Musculotendinous injuries in sporting dogs

Sean Murphy, DVM, DACVS

WestVet Emergency and Specialty Hospital
Department of Surgery
Boise, ID
USA

Musculotendinous injuries are a common cause of lameness in both athletic and nonathletic dogs. Tendon
injury may be acute from scenarios like an excessive loading event or through a laceration. More commonly,
tendon overuse supersedes the injury where repetitive microtrauma outweighs the reparative process
resulting in a swollen, painful and weakened tendon predisposed to further degeneration or failure
(tendinosis). Intrinsic tissue degeneration or age-related degeneration as seen in humans is not as common
of a failure mechanism in dogs. With regard to tendon injury, three grades of soft tissue tearing have been
reported. Grade1: stretching of the collagen fibrils and mild swelling but no mechanical instability, Grade 2:
mild tearing of collagen fibers with moderate swelling, bruising and some mechanical loss with mild
instability, Grade 3: severe tearing of collagen fibers with severe partial or complete rupture and complete
functional loss. Tendon healing is similar to typical wound healing with inflammatory, proliferation and
remodeling phases. The stages of wound healing along with the type of tendon are areas that can be
augmented with differing therapies.

SUPRASPINATUS TENDINOPATHY
Supraspinatus tendinopathy and accompanying shoulder pathology is a very common cause of forelimb
lameness in performance dogs. In an agility dog internet-based owner survey of perceived causes of injury,
shoulder strains were the number one reported lameness in 3,801 dogs. The supraspinatus tendon has a
very wide insertion over the greater tubercle and functions to extend the shoulder. Histology of
supraspinatus tendinopathy cases show primarily tendinosis with disorganized and discontinuous collagen
fibers with myxomatous degeneration indicating a chronic process of injury. Additionally, tendon
calcification can be seen in cases that have undergone cartilaginous metaplasia in the zone of injury which
then proceeds to calcium deposition. (Franson).

Historically most cases have a chronic history of lameness that is brought on by an acute high activity event.
Pain is often present on direct palpation over the insertion on the greater tubercle, on ROM with flexion and
to some degree extension. If mineralization is present radiographs are helpful but a skyline view must be
performed to differentiate between supraspinatus and biceps mineralization. Calcification may occur in
nonclinical cases as well, and only about ¼ of clinical cases will have mineralization. Ultrasonography is
the authors preferred advanced diagnostic in these cases as it is lower cost than MRI and changes in fiber
pattern, tendon size, and tendon shape are readily imaged. Concurrent biceps impingement and
associated pathology can also be seen and repeat US examinations allow one to assess therapeutic
progress.

Treatment options for supraspinatus tendinopathy include conservative management with anti-
inflammatories and rehabilitation therapy. Biologics including stem cell therapy or platelet rich plasma are
used in more recalcitrant cases in addition to extracorporeal shockwave therapy. In a case series of 327
dogs, 75% patients failed an NSAID trial and 41% of patients failed rehabilitation (Canapp). Elbow disease
was also common, with 54.5% of dogs showing concomitant elbow pathology on arthroscopic
exam. Ultrasound guided injections of adipose derived stem cells and PRP were reported by the same
author with a resolution of lameness in 88% of cases. Extracorporeal shockwave therapy (ESWT) has also
been used with some success, Muir described a small case series with resolution of lameness on reduced
mineral opacity of the calcific tendon lesions. In another case series, ESWT was performed in 29 dogs with
supraspinatus tendinopathy and biceps tendinopathy, 85% of dogs had good to excellent outcome per
owner assessment at 11 to 220 weeks post therapy. Of interest no dog had unilateral supraspinatus
tendinopathy in this study (Leeman). Similar studies with higher levels of evidence exist in the human
literature, a randomized placebo-controlled trial in people with calcific tendinitis of the rotator cuff ESWT
resulted in a significant clinical improvement compared with sham treatment and significant reduction in the
size of calcifications. (Gerdesmeyer).

Surgical removal of mineral bodies has also been reported, in 19 dogs with supraspinatus mineralization
11 gained excellent postop function, 5 good and 3 were poor (LaFuente). In another study, reformation of
calcified tissue was found in 4/4 dogs re-examined at a mean follow-up time of five years following surgical
removal; 3 of the 4 dogs showed no lameness. (Latinen).

INFRASPINATUS
Infraspinatus tendinopathy is often preceded by an acute overloading event. Imaging of the soft tissues at
these times often shows a large amount of myotendinous edema and swelling (Mikkelsen). A circum-
ducting gait may be noted 3-5 weeks following the injury in cases of contracture and fibrosis. Infraspinatus
contracture is a surgical disease and tenotomy typically results in return to full function thus other therapies
are not considered. Tendon calcification and osteochondromas of the infraspinatus bursa need to be
differentiated from contracture. Large amounts of calcification and heterotopic bone formation may be
present on radiographs or ultrasonic graphic imaging. Treatment pathology is generally centered around
conservative management with rehabilitation and intra-articular corticosteroids; surgical debridement can
be considered. In a case series, lameness was resolved in some cases but continued mild lameness was
a common finding despite treatment. (McKee)

BICEPS TENDINOPATHY
Mechanisms of injury for the biceps are similar to that of supraspinatus with tendinosis resulting from
repetitive strain and micro trauma. However, tendon failure from direct trauma may induce a partial rupture
leading to lameness that is often not well managed conservatively. Additionally, entrapment of the tendon
may occur with aberrant migration of OCD lesions as well as impingement by an enlarged supraspinatus
tendon. Imaging options are similar to that of supraspinatus disease in that calcified tendinopathy will be
present on radiographic evaluation, additionally osteophytosis throughout this inter-tubercular groove may
be present on skyline views. Ultrasound is again a test of choice and ultrasound may show core lesions
within the tendon in grade I and II strains, it can also delineate partial rupture of the biceps in grade III
strains. In cases of biceps tenosynovitis increased effusion is seen around the bicipital sheath, but one
must also consider other joint pathologies leading to global effusion such as subscapularis tendinopathy,
MGHL rupture, osteoarthritis, and OCD.

Medical and surgical management can be considered for bicipital tenosynovitis. When tendon
microstructure is relatively normal, intra-articular injection of methylprednisolone acetate can be used with
six weeks of activity restriction (Stobie). In cases with a tendon core lesion direct injection with biologic
therapies may be considered. In cases of failed medical management or partial tearing of the tendon,
arthroscopic biceps tenotomy or tenodesis may be considered (Taylor). The biceps does contribute to
shoulder stability thus tenotomy should be reserved for cases with true biceps pathology. Shoulder
inflammation can lead to synovitis surrounding the tendon origin on the supraglenoid tubercle and this
should not be mistaken for tendon pathology.

Partial tear of the biceps tendon on L arthroscopic image. Normal biceps tendon with mild synovitis for
comparison on the R image.

SUBSCAPULARIS
The subscapularis originates on the medial aspect of the scapula inserts proximately on the medial humerus
functioning to flex the glenohumeral ligament joint. The tendon is partially intra-articular thus it can be seen
on arthroscopy. Subscapularis disease is often a chronic and difficult lameness to evaluate, pain may be
present on any shoulder manipulation. Ultrasound diagnosis is somewhat limited as the deep location
within the axilla makes examination difficult and thus some lesions are missed. Large case numbers of
subscapularis pathology are not recognized within the literature but are reported in combination with severe
medial glenohumeral ligament rupture. In an MRI and arthroscopy study, we found nearly 50% of dogs had
subscapularis pathology (Murphy). In partial ruptures of the subscapularis exercise restriction and
rehabilitative exercise should be considered. Biologic therapies can be considered with direct injection
under arthroscopic guidance. In complete ruptures of the subscapularis the author has noted dogs to be
significantly lame with a normal MGHL. In these cases the subscapularis may be reconstructed through
medial open approach to the shoulder. Thermal capsulorrhaphy has also been described along with
synthetic ligament capsulorrhaphy of the medial shoulder (Franklin).

The subscapularis tendon (star) passing just under the MGHL (square), cranial is to the L of the image

COMMON CALCANEAL TENDONOPATHY

Common calcaneal tendinopathy can be a result of chronic overloading with tendon degeneration and
partial failure. Less commonly it presents as an acute overloading event or tendon laceration. Cases of
full or partial failure can be defined on the physical examination readily. In cases of complete tendon failure
(common, gastrocnemius and SDFT) the hock can be hyperflexed with the stifle extended. In cases of
partial failure, the gastrocnemius and common tendon failure result in a plantigrade stance, but the intact
SDFT becomes taught creating hyperflexion of the digits as the hock progresses more plantigrade.

L image shows complete rupture calcaneal tendon with hock hyperflexion during stifle extension. R image
shows partial rupture of the tendon with a plantigrade stance and digit hyperflexion

In cases of complete tendon laceration with an open wound, surgical treatment should be initiated as soon
as possible. All tendons should be anastomosed individually then the limb placed in external coaptation. In
cases of chronic tendinopathy with subsequent partial failure the author prefers to perform conservative
management first. In these cases, a bivalved cast is placed for a period of eight weeks. At 0 and 3 weeks
PRP injections are made directly into the tendon and tendon sheath with or without ultrasound guidance.
Dogs are assessed every 1 to 2 weeks and the standing joint angle evaluated for improvement during a
controlled weight-bearing stance. In cases with progress, dogs are switched to a neoprene splint with lateral
thermoplastic splint incorporated. The splint is removed during periods of inactivity but kept in place during
walking etc. for the next four months. Dogs are encouraged to utilize the brace without a thermoplastic
splint during high-impact activities.

Surgical repair of chronic calcaneal tendinopathy is challenging and prognosis varies among studies. A
decreased prognosis has been seen in chronic injuries >21 days old and in dogs that undergo strenuous
postoperative activity. In a report of working dogs, 70% returned to function however only 20% were able
to perform all duties. Failure rates during repair are expected to be 10-20%. A recent repair using loop
suture tenorrhaphy with the application of PRP and resorbable mesh in a subset of cases resulted in
excellent outcome in 11 dogs (Shulz). Two dogs in this case series had major complications that were
revised successfully and it is important to note that 50% of the dogs had an acute laceration to the tendon
which will typically result in a better outcome when compared to tendinosis.

SUPERFICIAL DIGITAL FLEXOR LUXATION

The SDFT is a less common cause of lameness and sometimes difficult diagnosis to reach. Shetland
sheepdogs are overrepresented and the condition is heritable. Luxations are reported as both lateral and
medial with malformation of the calcaneus or collateral attachments as possible underlying causes.
Swelling is typically present over the cap of the tuber calcaneus. With mild loading of the limb, medial or
lateral pressure over the tendon will result in subluxation.. Typically, imaging is not required and this
diagnosis made by physical exam. Surgical reconstruction of the medial or lateral retinaculum typically
yields return to normal function. (Mauterer).

1. Gerdesmeyer L, Wagenpfeil S, Haake M, Maier M, Loew M, Wörtler K, Lampe R, Seil R, Handle

G, Gassel S, Rompe JD. Extracorporeal shock wave therapy for the treatment of chronic
calcifying tendonitis of the rotator cuff: a randomized controlled trial. JAMA. 2003 Nov
19;290(19):2573-80..
2. Mikkelsen MA, Ottesen N. CT findings in a dog with subacute myopathy and later fibrotic
contracture of the infraspinatus muscle. Vet Radiol Ultrasound. 2019 Mar 18.
3. Schulz KS, Ash KJ, Cook JL. Clinical outcomes after common calcanean tendon rupture repair in
dogs with a loop-suture tenorrhaphy technique and autogenous leukoreduced platelet-rich
plasma. Vet Surg. 2019 Oct;48(7):1262-1270.
4. Mauterer JV Jr, Prata RG, Carberry CA, Schrader SC. Displacement of the tendon of the
superficial digital flexor muscle in dogs: 10 cases (1983-1991). J Am Vet Med Assoc. 1993 Oct
15;203(8):1162-5. PMID: 8244865.
5. Canapp, S. O., Canapp, D. A., Carr, B. J., Cox, C., & Barrett, J. G. (2016). Supraspinatus
Tendinopathy in 327 Dogs: A Retrospective Study. Veterinary Evidence, 1(3).
6. Cannapp S, et al. Suprasinatus Tendinopathy and Other Shoulder Problems. 17th ESVOT
Congress 2014, Venice (Italy).
7. Wall CR, Taylor R. Arthroscopic biceps brachii tenotomy as a treatment for canine bicipital
tenosynovitis. J Am Anim Hosp Assoc 38:169-75, 2002
8. LaFuente et al. Surgical Treatment of mineralized and nonmineralized supraspinatus
Teninopathy in Tewnty-four Dogs. Vet Surg 38:380, 2009
9. Latinen O, Flo G. Mineralization of the supraspinatus tendon in dogs: A long-term follow-up .
JAHA 36:26, 2000
10. Murphy S, et al. Magnetic resonance imaging findings in dogs with confirmed shoulder
pathology. Veterinary Surgery 37:631–638, 2008.
11. Stobie D, Wallace LJ, Lipowitz AJ, et al: Chronic bicipital tenosynovitis in dogs: 29 cases (1985-
1992). J Am Vet Med Assoc 207:201-7, 1995.
12. McKee WM, et al. Ossification of the infraspinatus tendon-bursa in 13 dogs. Vet Record 161:
846-852, 2007
13. Danova NA, Muir, P. (2003) Extracorporeal shock wave therapy for supraspinatus calcifying
tendinopathy in two dogs. Vet Record 152:208-209, 2003

14. Leeman JJ, Shaw KK, Mison MB, Perry JA, Carr A, Shultz R. Extracorporeal shockwave therapy
and therapeutic exercise for supraspinatus and biceps tendinopathies in 29 dogs. Vet Rec. 2016
Oct 15;179(15):385.