruciate ligament injuries
offers a superior long-term outcome than conservative management is very thin. There is no evidence
that dogs that undergo stabilization of a luxating patella do better in the long-term. There is no evidence
that dogs that undergo the removal of a fragmented medial coronoid process or an osteochondral flap do
better. There is no evidence that dogs that undergo femoral head ostectomies walk and feel better than
dogs with hip dysplasia that are managed conservatively. That lack of evidence may be due in part to the
fact that lameness and functional impairment in dogs are generally loosely defined and assessed
subjectively. If dogs are assessed subjectively before their management, the effectiveness of that
management cannot be determined. What should we do then? We should strive to assess dogs as
objectively as possible. We should strive to describe the impairment resulting from orthopedic problems
as objectively as possible.
Interventions should be proportionate to the severity of the disease. In other words, it seems ill advised to
perform an irreversible surgery in dogs that have mild clinical signs or whose clinical signs developed a
few days before their examination. For example, one should not consider doing a femoral head ostectomy
in a dog with signs of hip dysplasia that are mild, recent, and easily controlled with rest and NSAIDs. The
same rationale applies to the medical management of chronic orthopedic problems in dogs: Simple
therapeutic measures should be implemented at first, and more complex or costly measures should be
considered for the later stages of the disease. This will ensure that the therapy is adapted to the stage of
the disease and that it can be sustained over a long period. Therapeutic interventions must focus on
modalities and processes that have proven benefits in dogs or in humans rather than modalities and
processes without proven benefits. The anticipated cost and owner involvement for long-term
management of orthopedic problems should be discussed. Ineffective management options decrease
owners’ trust in the medical team and decrease owners’ ability to pay for effective treatment strategies.
Similar to OA management in humans, three management options for OA in dogs stand out because they
offer clear and unequivocal benefits: NSAIDs, weight optimization, and regular exercise. The evidence for
efficacy of these three forms of treatment is far greater than the potential efficacy of all other forms of
treatment. These options have a solid safety record, with a low rate of side effects and complications.
Their cost, compared to other forms of management, is also very reasonable and sustainable by many
owners. NSAID therapy is most convenient among these three options because, unlike exercise and
weight optimization, NSAID administration does not require significant lifestyle changes (e.g., walking
daily with a dog or dramatically changing the dog’s food intake). NSAID therapy is described below.
Weight Optimization
Weight optimization is extremely effective when managing OA in dogs. Weight optimization includes
avoiding excessively rapid growth during the first year of life because rapid growth increases the
likelihood that dogs that have the genes responsible for developmental orthopedic diseases will express
these genes. In other words, dogs with faulty genes responsible for a specific orthopedic disease (i.e.,
OCD, elbow dysplasia, hip dysplasia) are more likely to see these faulty genes expressed if they grow
rapidly rather than slowly. The process of eating freely with an unlimited amount of food available is called
ad libitum feeding. A limited food intake generally represents approximately 75% of the food consumed
during ad libitum feeding. Dogs with such limited food intake grow much less rapidly than dogs eating ad
libitum, but their adult size does not differ from dogs that grew more rapidly. Weight optimization is also
critical for adult dogs. Many dogs are overweight or obese. OA progresses much more rapidly in
overweight dogs than in dogs that are not overweight. Also, the clinical signs of OA decrease when
overweight dogs lose weight.
Exercise
Exercise is also a key strategy used to manage OA. While exercise intuitively means that arthritic joints
are going to have to do more work, exercise under controlled conditions is beneficial to arthritic joints.
Controlled exercise maintains muscular and cardiovascular fitness over an extended period. Exercise
only has limited value for weight management, and it should not be the sole strategy used to promote
weight loss because exercise cannot overcome excesses in caloric intake. Weight loss should be
achieved and sustained with dietary adjustments (that may be supported by the increase in basal
metabolism induced by exercise). Exercise is a long-term strategy that can maintain fitness at the first and
second stages of OA and regain fitness at the third and fourth stages of OA in dogs. In a study involving
Labrador retrievers with hip dysplasia conducted by our research group, lameness scores were lower in
dogs that were exercising more: Dogs that exercised > 1 hour/day had a lameness score that was 30%
lower than the dogs that exercised < 20 minutes per day.2
During the first and second stages of OA, dogs are naturally fit, and multiple exercise options are
available. Their goals are to maintain muscular and cardiovascular fitness and joint motion (through
regular exercise) and to avoid OA flares (through controlled exercise). Members of the clinical team
(veterinarians and veterinary technicians) play a key role in identifying these exercises, in training the dog
to perform them, and in training their owners to continue the exercise plan with their dogs. For these
dogs, most of the exercises are home based. For dogs in the third stage of OA, exercise is aimed at
recovering fitness and joint motion to boost exercise tolerances. Members of the clinical team should take
a more active role in the selection of appropriate exercises and the implementation of the program.
Similar to programs for dogs in the first and second stages of OA, the programs are initiated in the clinic
and then transition toward home-based programs to control their cost and sustain the efficacy over a long
period. For dogs in the fourth stage of OA, exercise programs should be more cautiously implemented
and should have more modest goals. Aquatic exercises may be more effective than land-based
exercises. Ambulation assistance and weight optimization may be necessary before exercises can be
performed. Exercises for dogs with limited mobility are more technically challenging than exercises in
dogs with less severe OA, and the transition toward home-based exercise is more progressive and
challenging. Dogs with OA that are effectively managed may never reach the fourth stage of the disease.
References
Full-text of these references and can be accessed from a Google Drive folder until April 1, 2017 at this
link: https://drive.google.com/open?id=0B42fOpwAkxItQnBOcG5kcHRaMXM
1. Witsberger TH, Villamil JA, Schultz LG, et al. Prevalence of and risk factors for hip dysplasia and
cranial cruciate ligament deficiency in dogs. J Am Vet Med Assoc 2008;232:1818-1824.
2. Greene LM, Marcellin-Little DJ, Lascelles BD. Associations among exercise duration, lameness
severity, and hip joint range of motion in Labrador Retrievers with hip dysplasia. J Am Vet Med Assoc
2013;242:1528-1533.