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MLS Master Class - Veterinary Imaging
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Practical treatment I:  The Forelimb

Carl Gorman BVSc MRCVS

Key words :   Laser, therapeutic, forelimb, shoulder, elbow

 

Overview

The simplest way of treating conditions is bylocalised treatment, where the laser is applied to the area affected by the pathology or exhibiting pain.  It is also possible to treat conditions globally by using the therapeutic laser to stimulate acupuncture points or myofascial trigger points.  Use of laser for acupuncture is outside the scope of these articles, but reference tables for energy settings recommended when performing laser acupuncture are available in the manual.

Myofascial trigger points (often just referred to as trigger points) are defined as hyperirritable points located within taut bands of skeletal muscle.  The points are a marked source of pain and discomfort.  They are routinely treated in human medicine, often by massage, but are relatively neglected in veterinary medicine.  They can be detected by feeling for taut bands of muscle and then palpating hard 'knots' or points which bring about a more severe reaction from the dog or cat when pressed.  Muscles containing trigger points are weakened and will atrophy.  The weakness and atrophy are reversible if the trigger point is relieved. (Fig 1).

 LA4F1       

 

Fig 1 Trigger points related to the shoulder

Once localised treatment of any musculoskeletal condition has been carried out, muscles should be checked for trigger points and if found these should be directly treated.  It is recommended to deliver 10 joules of energy per trigger point, though some deep or stubborn points may require 20 to 30 joules.  Joules are calculated by multiplying power (watts) by time (seconds).

The MLS laser has a setting for trigger points.  Use this setting once, and check the trigger point again.  If it has softened and is not tender, the treatment has been effective.  If it is still tender, then repeat the treatment.  This can be repeated once more (i.e. three treatments in all).  It is not recommended to use more than three treatments at one session in case of overstimulation of the point.

The shoulder

The shoulder or scapula-humeral joint is an enarthrosis connecting the humerus, and so the forelimb, to the scapula.  The main connecting tissue is the large joint capsule, reinforced by slender ligaments - the glenohumeral ligaments.  The adjacent muscles and tendons play a significant role in reinforcing the shoulder.  The joint capsule is thin walled (when healthy) and the glenohumeral ligaments are thin strips of tissue.  The surrounding muscles and their tendons are much stronger structures and reinforce the capsule and ligaments, compensating for their weakness.

The main structures are:

                Cranially:              Biceps brachii tendon and the end of the supraspinatus muscle.

                Laterally:              Infaspinatus and teres minor.

                Medially:             Tendon of the subscapularis.

                Caudally:              The long head of the brachial triceps.

Bone and cartilage conditions are more common in young animals, whilst older patients are prone to muscle or tendon injuries.

The aim of treatment is to reduce pain, inflammation and oedema of the periarticular tissues.  The reference landmark is the point of the shoulder (the acromion process).  The operator should try to treat the whole joint, which involves treating the tendons of the periarticular muscles above.

The muscle groups surrounding the shoulder are prone to contracture in the diseased joint.  Treatment of muscle contractures improves mobility and eases pain, so the surrounding muscle bodies should also be treated. (Fig 2, Fig 3)

                  LA4F2b

Fig 2  Treatment points for the shoulder

          LA4F3b

Fig 3  Treatment points for the shoulder (lateral and medial views)

The main muscles involved are:

  • Triceps
  • Deltoid
  • Biceps brachii
  • Supraspinatus
  • Infraspinatus
  • Brachiocephalicus

Trigger points may be found in the brachiocephalicus, triceps, deltoid and infraspinatus.

Examples of conditions of the shoulder

  • Osteochondritis dissecans (OCD) of the humeral head
  • Shoulder instability (from injury to surrounding tendons or joint capsule)
  • Tendonitis of the biceps brachii
  • Congenital dislocation
  • Contracture of the infraspinatus muscle

 

The elbow

The elbow is a hinge like diarthrosis connecting the proximal ends of the radius and ulna to the humeral condyles.  The connecting structures consist of the joint capsule (reinforced on the cranial side by a membranous ligament), medial and lateral collateral ligaments, and muscles and tendons which provide extra support on the cranial and caudal aspects of the joint.

Laser therapy is of benefit in both conservative and post-surgical treatment of conditions of the elbow.  In conservative management, laser therapy helps to reduce pain and inflammation of the periarticular soft tissues.  After surgery, the aim is to reduce pain and oedema while encouraging and speeding up healing of tissues.

All surfaces of the elbow should be covered during treatment, concentrating on those areas which are painful on palpation, and then evenly covering the whole elbow.  Work from both the lateral and medial sides, administering energy in an even manner over the whole joint. (Fig 4, Fig 5, Fig 6).

LA4F4                                   

 

Fig 4 Treatment points for the elbow

         LA4F5b

 

Fig 5 Treatment points for the elbow (lateral view)

 

                                                         LA4F6b

Fig 6 Treatment points for the elbow (medial view)               

The main muscles associated with the elbow are the triceps, the biceps brachii and the deltoid.  Trigger points affecting the elbow may be found in the triceps and the infraspinatus muscles.  The muscles of the neck should also be checked for any contractures.

Examples of conditions of the elbow

  • Elbow dysplasia
    • The commonest condition of the elbow, comprising:
      • Fragmentation of the medial coronoid process of the ulna (FCP)
      • Ununited anconeal process (UAP)
      • Osteochondritis dissecans of the medial humeral condyle
      • Incomplete ossification of the humeral condyles (IOHC)
      • Articular fractures
      • Osteoarthritis is common in the elbow, often as a sequel to elbow dysplasia (Fig 7)

 

LA4F7                    

Fig 7 Arthritic changes seen as a sequel to elbow dysplasia

The carpus

The carpus contains many articulations, all of which as classed as diarthrosis joints.  The articulations are:

  • Antebrachial-carpal articulation
  • Intercarpal articulations
    • These unite the bones of the carpus in two rows
  • Mid carpal articulation
    • This unites the two rows of bones
  • Carpo-metacarpal articulations
    • These join the second row of carpal bones to the metacarpals

A strong joint capsule surrounds the antebrachial- carpal articulation, reinforced by ligaments (dorsal, palmar  and collateral - radial and ulnar).   Numerous strong tendons run along the dorsal and palmar surfaces of the carpus. 

As for the elbow, conservative management with laser therapy aims to reduce pain and inflammation, while post-surgical treatment helps to reduce pain and oedema, whilst encouraging and speeding healing.

Cover all surfaces of the joint during treatment (dorsal, palmar, medial and lateral).  Concentrate on areas which are painful on palpation first, and then deliver the energy in an even manner over the whole joint.  (Fig 8, Fig 9, Fig 10).

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Fig 8  Treatment points for the carpus

          LA4F9b

Fig 9  Treatment points for the carpus (cranio-lateral view)

                                LA4F10b

Fig 10 Treatment points for the carpus (caudo-medial view)

Examples of conditions of the carpus

Conditions of the carpus often are a sequel to trauma

  • Sprains and strains
  • Tenosynovitis of the abductor longus muscle of the toe
  • Fracture of the radial carpal bone
  • Carpal disclocation
  • Small fractures of other carpal bones are not uncommon

Practical laser treatment of forelimb conditions

Frequency of treatment

Treatments should be administered two or three times weekly depending on the clinical condition.    

Programmes recommended

1)      Post surgery or for acute pain:

  • 'Post surgery', 'Acute inflammation' or 'Acute pain'
  • Normally use point mode.
  • Consider reducing intensity during the first 2 or 3 treatments (use 50% intensity rather than 100%)

2)      Conservative treatment of chronic conditions:

  • 'Chronic inflammation', 'Arthrosis' or 'Chronic pain'
  • Use point mode.

3)      Muscle contractures

  • For acute cases use 'Acute pain'.
  • For chronic cases use 'Sprain/strain'
  • Use scan mode to cover the contracted area and surrounding tissue.