General Physical
It is essential to perform a general physical examination as part of a lameness investigation, even if the lameness seems obvious.
The key reasons for this is that many of our patients will have co-morbidities which might impact on the diagnostic and treatment plans, as well as many also having other changes which are clinically relevant but may be missed on purely orthopaedic examination.
Assuming there are cooperative, perform a standard physical examination: starting at the head and working backwards. Examine the eyes, ears, nose, head and mouth, assess the mucous membranes and pulses as well as auscultating the chest. Carefully palpating the abdomen and assessing lymph nodes and skin is also important. Taking and recording temperatures, pulse and respiration is also key.
The purpose of this examination is to assess the dog’s overall health as other disease may have an impact on lameness, examples include:
- Patients with cardiac anomalies might need ‘non-standard’ sedation protocols.
- Patients with pyoderma might require this to be treated before considering any surgery.
- Alopecia and a ‘pot-bellied’ appearance may suggest undiagnosed hyperadrenocorticism, a common co-morbidity to cruciate disease in older Bichon Frise and other small dogs.
- The presence of significant concurrent disease could affect the diagnostic and treatment plan and will require additional discussion with owners. Missing things, or jumping to the orthopaedic condition risks complicating later discussions.
TOP TIP: “A patient can have as many diseases as they damn well please”
Hickums Dictum
Orthopaedic Examination in Dogs
Standing Evaluation
Once in the consult room, as well as the patients’ stance, it is important to perform or repeat a more focussed visual assessment of each joint and limb prior to the physical examination itself. Changes such as effusion, changes in alignment and limb length may be apparent at this stage and can be clinically important.
When performing the standing evaluation, assess muscle atrophy, joint effusion, and standing joint angle. Visual examination can also help check for what are typical presentations of common orthopaedic conditions such as elbow pain (front paws turned out) or calcaneal tendon injury (plantigrade stance).
Concurrent assessment of the contralateral limb is also important at the time of standing evaluation, a good trick to be able to better assess whether symmetry is present: mild muscle wastage often being difficult to identify visually but is clinically important and much more apparent when assessing both ‘sides’ concurrently. Perform this assessment while standing above or behind the patient – a valuable step of the physical assessment.
The standing evaluation also enables a basic neurologic examination, assessing proprioception, cervical range of motion/pain and for the presence of thoracolumbar pain or discomfort. Further details of how to perform a neurological examination is widely available elsewhere and not a focus of this module.
After standing evaluation, perform careful direct palpation of the joints and limbs to provide a more comprehensive assessment and identification of abnormalities present.
Orthopaedic Evaluation
Some authors recommend that the orthopaedic examination should be performed on a recumbent patient, the basis being they ‘feel’ subtle changes may be easier picked up. While this does make sense, for example, the muscles surrounding a bone would be less tense if non-weight bearing, many patients will not easily allow examination whilst recumbent and so it is important to hone your assessment skills in both recumbent and standing patients.
Also practice your physical examination in sedated patients, such as those admitted for radiography. This is not a replacement for examination of the conscious patient, but does help gain a better understanding of how to pick up more subtle changes such as joint laxity and better develop your skills for assessing factors such as range of motion.
What you detect in the conscious patient might be more clinically relevant and better correlate to the most clinically relevant changes, but seize every opportunity to ‘learn normal’.
As per the gait and visual assessment, the orthopaedic examination should be systematic, repeating it in the same way each time.
Although joint effusion might be easier to feel during standing examination because weight-bearing pressurises joint fluid toward the periphery of the joint, evaluation for effusion should still be performed while the patient is recumbent.
TIP: when assessing for effusion, especially of stifles and elbows, feel both the right and left joints in the standing patient at the same time. This allows you to ‘compare and contrast’ and makes detecting subtle changes easier.
Performing the examination in the exact same manner each time reduces the risk of clinically relevant changes being missed. It is also wise to assess the leg that you think is painful last – this should mean your patient is happier to be examined and also that you do not get distracted by one clinical finding.
TIP: Don’t get distracted by what you first find, the owner tells you, or the paw the patient holds up. Perform a thorough, repeatable examination in each and every patient.
Table 1: Dog Joint Landmarks and Effusion Palpation.
| Joint | Flexion Landmarks | Extension Landmarks | Joint Effusion |
| Phalanges | Digital and metacarpal or metatarsal pads touch | Normal standing position; pads should be in contact with ground | Externally palpable on dorsal aspect of joint |
| Carpus | Paw pads ‘only just’ touch the antebrachium on flexion | Normal standing position at 175-190 degrees | Palpated over the dorsal carpus when palpated in slight flexion |
| Elbow | Carpus can just about touch the shoulder | The elbow can almost fully straighten, 150 degrees is realistic. This less than cats. | Palpated by finding the lateral epicondyle and gently palpating caudally toward the ulna |
| Shoulder | The limit of flexion is around 125 degrees, significantly different to cats | Around 145 degrees of extension is realistic | Not palpable |
| Hock | When stifle is allowed to flex, the dorsal metatarsals will nearly touch the tibia. The hock will only flex slightly if stifle is not allowed to flex when hock is flexed (tibial compression test). | There is breed variation on the limit of full extension, up to 185 degrees is described. Compare to contralateral limb. | The transition of bone palpated from medial and lateral malleolus caudally towards the calcaneus |
| Stifle | 130 degrees flexion is possible, the tuber calcaneus should sit below the ischiatic tuberosity on flexion | 150 degrees of flexion, with the tarsus also extended. If tarsus is extended this will limit stifle extension | Palpated by feeling both sides of patellar tendon. Its definition lost by stifle effusion. |
| Hip | Stifle should be just about able to touch the ventral ilium | Femur can be extended caudally, almost parallel with spine | Not palpable |
Orthopaedic Examination – Palpation
Orthopaedic Examination of the patient should include the neck, shoulders, thoracolumbar area and all four limbs.
Ideally, palpation is started with the dog standing, making comparisons between the left and right side of the body easier.
TIP: Muscle atrophy of a forelimb often makes the spine of the scapula more prominent, due to the atrophy of the supraspinatus and infraspinatus muscles.
TIP: Muscle atrophy of a hind limb leads to a decrease in the size of the biceps femoris muscle, and is something that can be measured by comparing the circumference both thighs using a tape measure.
Classical palpation of the forelimb involves starting distally and working proximally; nails, toes metacarpal bones, carpus, radius and ulna, elbow, humeral condyles and greater tubercle, and shoulder joint. Classical palpation of the hind limb is similar and includes nails, toes, metatarsal bones, tarsus, tibia, stifle, femoral condyles and greater trochanter, and hip joint.
TIP: checking pads and nails as well as nail beds, is an important part of a lameness examination. Corns, foreign bodies and cracked nails with nail bed infections are all common causes of lameness.
The limbs are evaluated from distal to proximal, as joints located more distally are easier to isolate. Long bones should be carefully palpated where palpable, but firm palpation of soft tissue should be avoided.
When palpating joints use the CREPI system and assess for each of the following:
- Crepitus
- Range of motion
- Effusion or swelling
- Pain response
- Instability
Each of these five parameters should be assessed simultaneously: while one hand moves the joint throughout its range of motion, the other hand feels for crepitus, effusion or instability, and the examiner looks for a pain response.
TIP: Some believe that evaluation of the range of motion is the most critical part of the palpation because in many instances periarticular inflammation or fibrosis will limit the movement of the joint, especially in smaller, more intricate joints.
When palpating bones, crepitus (when a fracture is present), abnormal shape, and pain response should be evaluated. Some joints require specific tests. For example, the Hip Lift and Ortolani Tests of the hip joint can be evaluated in immature dogs and reflects the degree of subluxation of the joint. A cranial drawer sign is present in dogs with rupture of the cranial cruciate ligament.
Orthopaedic Examination in Cats
While much of the examination in cats is similar to dogs, there are some fundamental differences.
In cats, signs such as joint thickening, synovial effusion, reduced range of motion and crepitus are often less obvious than in dogs. Meaning that the medical history and assessment of muscle atrophy can be more important.
Perhaps slightly differently to dogs’, in cats the hip, stifle, tarsus, and elbow are often those more commonly affected, the carpus and shoulder/toes less likely.
Another challenge is assessing painful reactions upon palpation: are they in pain or just don’t like being handled, especially by you
Table 2: Normal Landmarks for Effusion and Range of Motion in Cats, adapted from W Gordon-Evans, Clinician’s Brief, 2021
| Joint | Flexion Landmarks | Extension Landmarks | Joint Effusion |
| Phalanges | Digital and metacarpal or metatarsal pads touch | Normal standing position; claws should be extendable | Externally palpable dorsally |
| Carpus | Paw pads touch the antebrachium on flexion | Normal standing position just past 180 degrees | Palpated over the dorsal carpal surface of the small carpal bones when palpated in slight flexion |
| Elbow | Carpus touches the shoulder | Straight limb from shoulder to carpus | Palpated by finding the lateral epicondyle and palpating caudally toward the ulna |
| Shoulder | Elbow travels lateral to the fourth rib toward the ventral aspect of the scapula | Limb points out past the head, almost parallel to the line of the spine | Not palpable |
| Hock | When stifle is allowed to flex, the dorsal metatarsals touch the tibia. The hock will only flex slightly if stifle is not allowed to flex when hock is flexed (tibial compression test). | Straight limb from tibia to metatarsals | The transition of bone palpated from medial and lateral malleolus caudally to calcaneus |
| Stifle | Tuber calcaneus touches ischiatic tuber | Limb is straight from femur to tibia when visualizing from lateral direction | Palpated by feeling both sides of patellar ligament |
| Hip | Stifle touches ventral ilium | Femur extends caudally, almost parallel with spine | Not palpable |
| Cervical spine | Head touches chest and both left and right shoulders | Head manipulated, with nose pointed dorsally | Not palpable |
| Thoracolumbar spine | Knees touch elbows to determine spinal flexion from lateral direction | Straight spine or slight ventral curve | Not palpable |