Episode 60: Identifying and Treating Orthopedic Disorders with Dr. Marty Greer

This episode of the Good Dog Pod explores canine orthopedic disorders. Host Laura Reeves is joined by renowned veterinarian Dr. Marty Greer to discuss some common orthopedic issues, as well as their symptoms, causes, and treatments.

What should I do if my puppy is exhibiting orthopedic problems? Immediately contact your veterinarian, as many orthopedic issues are time sensitive and need to be treated as soon as possible. In addition to this, Dr. Greer outlines several questions you can ask yourself to better evaluate what disorder your puppy is experiencing. The breed and age of the dog is very important, as some orthopedic problems are found mostly in large breeds and others are found mostly in small breeds. Then, recall if there is any history of trauma/physical injury in the infected area. Determine if the hurt area is in one limb, multiple limbs, or constantly changing. Finally, take your puppy’s temperature as a fever can be an indication of a certain set of orthopedic conditions. 

What are some common orthopedic disorders? First, take note that some orthopedic disorders are genetic, while others are caused by infections. Dr. Greer lays out a list of common issues, as well as a comprehensive description of each. Panosteitis is a bone inflammation commonly found in large, rapidly growing breeds marked by shifting leg lameness. OCD is an abnormal development of bone cartilage seen in shoulders, and is often difficult to pinpoint in x-rays. HOD is a very painful flare at the growth plates. Legg-Calve-Perthes affects hip joints, mainly in small breeds. Hip dysplasia is one of the most commonly known issues, and mainly affects large breeds. Some infections that can cause lameness include lyme disease, cellulitis, and strep canis. Dr. Greer recommends keeping large breed puppies on a diet specifically created for them, which has been proven to reduce such orthopedic problems.

Transcript

Laura Reeves [0:35] Welcome to the Good Dog Pod! I am your host, Laura Reeves, and we have Dr. Marty Greer. Marty, welcome. 

Dr. Marty Greer [0:50] Thank you. 

LR [0:51] I am very excited. This is going to be a really, really interesting one to me. You have a puppy, and it’s limping. So I thought we could go through some of the potential causes. Why is it limping? Let’s look into some of that, shall we?

MG [1:05] I think that’s a great idea. 

LR [1:08] We’re making this up. My puppy is 3 months old. It’s a German Wirehaired Pointer. And it has collapsed screening, and it was fine yesterday. 

MG [1:19] That sounds serious. There’s a long list of things that can cause puppies to have acute onset lameness. One of the things that you want to start off with is: What breed is the puppy? (Which you’ve already told us.) What age is the puppy? Was there any history of trauma? Is the puppy running a fever? Can you localize it to one limb or is it more than one limb? Or does it change around from one limb to another? All those things are important for us to take in the medical history. That’s where I would start, to find out those pieces of information. Then probably if there’s no fever, I would be looking most likely at an orthopedic problem, which could be anything from trauma—because heaven knows puppies can get into all kinds of trouble, even when you’re not looking—

LR [2:05] Even when you are looking!

MG [2:07] Exactly. Puppies get legs caught in crates. We’ve seen puppies that have fallen down stairs or had some kind of trauma. Sometimes there’s a history of that, but not always. Sometimes you weren’t in the house when it happened. I’ve seen little children pick up puppies and, of course, accidentally drop them. My attorney dropped a puppy of ours when he was at our house looking at our litter of puppies. He’s 6’4” and he dropped the puppy. I thought it was only kids!

LR [2:33] No! 

MG [2:33] He ended up buying a puppy from us, but it was a little bit worrisome for a bit. So there’s orthopedic problems. If they’re not running a fever, you’d be looking at an orthopedic problem or a nutritional problem. If they are running a fever, then we’re going to go down a whole completely different path. Those are the things that you need to start off with. As far as orthopedic problems, front legs we can frequently see OCD in the shoulder. We can see OCD in the elbow. Ununited Anconeal and Fragmented Coronoid in the elbow. Or in any of the legs, we can see Panosteitis. In the rear legs, we can also see OCD. Hip Dysplasia, Legs Perfused, Patella Luxation. In the front leg again, Premature Ulnar Growth Plate Closure. In any of the legs, we can see HOD or we can see trauma. We can start off with those as a pretty comprehensive list of differentials for orthopedic problems that we can see in young dogs.

LR [3:22] Excellent. Let’s talk about some that are genetic in basis and also maybe the top three most common. I know Panosteitis is real common in a lot of the larger breeds. OCD, I think, Osteochondritis Dissecans? Yes? Common. And HOD: Hypertrophic Osteodystrophy?

MG [3:45] Wow, you’re good. 

LR [3:47] Sad to say, I have actually personally encountered all three of these. 

MG [3:53] A lot of these are disorders of young, large breeds, fast-growing male puppies. Females can be affected, but not as frequently. It has to do with their rate of growth and those types of things. But not all things happen in large-breed puppies. Seems like legs perfused and Premature Ulnar Growth Plate Closure (so that the back leg and the front leg snag)—those will happen in smaller-breed dogs. Premature Ulnar Growth Plate Closure will occur in the Corgi, the Bassett, some of the chondrodysplastic dogs. Or it can happen in any dog if it has trauma to the leg if it’s enough trauma not to cause a fracture in the leg but enough trauma to compress the growth plates at the wrist or at the carpus. The ulna and the radius will stop growing in sync with each other, and you’ll end up with deviation of the foot and ligament. It’s not very common, but it is something that needs to be included in the differential in any puppy that’s had trauma. Sometimes they’ll come in and they’ll say, “Well, she fell down the stairs. She was limping a little bit. She seems okay.” If you don’t think that there’s a fracture there, frequently what we’ll do is we’ll take an X-ray at that point and then have them come back in a week to 10 days and see if there’s any indication that that deviation is starting to occur. There is a surgical intervention for that, but only if you get to it early and before the foot is significantly deviated. So it’s important not to wait too long, even if you don’t think that there’s actually a fracture. Take an X-ray.

LR [5:13] So let’s take them one at a time, shall we? Let’s start with Pano, because I think it’s probably the most commonly seen, at least in large-breed dogs.

MG [5:22] Panosteitis is typically a disorder of the large breed: heavily-boned, rapidly growing male dog. It can also occur in females, but it’s more common in males. It’ll cause a shifting leg lameness, meaning one day you think it’s a front leg, and the next day it’s the back leg. Sometimes there’s a low-grade fever associated with it. It can be really hard for an owner to try to describe to you, as a veterinarian, where the problem is. Because one minute, they think it’s one leg, and one minute, they think it’s another. In reality, that frequently can happen. On exam, if you start to palpate the dog’s leg, you’ll feel pain where the ⅓-⅔ of the bone joins the lower ⅓ of the leg, and the back side of the humerus, the back side of the femur—that’s where the blood vessel goes into the nutrient foramen and that’s where  the dogs complain about pain. If you take an X-ray too early in the course of Panosteitis, nothing will show up on the X-ray. It takes a few days to a few weeks for them to start to see any changes. The X-ray just shows a fluffy, vague kind of density inside the bone, where you normally would just see a very clear area, and you can see clearly where the outside of the bone is. You’ll see just a little fluffiness inside the bone. So it’s a little hard to pick up on X-ray. It’s not very clear. Sometimes it can be hard to tell which leg is the problem for the puppy. They may shift leg lameness. Some puppies are very cooperative when you’re going over them and feeling them. Other puppies are not. Their hair hurts. Everything hurts. Anywhere you touch them, they start to cry. It can be difficult to localize pain because everything from the tip of their toe to the shoulder hurts. Localizing pain can sometimes be a little tricky. Sometimes owners are really good at it. Sometimes they’ve picked up better signals than we have. It’s a little bit variable, and it can require some detective work to figure out where the pain is coming from.

LR [6:59] Excellent. And Pano—do we know anything, really? It’s been a while since I’ve looked into it. Do we have any new or good information about what’s causing Panosteitis and how do we treat it?

MG [7:11] It’s just a rapidly growing puppy. I don’t think there’s anything terrifically new with that. Treatment is anti-inflammatory. Typically, the non-steroidal anti-inflammatory. You don’t want to use a steroid in a young puppy if you can avoid it. But again, you also have to read the label on the packaging because there are some drugs that are good anti-inflammatories but not labeled for use in especially young puppies because of the risk to their kidneys and liver development. 

LR [7:37] So do you have a particular one that you’re able to recommend? Is this Rimadyl or not a Rimadyl? What are we talking about with this?

MG [7:45] My favorite is Meloxicam or one of the other medi-cam type of products, because it’s really easy to adjust the dose. It comes in a liquid form, so you can really specifically adjust the dose to the size of the puppy so you’re not doing your best to come up with the right dose, but you’re actually very accurate with it. But do have your veterinarian carefully read the packaging and make sure that your puppy isn’t too young to use it. Very young puppies can’t metabolize it and don’t do well on it. You want to be careful.

LR [8:14] Right, and Pano we see (at least what I’ve encountered; you’ll have more information on this) age-wise? That’s typically an older puppy that you’re seeing affected with Panosteitis? 

MG [8:24] Typically, but in German Shepherds, it can occur up until five years of age. So just because they hit a year, that doesn’t mean that they’re going to outgrow it. 

LR [8:31] Gosh!

MG [8:31] Yeah, I know. That’s really bad. There’s been a lot of people that have talked about vitamin supplements (Vitamin C, Vitamin K), and there really isn’t any strong evidence that shows that that’s helpful. In fact, you can overdose on vitamins. You don’t want to just go to the store and start pumping vitamins down your puppy. You want to make sure that you talk to your veterinarian about the appropriate dose. 

LR [8:53] Very good. Okay, so Pano! Next is probably OCD, don’t you think? The next most common.

MG [8:59] Yeah. I think OCD, and it’s a tricky one, too. It primarily occurs in the shoulder, but it can occur in the hoc (the back leg), in the knee, and in the elbow as well. It’s one of the four kinds of Elbow Dysplasia that we see. Not to get too far off here, but four Elbow Dysplasia causes are: OCD, Ununited Anconeal, Fragmented Coronoid, and Premature Ulnar Growth Plate Closure. Going back to OCD, most commonly seen in the shoulder. What it is is that, as the cartilage is developing inside the joint, regardless of which joint it is, it doesn’t adequately adhere to the underlying bone, and as a result, it turns into this little flap that will move back and forth inside the joint while the puppy is walking. Sort of like walking with a rock in your shoe. It’s pretty uncomfortable. It’s just depending on if it’s in the wrong place. It can cause some inflammation in the joint. The good news is the shoulder develops arthritis very, very slowly. The bad news is it can be a bugger to find on an X-ray. Even if you’ve got a good digital X-ray, and the puppy well-positioned, it can sometimes be very challenging to find. And the other real problem with it is that it frequently occurs in both joints at the same time, so both shoulders or both knees, both hocs. When you go in with a puppy, even if it’s only limping on one front leg, the recommendation is to take an X-ray of both shoulders. There’s some specific positioning that veterinarian radiologists want us to use so that they have the best chance of trying to find the lesion inside the joint, because it can be tricky to see on an X-ray. It’s a bit of a challenge.

LR [10:29] Definitely. Joint mice! I mean, what?! Joint mice. That’s the craziest thing. 

MG [10:35] It’s not just the mouse next to your computer. It’s inside your joint, too. So some of these patients end up needing to go surgery to remove the piece of cartilage. That cartilage, once it’s removed, never forms back to a normal, articular cartilage. It’ll develop a fiber cartilage instead. But it can be better than having that loose piece of cartilage, either flipping back and forth (attached on one end) or completely breaking off and serving as a giant mouse, like you said. The recommendation that our surgeon gives us for this is if you have a puppy that you suspect OCD in, take your X-ray, see if you can see it. And then you do one of two things: you either do 30 days of intense rest (crate rest). The puppy goes out on a leash, comes back in, basically stays in the crate for 30 days. Or you take that puppy out, and you just run the little wheels off of it with the hope that, if you rest it, the cartilage may re-attach, or if you exercise it hard, it may break loose, and then you don’t end up having to go to surgery. But frequently these dogs end up with surgery. This is a pretty cool place for arthroscopy, where they can just go in with a little scope, see the piece of cartilage, and if it’s small enough, it’ll come out through the incision that they’ve made. If it’s too large, they may either make the incision bigger to pull out the whole thing or they may take a chance on breaking it into smaller pieces (depending on the surgeon and their skill level and equipment level), take out little pieces of it, and clean up the joint without having to take the puppy in and open the whole joint up completely. 

LR [11:53] This is a genetic disease, right? OFA has an OCD database, correct? 

MG [11:59] Correct. If we’re talking Ununited Anconeal, Fragment Coronoid, Hip Dysplasia, Legs Perfused, Patella Luxation—they’re all orthopedic problems that are inherited. The only one that’s on this list that isn’t is either trauma or HOD. Even HOD seems to have a genetic component to it, in that we can tell which breeds are more likely to develop it. 

LR [12:20] And it also, from what I was able to learn when I had to deal with it, runs in families. It was a very interesting study that I did on it. So, treatment is surgery. Prevention is paying attention to your breeding practices, yes? 

MG [12:35] Right, and then for most of these orthopedic problems, not letting the puppies get too heavy or be on too much nutrition. They do make large-breed puppy diets that are commercially available. That’s made a huge difference in the orthopedic problems that we see. If you have a large-breed puppy, even if it’s not exhibiting signs of lameness, stick to the large-breed puppy diets that are made commercially. Please don’t start feeding raw meat diets and unbalanced diets to these puppies, because there’s a huge number of nutritional problems that we see associated with that. Use the diets that have spent millions of dollars on research—and I quite literally mean that, whether it’s Royal Canin or Iams or Hills Science Diet, Prescription Diet, and Purina Diet. They’ve all spent millions of dollars developing large-breed puppy foods that reduce the incidence of some of these diseases. Take advantage of those. Just feed them. Don’t get too creative with your diets. Don’t start adding calcium. Don’t start adding Vitamin A. Don’t start adding C and D. Just feed nutritionally appropriate foods to your puppy. 

LR [13:35] Absolutely. And high protein? Are you using high protein specifically or just the actual calories they’re getting when you’re talking about too much nutrient?

MG [13:46] It’s actually the calories that we’ll see.

LR [13:49] Very good. Our next one then would be HOD. Hypertrophic Osteodystrophy. 

MG [13:55] Again, this is a tough one. 

LR [13:57] The case study I started with—what I broke out with—that actually is a real thing that happened to me with one of my puppies. 

MG [14:05] And it does start off very acutely. The puppy can be absolutely perfectly normal one evening, and the next morning you get up and the ends of the bones just above the wrist and just above the hoc are swollen, they’re painful, they are running a fever. It’s sometimes associated with a recent vaccination. My people that have lines of dogs that they know they have HOD in—number one, of course, they’re careful with their breeding and they’re trying to breed away from that. But number two is they’re very careful with their vaccines, and they’re cautious not to give too many immunizations at one time. 

LR [14:35] Yes, indeed! So HOD—talk a little bit about the X-rays that you can use to diagnose this. First you have the fever, right? That is a big one that I heard. And then the X-rays, I thought was a fascinating piece. It was so classic, the way they described it. 

MG [14:53] There’s a very specific look that you see at the ends of the bone when you see an HOD puppy. You can see this layer at the growth plates at the front leg, at the wrist, at the distal, and at the back leg at the distal to the end. It’s very characteristic looking. The puppies will come in acutely painful. I mean, really painful. Not just a little bit sore. But these guys are really hurting. It happens very suddenly. It’s pretty startling to owners when it happens. And it tends to be a matching set. For instance, both front legs are going to be looking the same, or both back legs, which is a hint that it’s probably not trauma. If it’s trauma, you’re going to expect it to be just one leg. But if it’s caused by HOD, then you will see the matching front leg or the matching back leg. It can also cause problems in some of the other joints, but typically, it’s distal radius and distal tibia that’s most noticeable on X-ray. 

LR [15:45] Yeah, this puppy that I’m talking about was in so much pain he couldn’t stand up. He couldn’t stand up to pee. It was ugly. Again, causal factors?

MG [15:54] Genetics. Vaccines. Treatment consists of non-steroidal anti-inflammatory, like we talked about before. Something like Meloxicam or Rimadyl. Usually, they’ll do an antibiotic in case there’s any signs of pneumonia associated with it. 

LR [16:08] Pano, OCD, HOD, Legs Perf I think is one that’s interesting and definitely, again, has an OFA database for it? 

MG [16:19] Correct. It’s mostly a disorder of small-breed dogs. It’s usually just one side, unilateral. Again, the puppy at around 9-12 months will be completely normal, and then suddenly very lame on one leg. Very painful. An X-ray is very easily diagnosed on these, unless you think there could be some sign of trauma. We did have a puppy in the practice a few months ago where there was a lot of discussion back and forth on whether it was Legs Perfused or whether it was trauma. Trauma can cause a fracture at the same place, but basically what this is is a loss of blood flow to the neck of the femur and the hip joints. Because the blood flow is lost, you get an Avascular Necrosis, meaning that without blood flow, the tissues become necrotic, and then they collapse down so that the hip joint is no longer completely normal. Again, surgery is the option for this. It’s a very good outcome for these puppies. They feel much better after surgery, but you do remove the head and neck of the femur so the joint is never normal. They go on to form a false joint. These dogs are usually too small for an implant for a hip replacement, so it’s typical that these puppies (if it was a show puppy) probably will never regain a normal gait and probably will not be something that you can successfully go on to finish. But, again, it shouldn’t be something in your breeding program, so it’s not a hard decision to say that this puppy should probably be placed as a pet and not included in a breeding program.

LR [17:39] Absolutely. Any other that you’re thinking of in the genetic disorder before we move into infectious diseases and some of the other things we were talking about?

MG [17:47] Well, hip dysplasia is an abnormality in the hip joint in large-breed dogs. A lot of people understand this pretty well. Again, it can show up when the puppy is anything from very young (maybe 4 months up) and, frequently, if we take an X-ray, we’ll see that the puppies between 9 and 12 months is really pretty painful, and then they go on to be a lot more comfortable until they’re several years old, and then we can start talking about whether the dog needs to have any kind of intervention done surgically. But this is, again, a dog that should not be in a breeding program, so that’s another rear-leg-lameness problem. Another thing in the rear leg is the Patella Luxation. It can be trauma, but frequently it’s a genetic disorder, usually in small-breed dogs (but I’ve seen it in even larger-breed dogs, as large as Rottweilers). When the angulation isn’t correct in the rear leg and the patella doesn’t sit neatly into the groove of the front of the femur, it’ll slide on and off. Those puppies will be acutely lame, and then the patella pops back into position, and then they go running off looking completely normal, and then two minutes later, it’s popped out again. It can be very confusing for owners because they’re just not sure what the underlying problem is. Ununited Anconeal and Fragmented Coronoid processes are where the growth plates in the elbow (the anconeal is just above the elbow and the coronoid is just below the elbow where the elbow hooks around the end of the humerus) don’t adequately close, and then they end up with a joint moused in that. There’s not good construction of that joint so that may or may not end up to be a surgical intervention. Elbow dysplasia is in the OFA database as well, and we recommend a lot of dogs get their elbows X-rayed at the same time that we X-ray them for hip dysplasia in the screening program because you don’t want to end up breeding dogs with this disorder. It is really common in certain breeds: German Shepherds, Bernese Mountain Dogs, some of those breeds. Be very, very cautious. Labradors—my gosh. I’ve seen a lot of Labradors with this. It doesn’t get diagnosed until they’re maybe 5 or 6 years old, and then by then surgical intervention can be very difficult. I understand there’s one place in the country that’s doing elbow reconstruction implants, and I believe that’s in Georgia. Things are really advancing pretty interesting choices for clients to make. But it is an expensive intervention that can be life-changing for the dog. 

LR [20:03] Absolutely. What are some of the other—are we thinking tick-borne diseases?—infectious diseases that could be causing a young dog to be lame? 

MG [20:12] Certainly tick-borne diseases, including Lyme’s disease, but not exclusively. It can be other things that can cause some of those things as well. And then as I was thinking through this, I came across a few things that I knew about and a few things that I didn’t. Juvenile cellulitis, which would be puppy strangles, as a possible cause for lameness. Usually that causes skin disorders around the muzzle and the ears. If it’s advanced enough, if the lymph nodes are painful for the dog, they can have front-leg lameness. Discospondylitis is kind of an odd little disease. I would see maybe one or two cases of it a year. It’s typically rear-leg lameness in a young dog, associated with a fever. They’re very specifically painful in the area where the growth plate of the vertebrae is. An X-ray initially, again, may not look like anything but if you come back and X-ray a few weeks later, you can see a fuzziness in that area. These dogs respond very, very well to an antibiotic. It doesn’t mean that every time you have a puppy with lameness, you should automatically put them on an antibiotic, but it is something to include in the list of differentials. Like I said, we see a couple of these a year—just enough to keep you on your toes. Sterile meningitis is another disorder we can see in puppies. It’s usually associated with neck pain and fever, but it can be hard to tell if it’s pain in the neck or pain in the front legs on young dogs. Like I said, if their hair hurts and everything hurts, they complain when you touch them. But sterile meningitis is usually associated with a fever, as is immune-mediated polyarthritis. Both of those can be seen in young dogs. The scary part about strangles, sterile meningitis, and immune-mediated polyarthritis is many times we have to put those dogs on a fairly significant dose of steroids to control the disease. You’ve got to be absolutely dead-on certain before you blast a puppy with steroids that you know you’re treating an immuniated disease and not something infectious. Because if it is an infectious disease and you put them on that dose of steroids, you could cause the disease to get much worse. You’ve got to be very comfortable in your diagnosis. And then there are a few things that are a little bit more rare. Strepto and Streptanus can cause lameness, and it’s a problem in young puppies and young kittens. Recently, our local shelter had an outbreak from some dogs that were brought in from the South. It can be infectious. It has a very low risk, but a potential risk to humans handling those patients. Those have to be carefully managed. Then we’re kind of getting into the more rare things, like Toxoplasmosis and Neospora, which cause not just a lameness but a neurologic weakness in (frequently) the rear legs. If the mother was infected with either Toxo or Neospora, the puppies could be born with this. I’ve seen a couple of cases of it. It’s not at all common, but it is something out there that if you’re chasing a lameness or a weakness or something, and you’re not quite sure what it is, it’s something that’s worth discussing with your veterinarian. The treatment, again, is an antibiotic, but specifically gentamicin. It’s not the typical antibiotic that you pull off the shelf, like you would usually use Doxycycline if you thought it was Lyme’s disease and the puppy was old enough and its teeth were all in. Or Amoxicillin. Discospondylitis will get better with Amoxicillin. It doesn’t require high-powered antibiotics. But Toxo or Neospora, those will require specifically Clindamycin. I just want to make sure we don’t overlook cats completely in our discussion, because there is this odd little calicivirus that we can see in young kittens. Even if they’re appropriately vaccinated, they can still pick up a calici, and it will cause very suddenly lameness and fever in kittens. Personally, I had two of my own very young kittens that came from a shelter that ended up with it. It’s a little off-topic, but don’t forget that cats can end up with an infectious cause for this as well.

LR [23:44] Alright! We covered a lot of ground here, man. 

MG [23:47] We did. And there’s one other thing I just want to very briefly mention. We see puppies that end up growing really fast. Again, typically male dogs. They’ll end up with a calcium phosphorus imbalance. It’s not particularly well understood by most veterinary nutritionists or veterinarians, but we’ll see puppies that have this bone breaking over the wrist. So when they stand, instead of standing with their toes underneath them, the toes start to buckle forward and the wrist is in front of the toes. I commonly see this in puppies that are growing very quickly and that are on too hot of a diet. So we’ll switch those puppies to a large-breed puppy food (if they’ve been on regular puppy food) or even to an adult breed food for a week or two. They straighten right out. They look really good. But if you don’t catch it at a vaccination appointment, or if you don’t notice it or your veterinarian doesn’t notice it, it can be progressive and can be very difficult to get these puppies straightened back out. 

LR [24:42] I think we could do an entire episode on feeding your puppies to grow them properly. I think that would be an amazing topic. 

MG [24:50] I think that’d be great. 

LR [24:52] Thank you so much, Marty! I sure appreciate your time, and we’ll talk to you again soon!