Mia is a 7-year-old German Shepherd that I met in October of 2015. She was referred for a left front leg lameness that had been going on for a few months. Mom had Mia since she was a pup, and no major issues were in her history. She was on some supplements, but no medications when I met her.
Mia is a large framed dog, and weighed in at 107 pounds when I first met her. She was about 10 pounds overweight. On physical exam, she had a definite left front lameness, with pain on the palpation of her biceps tendon. I also found bilateral hip joint pain, and lower back pain which had not been found before.
After checking her complete blood count, blood chemistry, thyroid function, and urine for any underlying diseases (there were none), I sedated Mia to further evaluate the painful areas. Radiographs showed severe arthritis in both hip joints. Mia also had spondylosis (bridging arthritis of her vertebrae) and mineralization of the biceps tendon in both shoulders.
Biceps tendonitis can occur for many reasons, but my suspicion in her case was years of chronic overload on her front legs. Because of her painful hips, she would transfer her weight to her front legs and overwork them. This shows us how animals can be sneaky about their problems and hide them from their owners for years.
While sedated, I injected Mia’s biceps tendons with long acting cortisone. The goal here was to provide targeted relief and anti-inflammatory action in the painful leg. Mia’s sedation was reversed and I sent her home to rest for 2 weeks. I discussed with her owner all the findings, and suggested that Mia may need surgery for her hips.
When I saw her again, the left front lameness was nearly resolved. It was no longer tender to the touch, and she walked evenly on her legs. With the pain reduced, we could now work on building strength and addressing her other issues. Mia was seeing our veterinary chiropractor to help with her posture, and I wanted to work more with Mia’s arthritic hips.
I didn’t inject her hips earlier for two reasons. One, it wasn’t why she was currently painful and limping. Two, since they had never been diagnosed before, mom needed some time to process her options on it. At her two week recheck, we started an Adequan injection series. This goes under the skin and penetrates the synovial joints to help improve joint fluid. By doing this we could help her and allow Mia to tell us what she needed. Adequan is a great option for dysplastic/arthritic hips, and I use it as one of my first options.
Another key step in managing arthritis is managing obesity. Mia was 10 pounds overweight, so we worked on a weight loss plan for her. In two months she dropped 8 pounds and was moving much easier! (Mom inadvertently was feeding her 3-4x her daily calorie requirements. Some quick math on my part made for her rapid weight loss.)
After the injections and adjusting her diet, our rehab team worked with Mia through underwater treadmill workouts, photobiomodulation (therapy laser treatments), core strengthening, and muscle building. By December 2015, Mia was 98 pounds and moving very well. She went from walking 10 minutes per walk to 45-50 minutes per walk, 5-7 times a week!
We maintained Mia in a rehab program all winter long and she was doing well. In March 2016, she came in favoring her right hind leg. Mom was concerned it was her hip, but I found pain and swelling in the right knee. My physical exam findings were consistent with a strain or partial tear of her cranial cruciate ligament. This is essentially the ACL in dogs, and is a common cause of injury.
After reviewing options with the owner, I again sedated Mia and injected the right knee with a combination of short acting cortisone and hyaluronic acid. This allowed for targeted anti-inflammatory action (like her shoulders a few months ago) and the hyaluronic acid helps to improve the viscosity in the joint, protecting the cartilage and giving time for the ligament to heal. While I was there, I injected this same combination into both hip joints to relieve discomfort there as well.
Mia resumed her rehab program a week later, and her right knee pain resolved. The swelling I had found before was gone, and she was bearing weight fully on the leg.
In May 2016, Mia’s left hip became very painful. She was having trouble standing up, putting weight on it, and lying down. We tried a course of oral medications, but only had mild improvement. That month our surgeon did an FHO procedure on Mia’s left hip to remove the bone on bone contact that was causing Mia so much pain.
Side note: There are two main surgical options for hip arthritis. One is a total hip replacement, where an artificial ball and socket are placed to create a new joint. This is commonly done in people and is done regularly in dogs also. It is the gold standard and has excellent outcomes. It can be expensive, and there is a restricted period on the patient because the bone must heal and hold the implants in place.
An FHO (or FHNE) is the other option. The femoral head and neck is removed and a false joint is created. This removes the worn-out cartilage and exposes bone/nerve endings that cause a lot of pain. No implants are needed, and the healing time is about 2 weeks. The key is to be aggressive in rehabilitation with these patients, to encourage them to use the leg. It is not as expensive as a hip replacement and has very good outcomes. It was done in people before hip replacement became the go-to option.
Mia did great through surgery and anesthesia, and excelled in her rehab program. Within a month, she was fully weight bearing, and improved her muscle mass in all her legs. She got back to her 45-50 minute walks within 2 months and we stopped seeing her for rehab in October 2016.
The plan was to keep her active and happy, and then see when/if she would need further rehab or surgery. She would continue to have regular veterinary chiropractic appointments and remain active. This also allowed her owner to catch up on finances. She had pet insurance but it doesn’t cover everything.
I saw Mia at the end of January 2017. She weighed 94 pounds, but was having trouble walking and moving. She was already on gabapentin and meloxicam and her joint supplements. About 2 weeks ago, she had started acting sore and was less inclined to walk, but the last 3 days before I saw her, she was painful when going outside and was favoring her right hind leg, holding it up and not wanting to stand on it.
My physical exam showed that her knee was fine, but the pain was coming from her hip. No neurological problems were noted, but the pain was back in both of her bicep tendons as well. After reviewing options with the owner, I checked some basic organ function (blood tests) and presented treatment options.
We could do the injections we had done before, or we could try a different approach. This new approach would be to collect Mia’s blood and bone marrow and inject platelet rich plasma (PRP) and her own stem cells into the painful areas. This is called regenerative medicine.
Side note #2: Platelet rich plasma contains numerous growth factors that facilitate tissue healing and repair. Growth factors are small proteins that are contained within a compartment inside the platelet. When a platelet is exposed to an area of damage or to fibrinogen, it becomes activated and releases its growth factors. These growth factors play an important role in tissue repair by promoting new vessel formation, enhancing cellular proliferation and promoting extracellular matrix formation.
When stem cells are injected in a concentrated form, they perform various functions to repair and regenerate tissue. They can differentiate into the surrounding tissue types which can include bone, cartilage, tendon, ligament, muscle, and nervous tissue. Other primary functions of stem cells in regenerative therapy includes: activating surrounding resident stem cells, stimulating new blood supply, recruiting additional cell types to aid in tissue repair, stimulating healing and tissue growth with the release of cytokines and growth factors, decreasing inflammation by moderating inflammatory pathways, reducing and/ or eliminating scar tissue, and creating a scaffold for healing tissues.
I did this in mid-February for Mia, and saw her this week for her recheck. Her right hind lameness has resolved, and both shoulder tendons are normal to the touch. This will be a slow road with her, I equate regenerative medicine to re-seeding your lawn. It may not look like you did much the first few weeks, but once the seeds sprout and the grass grows, it can be wonderful. In Mia’s case, it was also covered by her pet insurance.
Mia is back on a regular rehab program with our team and is improving weekly. Mom realizes that she may ultimately need surgery for her right hip, but for now she can work on strengthening Mia again and having her be in the best comfort and shape possible.
Stay tuned for regular updates on Mia. Here are a few pictures of her throughout the process, including her bone marrow collection and joint injections a few weeks ago.