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Evaluation of Iliopsoas Strain with Findings from Diagnostic Musculoskeletal Ultrasound in Agility Performance Canines – 73 Cases

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Evaluation of Iliopsoas Strain with Findings from Diagnostic Musculoskeletal Ultrasound in Agility Performance Canines – 73 Cases Evaluation of Iliopsoas Strain with Findings from Diagnostic Musculoskeletal Ultrasound in Agility Performance Canines – 73 Cases Robert E. Cullen DVM 1 Debra A. Canapp DVM, DACVSMR, CCRT 1* 1 Brittany J. Carr DVM 1 David L. Dycus DVM, MS, DACVSSA, CCRP 2 Victor Ibrahim MD 1 Sherman O. Canapp, Jr DVM, MS, DACVSSA, DACVSMR, CCRT 1 Veterinary Orthopedic and Sports Medicine Group, 10975 Guilford Rd, Annapolis Junction, MD 20701 2 Regenerative Orthopedics and Sports Medicine, 600 Pennsylvania Ave SE, Washington, DC 20003 * Corresponding Author ([email protected]) ISSN: 2396-9776 Published: 13 Jun 2017 in: Vol 2, Issue 2 DOI: http://dx.doi.org/10.18849/ve.v2i2.93 Reviewed by: Wanda Gordon-Evans (DVM, PhD, DACVS) and Gillian Monsell (MA, VetMB, PhD, MRCVS) ABSTRACT Objective: Iliopsoas injury and strain is a commonly diagnosed disease process, especially amongst working and sporting canines. There has been very little published literature regarding iliopsoas injuries and there is no information regarding the ultrasound evaluation of abnormal iliopsoas muscles. This manuscript is intended to describe the ultrasound findings in 73 canine agility athletes who had physical examination findings consistent with iliopsoas discomfort. The population was chosen given the high incidence of these animals for the development of iliopsoas injury; likely due to repetitive stress. Methods: Medical records of 73 agility performance canines that underwent musculoskeletal ultrasound evaluation of bilateral iliopsoas muscle groups were retrospectively reviewed. Data included signalment, previous radiographic findings, and ultrasound findings. A 3-tier grading scheme for acute strains was used while the practitioner also evaluated for evidence of chronic injury and bursitis. Results: The majority of pathologies were localised to the tendon of insertion, with the majority being low grade I-II strains (80.8%). Tendon fibre disruption (71.2%) and indistinct hypoechoic lesions (91.8%) were the most common of acute changes noted. Hyperechoic chronic changes were noted in 84.9 percent of cases. Acute and chronic changes were commonly seen together (62.8%). Conclusion: Diagnostic musculoskeletal ultrasound was used to identify lesions of the iliopsoas tendon consistent with acute and chronic injury, as well as identifying the region of pathology. The majority of agility performance dogs had low grade acute strains based on the tiered system, with mixed acute and chronic lesions being noted frequently. Application: Diagnostic musculoskeletal ultrasound provides a non-invasive diagnostic modality for patients suspected of having an iliopsoas strain. INTRODUCTION Muscle strains are a commonly assessed injury amongst working and sporting animals.2,5,20 A previous survey with agility dogs found that thirty-two percent of the population had some degree of orthopaedic lameness during training, and that fifty-three percent of those evaluated by a veterinarian were due to muscle or tendon injury.5 The muscle is prone to acute strain from excessive stretch while engaged in eccentric contraction, wherein the external forces being driven across the muscle overload the contractile force of the muscle itself.3,4,23,28-29 The fibres of the muscle may then become disrupted and lose continuity, with additional disruption of the vascular supply leading to interstitial haemorrhage and swelling.28 Thirty-two percent of hind limb muscle strains in dogs involve the iliopsoas muscle group.6 Acute and chronic injury to the iliopsoas muscle groups has been a topic of interest in recent years with an increasing attention to diagnosis and treatment of this condition. Clinical presentation with iliopsoas discomfort can include gait abnormalities and lameness with decreased coxofemoral extension. The lameness may be similar to patients with cranial cruciate ligament injury or hip Veterinary Evidence p a g e | 2 ISSN: 2396-9776 Vol 2, Issue 2 DOI http://dx.doi.org/10.18849/ve.v2i2.93 total pages: 17 dysplasia. When evaluating a patient with iliopsoas discomfort, a shortened stride with decreased hip extension is characteristic but not distinctive for iliopsoas in particular.2-3,20,22 Upon palpation there may be pain, spasm, and discomfort of the iliopsoas. Furthermore, many patients will be hesitant to allow coxofemoral extension with abduction and internal rotation as this specifically places stretch on the muscle and tendon in question. An acute injury to the muscle or tendon has been characterised in 3 grades based on appearance during advanced imaging. Early human 3-tiered gradation structures have involved those based on clinical presentation33, but which have correlated well with later systems based on musculoskeletal ultrasound findings34,35, upon which we based our findings. Grade I strains have intact architecture and muscle function but with focal oedema or haemorrhage with less than 5%of the muscle involved. Such strains are generally the result of repeated muscle contractions resulting in mild muscle cell damage at the sarcomere. These injuries are rarely noted or diagnosed asides from athletic or performance animals, and generally resolve with appropriate rest in <1 week. Grade II strains have increased muscle involvement, mild fibre disruption, increased oedema or haemorrhage, and reduced strength of the musculotendinous unit. Grade III strains involve significant fascial tearing, muscle fibre disruption, and significant oedema or haemorrhage formation.2,33-35 (Table 1) Table 1: Grading Scheme for Acute Musculotendinous Strain Injury GRADE DESCRIPTION GRADE I (“Mild strain”) no loss of function, <5% muscle involved, focal oedema or haemorrhage GRADE I-II As above but with mild fascial tearing GRADE II (“Moderate strain”) reduced strength of musculotendinous unit, >5% muscle involvement, mild fibre rupture, increased oedema/haemorrhage GRADE II-III As above but with fascial tearing, mild fibre disruption GRADE III (“Severe strain”) significant fascial tearing, significant to complete muscle fibre disruption, significant oedema/haemorrhage It is important to distinguish tendon strain and injury from muscle belly damage. The tendon unit primarily acts as a structure to transmit contractile force of the muscle. As such, they are often not rigid structures but have various degrees of elasticity and compliance. The general theorem of tendinous strain involves microtrauma and chronic overuse leading to a mechanical breakdown of the tendon. The lack of collagen support predisposes the structure to significant macroinjury. Gradation of tendon strains follows the same criteria and categories as that involving muscle trauma, differing only in the component of elastic recoil deformation. 8-9 The bursa is a tissue envelope surrounding the tendon of insertion as it approaches to and attaches to the lesser trochanter. This fluid-filled membrane allows for decreased friction between the tendon and bone. Bursitis, inflammation of the tissue membrane with resultant swelling and fluid collection, has been noted with other tendinous injuries. The bursa is collapsed in healthy patients, but can become enlarged and fluid distended in cases of acute or chronic injury.17-18,23-24Acute and chronic bursitis inflammation can often be Veterinary Evidence p a g e | 3 ISSN: 2396-9776 Vol 2, Issue 2 DOI http://dx.doi.org/10.18849/ve.v2i2.93 total pages: 17 characterised, with acute injury showing as an anechoic fluid pocket and chronic injuries often having a thickened membrane and hyperechoic changes or debris within the space.31,32 Descriptions of imaging modalities for iliopsoas pathologies have been reported.11,14-17,19,23-26 Radiographs are unlikely to show evidence for iliopsoas strain, although they may detect mineralisation of the tendinous attachments, or enthesiophytosis, which has been seen with some instances of fibrotic myopathy and other chronic injuries.11 Computer tomography (CT) evaluation for acute iliopsoas strain has been previously described and found to be accurate for assessing intramuscular oedema and inflammation.14 Magnetic resonance imaging (MRI) has also been described for the assessment of iliopsoas injury in human and canine patients.15 However, these advanced imaging modalities are expensive to undertake, and require general anaesthesia. Due to expense and anaesthesia, it is also difficult to coordinate recheck evaluations to assess the injury following treatments. Diagnostic musculoskeletal ultrasound evaluation has become a valuable and practical tool in assessing the iliopsoas and surrounding musculature. It is used frequently in human medicine for diagnostic evaluation of iliopsoas injuries, as well as for therapeutic injections.19, 23-24 While sedation is required for veterinary evaluation, full anaesthesia is not needed to perform an evaluation, which makes it of benefit over CT and MRI. It is also less expensive, making it a more viable option for both initial diagnostics and recheck examinations. Ultrasound evaluation of normal iliopsoas muscles was first reported in 2008 by Cannon and Puchalski where it was found that assessment of the whole iliopsoas muscle group could be performed using 8-5mHz curvilinear and 12-5mHz linear transducers with similar findings in cadaver specimens and live dogs.16 Additional ultrasound studies have been performed to identify the femoral nerve passage through the iliopsoas musculature.25-26 However, there have been few notations in literature regarding abnormalities of this muscle group using musculoskeletal ultrasound evaluation
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