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com
Companion animal practice
Harry Scott graduated from
Liverpool in 1977. He worked
in small animal general practice
and completed certificates in
dermatology and orthopaedics
followed by a fellowship by
examination in canine spinal
surgery. Since 1999, he has
worked in referral practice both in
the UK and abroad, and is currently
head of orthopaedics at Southern
Counties Veterinary Specialists. He
holds the RCVS diploma in small
animal surgery (orthopaedics)
and is an RCVS specialist in small
animal surgery (orthopaedics). He
has recently become a certified
canine rehabilitation practitioner.
Philip Witte graduated from
Bristol in 2005. He spent two
years working in mixed general
practice in Herefordshire followed
by six months working with
Cape buffaloes in South Africa.
He subsequently completed an
internship in surgery at Southern
Counties Veterinary Specialists,
where he is now an orthopaedic
resident. He is currently working
towards the RCVS certificate in
advanced veterinary practice
(small animal surgery).
doi:10.1136/inp.c7447
20 In Practice  January 2011 | Volume 33 | 20–27
Investigation of lameness in dogs
1. Forelimb
Harry Scott and Philip Witte
Lameness associated with musculoskeletal disorders of the forelimb accounts
for approximately 25 per cent of the authors’ canine referral caseload.
Lameness due to an underlying neurological disorder is less common and
is often associated with weakness and, in some dogs, neurological deficits.
Most cases of chronic forelimb lameness of musculoskeletal origin seen at
the authors’ clinic involve the elbow or, less frequently, the shoulder. The
practitioner should, however, be mindful of the fact that lameness can be
associated with any aspect of forelimb function. When dealing with chronic
forelimb lameness, a diagnosis can be elusive and, with limited investigative
techniques, frustrating. A structured approach to the investigation of lameness
is therefore vital if the practitioner is to treat or refer animals appropriately.
This article describes a step-by-step approach to investigating lameness in
the forelimb in dogs. A second article, to be published in the February issue
of In Practice, will describe the approach for investigating hindlimb lameness.
Signalment be perceived as such by some clients. Accurate history
taking necessitates specific initial questioning.
Signalment can help to formulate a list of differential Osteoarthritis is a common cause of forelimb lame-
diagnoses. For example, forelimb lameness in English ness in the adult dog and typically presents with insid-
springer spaniels may be associated with incomplete ious-onset transient stiffness on rising after rest and
ossification of the humeral condyle (IOHC), while the gradually progressive waxing and waning lameness,
primary differential diagnosis for forelimb lameness especially after exercise. Lameness in dogs with osteo­
in juvenile Labrador retrievers may be elbow dyspla- arthritis may have a more acute and severe presenta-
sia or, more specifically, fragmentation of the medial tion following a sprain associated with overactivity or
coronoid process. Therefore, while both diagnoses sepsis as a result of haematogenous spread. A 12-month
should be listed as differential diagnoses for both history of mild intermittent lameness or reluctance to
breeds, signalment can alter the ranking. walk before acute-onset severe lameness may only come
to light in response to appropriate questioning. In the
absence of a detailed history, a practitioner may fail to
History recognise the full aetiology of a case of lameness.
As with any other discipline, it is important to obtain
a thorough history when investigating orthopaedic Gait examination
disease. Furthermore, a detailed knowledge of response
to previous treatments will prove useful in decision Gait can be defined as the sequence of limb and body
making. Client perception of current and desired fore- movements used for locomotion. Gait analysis is the
limb function can vary widely. The owner of a lapdog study of locomotion. For the purposes of this article,
Shih-Tzu may be less aware of, and less concerned with, lameness is any variance from a normal gait (includ-
mild forelimb lameness than the hill-walking owner ing ataxia or paresis) and a stride is the cycle of body
of a usually extremely active Border collie. Lameness and limb movements that begins with the contact of
should be addressed with equal attention in both of one foot on the ground and ends when the same foot
these dogs, but client perception of the problem may contacts the ground again. With every stride each indi-
vary. Some owners will not perceive stiffness when ris- vidual limb goes through a step cycle that comprises a
ing as abnormal, particularly in older dogs, despite this stance (weightbearing) phase and a swing (non-weight-
being commonly associated with chronic joint pain. bearing) phase. In the average dog, each forelimb is
Similarly, clients will grade lameness in different ways. responsible for 30 per cent of weightbearing when
While some clients will present a dog with very mild or standing. Before gait assessment, a thorough general
intermittent lameness, others may present the dog only examination should be performed to ensure that non-
when it is severely lame and non-weightbearing. Gait specific signs of overall ill health are not omitted from
asymmetry constitutes lameness, although it may not the decision making.
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The initial part of an orthopaedic examination
should include observation of the dog’s gait and stance
in the consulting room (orthopaedic examination of
the forelimb in dogs will be discussed in more detail
in an article to be published in the March 2011 issue
of In Practice). For example, dogs with elbow dysplasia
will often sit or stand with the elbow adducted and
the distal extremity supinated. Gait analysis should
be conducted at a walk and at a trot. The dog should
be led for a distance of about 15 metres directly away
from and then towards the assessor to allow gait obser-
vation in both directions. To fully assess the gait, it
is often also useful to walk alongside the dog or have
it walked past the examiner. Initial evaluation should
be performed at a slow walk (a symmetrical four-
beat gait) so that the movement of each limb can be
observed individually.
Mild lameness that may not be detectable when the
dog is walking will become more apparent when the
animal is made to trot as more force is placed on the
limbs at greater velocity. However, at a trot (a symmetri-
cal two-beat gait), diagonal fore- and hindlimbs strike
the ground simultaneously, making differentiation
between fore- and hindlimb lameness more difficult.
It should be noted that some dogs will preferentially
adopt a pacing gait rather than a trot. Pacing is similar
to the trot except that there is less range of joint motion
and, instead of diagonal, ipsilateral fore- and hindlimbs
strike the ground simultaneously. The pace may appear
stiff and stilted compared with the trot and there is
more side to side rolling of the body. The pace is a nor-
mal gait for some dogs (usually large breeds), but may
be used preferentially by some dogs with osteo­arthritis
to reduce joint excursion. A video record of the gait can
be useful to monitor changes over time and is especially
useful for smaller dogs and those with faster gaits so
that they can be viewed in slow motion. A system of
subjective lameness grading is outlined in Table 1.
By altering the carriage of the head, lame dogs
attempt to reduce the forces acting through a painful
forelimb. Head nodding is one of the most useful signs
of forelimb lameness. The head is raised when the lame
limb is weightbearing and lowered (‘nodded’) when
the sound limb is weightbearing. A nod of the head
is sometimes accompanied by dropping of the shoul-
der on the contralateral side to the lameness. Lateral
deviation of the head transfers some of the weight of
the head and neck to the sound limb. It should be noted
that head nodding, although less marked, can also be
Box 1: Key visual signs of forelimb
lameness
■■ Stride/step alterations
●● Short-stepping (‘limp’)
●● Ratio of stance to swing portion
■■ Head posture
●● Head nodding
●● Lateral head deviation
●● Ventral head deviation
■■ Altered limb movement
●● Circumduction
●● High-stepping versus claw scuffing
■■ Altered limb placement
●● External rotation
●● Internal rotation
Companion animal practice
Table 1: Grading lameness at a walk and trot
Grade Description
0 (None) No lameness is observed at a walk or trot
1 (Mild) Lameness is present, but may only be consistently apparent at a trot
2 (Mild to moderate) Mild lameness is obviously present at a walk and is worse at a trot
3 (Moderate) Obvious lameness is present at both gaits
4 (Moderate to severe) Obvious lameness is present at both gaits and may be intermittently
non-weightbearing
5 (Severe) Lameness is non-weightbearing most or all of the time
Grading lameness can be useful for monitoring changes in the severity of lameness over time,
and may also be indicative of the condition involved
a feature of hindlimb lameness. In cases of hindlimb
lameness, the head will tend to nod down when the
affected hindlimb contacts the ground.
Disparity in the stride length is seen as a ‘limp’. This
indicates avoidance of equal weightbearing and/or
flexion and extension in the forelimbs. Theoretically,
by reducing the cranial portion of a stride, a dog may
minimise shoulder extension. Similarly, by reducing
the caudal portion of the stride, shoulder flexion,
elbow extension and weightbearing may be reduced.
By swinging the affected forelimb in a semicircle
during the swing phase (circumduction), a lame dog
may avoid movement of painful joints. High-stepping
(hypermetric) gaits and dragging limbs are often associ-
ated with neurological disorders of the cerebellum and
relevant upper or lower motor neurons, respectively,
although this may also be associated with attempts to
reduce weightbearing on painful limbs or alter the posi-
tion of painful joints. Neurological assessment should
be performed if deemed necessary (see McKee 2007 for
further information).
Physical examination
Following gait examination, the examiner should
know which limb(s) is/are affected. The purpose of the
physical examination is to localise the affected area
or joint on the limb. Physical examination of affected
limbs should always be performed in conjunction with
an assessment of the contralateral limbs, bearing in
mind that conditions may be bilateral. Examination
should be performed in a systematic and consistent
manner (eg, from distal to proximal), so that nothing
is missed. Contralateral limbs should be palpated first
so that the dog becomes accustomed to being handled
before any painful areas are touched.
Palpation of musculature
Palpation of musculature can provide information
about the use of a limb over a period of time. Disuse
(or reduced use) atrophy will produce a palpable asym-
metry in the musculature within a few weeks, which
is easiest to appreciate adjacent to a bony prominence
(eg, the scapular spine). In general, the muscles that
are most vulnerable to atrophy are anti-gravity mus-
cles that cross a single joint (eg, the supraspinatus
and infraspinatus). Muscles that are least vulnerable
are flexor muscles that cross more than one joint (eg,
the biceps brachii). Muscle mass is generally slower
to recover, and apparently normal animals will show
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Companion animal practice

atrophy for weeks or months following resolution of Manipulation of specific joints

lameness as muscle bulk returns.
Palpation of bones
Bone conformation may be determined by palpation,
although imaging, particularly computed tomography
(CT) (see later), is more useful for investigating angu-
lar deformities or torsion. Swelling and discomfort
at the proximal humerus or distal radius/ulna in an
adult dog warrants further assessment for bone neo-
plasia, including examination of the local lymph nodes
(osteo­sarcomas rarely spread to lymph nodes, but these
should not be neglected) and thoracic radiography in
three views. A marked pain response elicited on palpa-
tion of bone is a feature of panosteitis, which is seen
predominantly in juvenile German shepherd dogs. An
attempt should be made to differentiate bone pain
from surrounding soft tissue or adjacent joint pain.
Palpation of joints
Joint effusion (fluid distension of the joint capsule)
may be palpated most readily in the standing animal
at specific sites for particular joints (eg, just caudal to
the lateral epicondyle in the elbow joint). Harder joint
thickening is suggestive of fibrosis, periosteal reaction,
new bone formation and a more chronic disease. Due
to overlying soft tissues, shoulder joint effusion and
thickening cannot usually be appreciated. During the
course of an examination, firm digital pressure applied
to areas of pain may elicit signs of resentment, allow-
ing an examiner to localise the source of discomfort.
Reproducible resentment responses to firm digital pres-
sure applied in the region of the anconeal process or
medial aspect of the coronoid process indicate the need
for further investigation of ununited anconeal and frag-
mented coronoid processes, respectively.
Manipulation of joints
All joints in the limb should be tested in flexion,
extension, and internal and external rotation to note
the range of motion, resentment, crepitus and end-
feel. End-feel is the sensation felt by the examiner’s
hands when the end of passive range of joint motion
is reached (Table 2). Tissues limiting passive range
of motion may be normal or pathological and may
include muscles, ligaments, tendons, the joint capsule
and periarticular fibrosis or bone (osteophytosis). If
pain is felt before resistance, the end-feel is empty and
the primary problem is pain and not physical restric-
tion of joint motion.
Shoulder
The shoulder joint has minimal intrinsic stability,
relying on static (joint capsule and ligaments) and
dynamic (rotator cuff muscles and tendons) stabilis-
ers to maintain alignment of the glenoid and humeral
head. Stability is maintained mainly by the medial and
lateral glenohumeral ligaments and muscles that cross
the scapulohumeral joint, primarily the subscapularis
medially, the infraspinatus laterally and the biceps
brachii tendon craniomedially. The static stabilisers
do not appear to have a significant role in providing
joint constraint during normal range of joint motion.
Rupture or degeneration of any of these stabilisers
Box 2: Shoulder abduction test
The shoulder abduction test has been advocated for
assessing medial ligamentous joint instability. This
should be performed with the dog under sedation
or general anaesthesia. The dog is placed in lateral
recumbency with the affected limb uppermost and the
elbow maintained in a neutral position to avoid internal
rotation. To perform the test, the examiner should
hold the scapula in a fixed position with one hand and
abduct the limb at the shoulder joint using the other
hand. An increased abduction angle is considered
indicative of medial instability. Normal abduction
angles are usually around 30°. False positive results may
be seen if there is shoulder muscle atrophy from any
cause, although angles greater than 40° are more likely
to be significant. The affected shoulder should always
be compared with the contralateral joint.
Box 3: Biceps tendon test
The biceps tendon test is performed in the conscious
dog by flexing the shoulder fully (ie, stretching the
biceps muscle tendon unit) and applying digital
pressure in the intertubercular groove on the
craniomedial aspect of the proximal humerus to test
for a pain response. A positive result may be indicative
of abnormalities of the biceps tendon of origin.
However, the validity of the test has been questioned
because this manoeuvre also places tension on the
tendons of insertion of the biceps and brachialis
muscles on the ulna, which forces the medial coronoid
of the ulna against the radial head and produces pain
in dogs with medial coronoid disease. In the authors’
experience, many medium and large breed dogs
referred for apparent shoulder pain are lame due
to elbow joint pathology.

Table 2: Variation in end-feel*

Name Description Significance
Bony/hard Bone approximates bone, resulting in an abrupt stop Always pathological. May be indicative of excessive
as two hard surfaces engage periarticular osteophytosis
Capsular/firm A firm but slightly yielding end-feel associated with Abnormal if associated with reduced range of
tension in the joint capsule motion. Pathological end-feel is generally harder
than normal capsular end-feel
Tissue Motion is stopped by compression of soft tissues or Abnormal if occurs too early in the range of motion
approximation/ fluid resulting in a reduction in the range of motion or in a joint normally having a capsular end-feel.
soft with a soft end-feel May be seen in joints with substantial joint effusion
or periarticular oedema
Empty The end point is not felt due to the patient resisting Pain
full range of motion before resistance is reached
*End-feel is defined as the sensation at the end of passive range of joint motion

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Companion animal practice

may result in lameness and instability. The shoulder’s

loose ball and socket arrangement lends itself to assess-
ment of flexion and extension, mediolateral instability
(adduction and abduction) and internal and external
rotation. The shoulder abduction test (Box 2) and the
biceps tendon test (Box 3) may be performed as part of
the examination for shoulder-related lameness.
Elbow
The elbow should be assessed in flexion and extension
to note the range of motion and any resentment shown
by the animal, as well as the presence or absence of
crepitus. Pronation and supination of the elbow joint
performed in flexion and extension may provide infor-
mation about discomfort associated with stressing the
medial or lateral collateral ligaments, respectively.
Box 4: Views of the shoulder
Mediolateral
■■ Patient in lateral recumbency, with slight dorsal
rotation
■■ Limb of interest closest to the plate pulled cranially
■■ Contralateral limb is pulled caudally and dorsally
■■ Neck extended so that the trachea is not
superimposed over the shoulder joint, as the
cartilaginous rings may obscure true lesions
Caudocranial
■■ Patient in dorsal recumbency
■■ Limb extended and pulled cranially

Carpus
The carpus consists of three levels of joints and stabilis-
ing soft tissues. The number of conditions commonly
affecting these joints is small, mostly consisting of frac-
tures of the styloid processes, trauma to the collateral
ligaments, hyperextension injury and fracture/luxation
of individual carpal bones. Instability, discomfort and
soft tissue swelling in the area of the carpus are gen-
erally easily recognised features of these conditions. Positioning for mediolateral (Fig 1a, above) and
Radial carpal bone fractures may cause chronic discom- caudocranial (Fig 1b, below) radiographs of the
fort that is apparently localised to the dorsal proximal right shoulder
carpus and are particularly common in boxers. This
condition is thought to be associated with incomplete
ossification of one or more of the three ossification cen-
tres within the developing radial carpal bone, although
traumatic shearing injuries of the dorsal surface of the
radial carpal bone are possible in all breeds.

Metacarpus and manus

The metacarpophalangeal and interphalangeal joints
are uncommon sources of lameness. Chronic fluctu-
ating lameness as a sequela to malunion/non-union
of previous digital fractures is rare. The presence of
foreign bodies, particularly in interdigital webbing
and the pads, must not be omitted from the list of dif- The scapula should be assessed radiologically in a
ferential diagnoses in cases of chronic forelimb lame- similar manner to the long bones. Periosteal reaction,
ness. In greyhounds and other sight hounds, corns are new bone formation and areas of lucency observed
a common cause of chronic forelimb lameness, which radiologically within the scapula carry the same sig-
is exacerbated by exercise on hard ground. Corns typi-
cally affect the main weightbearing digital (third and
fourth) pads of the forelimb.

Radiography

Radiography is typically the primary imaging modality

for the investigation of lameness in dogs. Orthogonal
radiographic views should be obtained for all cases.

Scapula and glenohumeral joint

Radiography of the scapula and glenohumeral joint
is limited due to the close proximation of the thorax
and increased musculature around the proximal tho-
racic limb. The two standard orthogonal views are
caudocranial and mediolateral (Box 4). Oblique angle Fig 2: Flattening of the
views are not routinely performed, but may be ben- subchondral bone (arrow)
of the caudal humeral head
eficial for investigating small lesions of the glenoid or
in lateral radiographs is
humeral head and fractures of the scapula. indicative of osteochondrosis

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Companion animal practice

nificance as in the long bones. The most common indi-

cation for radiography of the scapula is fracture, and
multiple views and CT (where available) should be per-
formed for a complete assessment. Glenohumeral joint
luxation usually occurs in a medial direction and is
clearly appreciable radiographically. Osteochondrosis
of the proximal humerus can occur in young middle to
large breed dogs, and is apparent on the lateral radio-
graphic view of the shoulder as a well-circumscribed
lucency in the subchondral bone of the caudal humeral
head (Fig 2), with an overlying linear radiopacity if
there is a mineralised cartilage flap (osteochondritis
dissecans). Contrast arthrography (injection of 2 to 3
ml iohexol 300 mg/ml diluted at a ratio of 50:50 with Fig 4: Periosteal new bone overlying the proximal
aspect of the anconeal process is known as a ‘ridge
sterile water) can be used to highlight an unmineral- sign’ (white arrow). An area of bone sclerosis within
ised cartilage flap. Two to three times this volume of the subchondral bone of the ulna at the level of the
iohexol at the same concentration can be used for con- semilunar notch is indicative of medial coronoid
disease (black arrow)
trast studies of the biceps tendon in the intertubercular
groove.

Elbow and humerus

The elbow is more readily radiographed with less
soft tissue overlap than the shoulder. It is, however,
a close-fitting joint and radiographic assessment is lim-
ited by the inevitable radiographic superimposition of
various features of the humerus, radius and ulna within
the articulations. Mediolateral (neutral), medio­lateral
(flexed) and craniocaudal radiographic views of the
elbow should be performed as standard for a thorough
investigation (Box 5); two extra oblique views may
provide additional information in selected cases.
The neutral mediolateral view shows the bone
margins of the humeroradial and humeroulnar joints
and overall elbow congruity. The flexed mediolateral
view is performed to highlight the anconeal process by
removing the superimposition of the medial humeral Incomplete ossification of the humeral condyle (IOHC)
epicondyle. New bone formation on the proximal (Fig 5a, left) (arrow) and osteochondrosis of the medial
aspect of the anconeal process is known as a ‘ridge part of the humeral condyle (Fig 5b, right) (arrow) may
be apparent in craniocaudal radiographs of the elbow,
sign’ and is usually indicative of elbow dysplasia in
although these lesions (particularly IOHC) can be
immature dogs (Fig 4). Subchondral sclerosis in the easily missed. Computed tomography is therefore the
ulna at the level of the semilunar notch visible in a modality of choice for accurate imaging of the elbow

Box 5: Views of the elbow

Mediolateral (in both neutral and
fully flexed positions)
■■ Patient in ipsilateral lateral
recumbency
■■ Limb of interest closest to
the plate
■■ Contralateral limb pulled
caudally
Craniocaudal Craniomedial-caudolateral oblique
■■ Patient in sternal recumbency ■■ As for the craniocaudal view, but with
■■ Limb of interest extended cranially some outward rotation (about 15°)*
■■ Head and neck deviated to the contralateral side
*The oblique views
Craniolateral-caudomedial oblique are not routinely
■■ As for the craniocaudal view, but with some performed at the
inward rotation (about 15°)* authors’ clinic

Positioning for mediolateral (neutral) (Fig 3a), mediolateral (flexed) (Fig 3b) and craniocaudal (Fig 3c) radiographs of the right elbow

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mediolateral view of the elbow is one of the first radio-
logical signs apparent in dogs with elbow dysplasia.
The craniocaudal view of the elbow highlights the
margins of the humeral condyle. The epicondylar ridges
are common sites for periarticular new bone (osteo­
phyte) production as a result of elbow osteoarthritis.
This view also facilitates assessment of the continuity
of the humeral condylar articular surface (eg, distal
humeral osteochondrosis, ‘kissing lesions’ associated
with coronoid disease and incomplete ossification of
the humeral condyle, Fig 5).
Oblique views of the elbows are often taken follow-
ing the appearance of suspicious lesions on mediolateral
and/or craniocaudal views. The craniolateral-caudo-
medial oblique view allows further visualisation of the
medial coronoid process. The craniomedial-caudo­
lateral oblique view offers superior highlighting of the
lateral epicondylar and radial articular margins.
Carpus and manus
The carpus consists of seven bones in two rows stabi-
lised by a sheath of soft tissues, the short radial and
short ulnar collateral ligaments and numerous small
ligaments. Radiographic interpretation is limited due to
superimposition of the other bones. Standard orthogo-
nal views should be obtained as a minimum database.
Stressed dorsopalmar or mediolateral views may eluci-
date medial/lateral or palmar instability, respectively
(Box 6).
Fractures of the distal ulna or radius (styloid proc-
esses) are often associated with carpal joint instability,
laterally or medially, respectively. Such fractures are
seen clearly on dorsopalmar views, although they may
be obscured in mediolateral views. Stressed views of
these lesions are sometimes useful.
Fractures of the radial (seen mostly in box-
ers), accessory (particularly in racing greyhounds)
and ulnar (rare) carpal bones can be appreciated on
radiographs, although CT is the imaging modality of
choice for assessing these bones. Chip fractures of the
numbered carpal bones are also not uncommon, with
Fig 6: Arthroscopic image of the left elbow of a
dog showing a loose osteochondral fragment of
the medial coronoid process and severe erosion of
articular cartilage with exposed subchondral bone
on the medial part of the humeral condyle (medial
compartment disease). White articular cartilage is
apparent on the lateral part of the humeral condyle
Companion animal practice
Box 6: Views of the carpus
Dorsopalmar views (including stressed
valgus/varus)
■■ Patient in sternal recumbency
■■ Limb pulled cranially
Stressed dorsopalmar views (valgus and varus)
■■ Can highlight carpal instability, which is often
present if there is collateral ligament injury
Mediolateral
■■ Patient in lateral recumbency
■■ Limb of interest should be placed closest
to the plate
Stressed mediolateral (flexion and extension)
■■ May be used to highlight instability secondary
to hyperextension injury
small bone chips or avulsion fracture fragments often
lying adjacent to the normal structures. Fractures of
the proximal aspect of the fifth metacarpal bone are
almost invariably associated with palmar instability/
hyperextension injury.
Arthroscopy
Arthroscopy is commonly performed in the larger
joints of the forelimb – that is, the shoulder and
elbow – and, occasionally, the antebrachiocarpal
joint. Shoulder arthroscopy can provide information
regarding injury to the soft tissue structures, notably
the articular cartilage, the synovial membrane, the lat-
eral and medial glenohumeral ligaments, the origin of
the biceps tendon and the insertion of the subscapu-
laris tendon, all of which are thought to be sources of
significant forelimb lameness.
Indications for arthroscopy of the elbow include
radiographic signs of ulnar subchondral sclerosis in
the region of the semilunar notch, periarticular new
bone formation and directly appreciable lesions of
the anconeal or coronoid processes, or osteochon-
drosis of the humeral condyle. Arthroscopy has been
shown to allow a more detailed and more extensive
view of the elbow than arthrotomy and is considerably
less invasive. As well as being a useful diagnostic
tool, arthroscopy facilitates minimally traumatic
removal of osteochondral fragments and debridement
of cartilage defects (Fig 6).
Synoviocentesis
Synovial fluid samples may provide evidence of trau-
ma (eg, macrophages showing erythrophagia suggest
previous haemorrhage) and inflammatory (septic or
immune-mediated) conditions. The joints that are
routinely tapped are the shoulder, the elbow and the
carpus. The shoulder is typically approached cranio­
laterally with the limb held in a neutral position. The
elbow is approached from the medial or lateral direc-
tion, distal to the medial or lateral epicondyle, with the
needle aimed at a gentle proximal incline. The ante-
brachiocarpal joint is most commonly aspirated with
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Companion animal practice

the carpus fully flexed via a dorsal approach with the
needle introduced perpendicular to the skin into the
radiocarpal joint space. The middle carpal and car-
pometacarpal joints communicate with one another,
and can be approached in the fully flexed carpus from
a dorsal direction. Occasionally, aspiration of one or
more of the metacarpophalangeal joints may be indi-
cated. The normal joint is difficult to aspirate, although
an effused joint may be sampled from a dorsal approach
(taking care to avoid the digital extensor tendon and
dorsal sesamoid).
Gross assessment of joint fluid involves evaluating
the volume, colour, turbidity and viscosity of samples.
Aspiration of more than 1 ml of synovial fluid can usu-
ally be assumed to be abnormal. The fluid should be
colourless to clear light yellow. Discoloration may be
indicative of joint pathology, prior haemorrhage or
contamination with fresh blood during aspiration.
A turbid joint fluid indicates a raised cell count. The
normal viscosity of synovial fluid should allow the for-
mation of a strand of fluid between finger and thumb
stretching up to 3 cm.
Reduced viscosity is a non-specific indicator of joint
pathology. Any synovial fluid deemed to be apparently
abnormal should be submitted to a laboratory for cyto-
logical examination.
Further imaging
Further diagnostic imaging of the canine forelimb
using CT, ultrasonography, magnetic resonance imag-
ing (MRI), and nuclear scintigraphy can provide valu-
able diagnostic information and can help to localise
lameness. Access to these modalities is largely limited
to referral centres. Nuclear scintigraphy is used pri-
marily to localise increased rates of bone remodelling
which, in subtle causes of lameness, can help to identify
the site of pathology. However, this is a scarcely avail-
able imaging modality in the UK. Ultrasonography of

Box 7: Differential diagnosis

Lameness localised to the joints of the forelimb

Shoulder
■■ Osteochondrosis/
osteochondritis dissecans ++
■■ Congenital luxation +
■■ Shoulder dysplasia +
■■ Bicipital tendinopathy/
rupture +
■■ Subscapularis
tendinopathy +
■■ Traumatic luxation +
■■ Glenohumeral instability/
subluxation +
■■ Infraspinatus bursal
ossification +
■■ Infraspinatus/supraspinatus
contracture +
■■ Supraspinatus tendon
calcification +
■■ Incomplete ossification
of the caudal glenoid +
■■ Metaphyseal osteopathy +
Elbow
■■ Elbow dysplasia
Fractured medial coronoid
●● 
process +++
●● 
Osteochondrosis/
osteochondritis dissecans ++
●● Ununited anconeal process ++
●● Incongruity ++
■■ Ununited medial epicondyle +
■■ Congenital luxation
(type I, type II) +
■■ Incomplete ossification of
the humeral condyle +
Carpus
■■ Valgus/varus hyperextension
injury ++
■■ Incomplete ossification of the
radial carpal bone (boxer) ++
■■ Dorsal radiocarpal ligament
trauma +
■■ Carpal ulnar and radial
collateral ligament trauma +
■■ Carpal laxity +
■■ Accessory carpal bone
displacement/avulsion
fracture +
■■ Centrodistal lameness (plantar
ligament enthesopathy
and centrodistal joint
osteophytosis) +
Any joint
■■ Osteoarthritis +++
■■ Polyarthritis ++
■■ Septic arthritis ++
■■ Articular fracture ++
■■ Joint neoplasia +
Any bone/soft tissue
■■ Neoplasia ++
■■ Sepsis +

Lameness localised to the bones/soft tissues of the forelimb

Scapula ■■ Osteochondrosis/ commonly affects the distal
■■ Shoulder dysplasia + osteochondritis dissecans ++ radial metaphysis) +
■■ Incomplete ossification ■■ Panosteitis ++ ■■ Abductor pollicis longus
of the caudal glenoid + ■■ Early growth plate closure tenosynovitis +
leading to caudal/cranial
Humerus bowing ++ Digits
■■ Panosteitis ++ ■■ Congenital deformities ++ ■■ Fracture – chronic/
■■ Incomplete ossification ■■ Neoplasia ++ acute +++
of the humeral condyle ++ ■■ Retained endochondral ■■ Luxation ++
■■ Flexor tendon cartilage core (ulna) + ■■ Sesamoid disease ++
enthesopathy + ■■ Bone monostotic/congenital ■■ Corn ++
■■ Neoplasia ++ cysts + ■■ Osteomyelitis +
■■ Bone cyst + ■■ Osteomyelitis + ■■ Septic arthritis +
■■ Osteomyelitis + ■■ Hypertrophic pulmonary
osteopathy (Marie’s Any bone/soft tissue
Radius/ulna disease) + ■■ Neoplasia ++
■■ Fracture +++ ■■ Metaphyseal osteopathy (most ■■ Sepsis +

Immature dog, Mature dog, + Rare, ++ Seen with some regularity, +++ Common
Note some conditions may be seen in both immature and mature dogs

26 In Practice  January 2011 | Volume 33 | 20–27

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the forelimb can be useful in the investigation of soft
tissue injuries of the shoulder (Cogar and others 2008)
although it requires the use of specialised equipment
and expertise. CT is clinically useful for evaluating
joint and bone pathology, with higher sensitivity and
specificity than conventional radiography, and is more
readily available than MRI. CT is invaluable for inves-
tigating elbow-related lameness. MRI offers sensitivity
comparable to that of CT for joint and bone pathology
along with higher specificity in the diagnosis of soft
tissue lesions in the forelimb. When investigating fore-
limb lameness, MRI is commonly reserved for imaging
shoulders where it may complement arthroscopy by
allowing visualisation of the extra-articular soft tissue
structures such as the rotator cuff muscles.
Biopsy
Radiographic signs of osteolysis with proliferation
and sclerosis, cortical destruction along with peri-
osteal new bone formation (sometimes resulting in a
Codman’s triangle) suggest bone neoplasia. Primary
osteosarcoma is by far the most common type of bone
neoplasia and typically arises from the metaphyseal
region of the proximal humerus and distal radius.
Aggressive osteomyelitis (which may be bacterial
or fungal; the latter has been rarely reported in the
UK) may appear similar radiographically. Some very
lytic bone tumours may resemble cystic bone lesions.
Unlike osteosarcoma, joint neoplasia such as synovial
sarcoma is an uncommon cause of chronic progres-
sive lameness. Radiographically, joint tumours usually
have a poorly defined periosteal reaction and multiple
punctate osteolytic lesions involving the epiphyses
on either side of the joint. Although radiographic find-
ings may be highly suggestive, definitive diagnosis of
bone and joint tumours requires biopsy. Proper staging
of suspected neoplastic conditions must be performed.
Bone biopsies are easily obtained using a Jamshidi
needle (Fig 7). The technique involves making a stab
incision overlying the lesion (this should be sited
so that scar removal is possible at later surgery) and
advancing the needle into the bone. The stylet should
then be removed and the needle advanced a further
2 cm with a gentle to-and-fro twisting motion. Several
samples should be harvested. Samples may be rolled
onto a slide to create an impression smear for more
rapid cytological assessment before fixing in formalin
Fig 7: Jamshidi needle used to acquire core biopsy
samples of bone
Companion animal praCtiCe
for histopathology. The results of a recent study indi-
cate that ultrasound-guided fine-needle aspiration of
aggressive bone lesions is also a viable technique for
identifying malignant mesenchymal cells and for diag-
nosing appendicular sarcomas (Britt and others 2007).
Summary
Effective treatment of forelimb lameness requires
accurate diagnosis. Investigation of forelimb lame-
ness should begin with gait analysis, which may not
accurately predict the joint in question, but does pro- Acknowledgements
vide information regarding the severity of disease and The authors would like to thank
the limb affected. Palpation and manipulation of the Steve Joslyn and Mark Bush
for their suggestions during
forelimbs of the conscious animal should follow gait
the preparation of the original
analysis. Radiography, biopsy sampling and advanced manuscript of this article and
imaging may be necessary, as appropriate. A struc- the nurses at Southern Counties
tured approach to investigation is vital to ensure that Veterinary Specialists for their
appropriate therapy is instituted. help with the images.
Further reading
BRITT, T., CLIFFORD, C., BARGER, A., MOROFF, S., DROBATZ, K., THACHER, C. & DAVIS,
G. (2007) Diagnosing appendicular osteosarcoma with ultrasound-guided fine-needle aspiration:
36 cases. Journal of Small Animal Practice 48, 145-150
COGAR, S. M., COOK, C. R., CURRY, S. L., GRANDIS, A. & COOK, J. L. (2008) Prospective
evaluation of techniques for differentiating shoulder pathology as a source of forelimb lameness
in medium and large breed dogs. Veterinary Surgery 37, 132-141
COOK, J. L. & COOK, C. R. (2009) Bilateral shoulder and elbow arthroscopy in dogs with forelimb
lameness: diagnostic findings and treatment outcomes. Veterinary Surgery 38, 224-232
MCKEE, M. & MACIAS, C. (2004) Orthopaedic conditions of the shoulder in the dog.
In Practice 26, 118-129
MCKEE, M. (2007) Lameness and weakness in dogs: is it orthopaedic or neurological?
In Practice 29, 434-444
ROCH, S. & GEMMILL, T. (2009) Orthopaedic conditions of the metacarpus, metatarsus
and digits in dogs. In Practice 31, 484-494
SAUNDERS, D. G., WALKER, J. R. & LEVINE, D. (2005) Joint mobilization.
Veterinary Clinics of North America: Small Animal Practice 35, 1287-1316
In Practice January 2011 | Volume 33 | 20–27 27
 Downloaded from inpractice.bmj.com on February 25, 2014 - Published by group.bmj.com

Investigation of lameness in dogs: 1.

Forelimb
Harry Scott and Philip Witte

In Practice 2011 33: 20-27

doi: 10.1136/inp.c7447

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