CuraCore Academy Talks
Save the Stifle
Dr. Narda G. Robinson

Hi I’m Dr. Narda Robinson, president and CEO of CuraCore MED and CuraCore VET. Today’s CuraCore Academy Talks will focus on Save the Stifle. We’re going to look at myofascial pain syndromes, referred pain patterns, and muscular anatomy. All with the goal of saving the stifle from unnecessary or unnecessarily invasive surgical procedures.

So here’s a candidate for integrative rehabilitation and physical medicine, or some would see this individual as a TPLO prime suspect. Or maybe he or she has had a TPLO. We can see how kind of bulky that right stifle area is and how it’s rather straight. We can also see a lumbosacral kyphosis and the tail is somewhat low. And if we really look at the whole dog then we see there could perhaps be some ventral flexion of the neck. Not that I’m suspecting necessarily a caudal cervical compressive myelopathy because that would be much more flexed.

And I think that the front limbs would be straighter. But could there be some unweighting from the back to the front? And therefore even though we’re going to focus this time on the muscular anatomy that has been shown in people to refer pain to the stifle or the knee joint, there’s actually the whole conglomerate of the entire patient that we have to observe, understand, palpate, ask about, watch move, all that.

If we even then employ the How to See a Dog methodological approach just to seeing them. Do you notice the hair coat changes over the dorsum here at this right lumbar mid lumbar region? And it’s somewhat irregular over that croup or that rumpus area. So what is the significance of that? And was there in fact a surgery? Or maybe there wasn’t a surgery, and this individual was recovering from perhaps a cruciate ligament laxity, cranial cruciate on his or her own. So these are things that we don’t know.

But my premise is that veterinarians have been cultivated to assume that if there is a pelvic limb lameness that it is cranial cruciate ligament disease or injury until proven otherwise. And that the gold standard approach is surgery, and the gold standard approach in surgery is TPLO or tibial plateau leveling osteotomy.

So the problems I see in this field is that there is a general lack of awareness of the issues related to myofascial pain syndrome. And given the widespread prevalence and significance of our soft tissues in terms of pain and movement, comfort, activities of daily life, ability to move correctly, efficiently, with good posture, this is a problem across the board with veterinary and human medicine. Now even again with human medical schools, but in the professional veterinary medical or PVM curriculum, there is little to no instruction for students on the art and science of myofascial palpation and the significance of soft tissue dysfunction in our patients.

And then further the pro-surgery machine that pushes TPLO as the gold standard for presumptive cranial cruciate injury, yes even in small dogs, you’ll see a Corgi later on that had a TPLO, young dogs and cats, feeds off the fuel of billions of dollars of income every year. That’s not to say that everybody that does a TPLO is out for the money. But let us not ignore the fact that whether it’s a veterinary school a private practice, an orthopedic group, whatever, they bring in a lot of money. And that’s just even with the surgical intervention itself, never mind the up to thirty five percent or more of complications that result. Not to mention the permanent change in their anatomical configuration.

So it’s not about designing more creative or invasive surgeries, more elaborate rehabilitation approaches, or piling on more integrative medicine procedures. While I love integrative medicine and rehabilitation, it begins with astute and anatomically informed palpation. Because if you can’t identify the problem, you can’t implement a clear and effective solution.

So here’s Deanna Rogers, who’s one of the physical therapy instructors in our Integrative Rehabilitation and Physical Medicine program called MOVE. And she’s working here with Abbott, and she’s getting a treat. And Abbott is quite interested. What do you notice about Abbott right off the bat? That’s right. There’s a right forelimb missing. And so Abbott only has three other limbs now. And when you watch him walk, they’re not all doing the best they could, in part because they’ve all got more function to do and weight to bear. And you can look at how he’s sitting. I mean by nature, by mechanics, by architecture, that individual needs to do some changes in his back, in his weight loading and offloading. But that’s going to have repercussions for his whole body and mind and prognosis for the future. So if we’re going to help Abbott do the best he can in his life with as little joint breakdown as possible, there are many different avenues with which we can come at that. But the first and foremost that we need to address is how the soft tissue is manifesting stress and strains, and what we can do about it.

So we have 10 facts that I’d like to cover about myofascial pain syndrome and the stifle. Number one. Several pelvic limb muscles when dysfunctional will refer pain to the knee or stifle. So this isn’t talking about any pelvic limb like restriction or discomfort that may make an individual lame. This is only looking at the muscles that have typically been shown to refer pain to the knee or stifle. And it’s humans that can report that. So that’s we where we are making an extrapolation. And we should acknowledge that. But given that the nervous system and the muscles are roughly similar in where they attach, where they go, what they allow the animal to do, then we can go with that. What is different though is a quadruped versus a biped. So there might be differences. But the thing is that even if they feel referred pain in a certain area, when you begin to look at the comparison of the muscles with the referred pain pattern as I will show you here in this talk, you can see that there is quite a bit of overlap.

So when we’re performing a comprehensive myofascial evaluation on the dog and when we find areas of tension or tenderness or dis-ease, then there is likely to be a consequence in terms of referred pain. And while we may not be able to hear that verbally in English, in full sentences, we can treat that. And then address thereby the referred pain that has resulted.

Number two. Pelvic limb lameness could also occur due to other muscles referring elsewhere as I just said. Hence the requirement for a complete evaluation. Now dysfunctional zones may trigger pain in the cranial, caudal, medial, or lateral aspects of the stifle. And this is something that many individuals forget when you’re evaluating an animal, even those that are doing palpation because you need to focus all the way around. If there’s neck pain we go circumferentially. Truncal pain, stifle pain, elbow pain. It’s not just what you see. It’s all the way around. Cross fiber palpation reveals shortened ropey bands of muscle that may respond with a local twitch response if strummed. But don’t do this repeatedly.

So you can do this on your own forearm. And you have extensor muscles that go from your lateral epicondyle to your hand or wrist. And those muscles are going this way. And so the palpation will be cross fiber. And that’s where you can feel those ropey bands. And as the palpati you can feel okay, now go down, get some resistance back at you. So you’re pressing and you can feel that those ropey bands slipping under your fingers. And also when you’re sensing it, you can feel which ones are more particularly tender to palpation.

But the premise here is not to just find oh okay yeah there’s a trigger point, there’s a trigger point, there is a trigger point. Really the more nuanced and astute palpater will go from end to end of the muscle. So yes there’s easy stuff to find in the middle of the muscle belly. But then follow that to the attachment. And even if you don’t remember where the attachments are, you can just use your growing informed palpation. So those neurological connections that you’re building. And follow that muscle to the attachment site. Because the myotendinous junctions are rich with proprioceptors and sensory elements that will also inform you that there’s dysfunction. And it might be that certain parts of the muscle have the most exquisite type of tenderness. And with a human, that’s what we can target.

But nowadays if you’ve ever seen the trigger point diagrams that have little annotations whether it’s a black x, a white x, or a little star or some kind of thing that says well this trigger point produces this kind of referred pain, that’s actually gone out of vogue because the people that are now looking at trigger point pathology, and writing about it, and have taken up the mantle after Travell andnSimons you know have passed on. But they’re seeing you know when Janet Travell and her colleagues were identifying the referred pain patterns from pressing one of these zones in the 1950s, and then subsequent decades, they weren’t, they didn’t have it at the time. They were pioneers. And so they didn’t have algometers and objective measurements to identify okay, which is more tender, which is less tender. They just kind of mapped it out based on the people that they looked at. And the diagrams with the xs, those are from their collective observations. But nowadays the feeling is that you really do have to palpate the entire muscle from attachment to attachment in order to ascertain whether there is a presence of a referred pain or a trigger point.

Referred pain will be subjective on the individual, but you can watch them. You can watch them blink, yawn, lick their lips, turn at you, give you stink eye, all these different things. And so it really behooves you to be anatomically aware. Have a 3D representation of the musculature of your patient in your mind so that you’re not just palpating aimlessly, going oh oh oh okay you know that you can understand whether it’s the shoulder the elbow or the stifle or the hip or whatever. That okay here are the quads. I’m going to palpate them in a certain way because I’m going cross fiber for the quadriceps and there’s four of them. So I know which ones I’m going to examine and where they are. Biceps femoris, semimembranosus, semitendinosus, popliteus. We’re going to cover those muscles. But if you’re just kind of just vague, and going like this on the surface it’s not going to help anybody. It’s going to waste everybody’s time and mislead you, potentially. So we want that cross fiber palpation. We’re going to find short ropey bands. But we want to follow that from end to end.

And as I just said, in the old days, Travell and Simons diagrams, which are not these. These are just stock photos from Shutterstock. But so they’re using a different motif. But they’re showing yeah here’s a trigger point, and here’s a trigger point. Typically in the middle of the muscle belly or at attachment sites. But palpate end to end is the key. And this is not just about muscles and fascia. So the myofascia. But this is about the nervous system. Because it’s the nervous system that maintains this heightened tone and dysfunctional kind of physiology in the muscle tissue, it’s not just the peripheral muscles or it’s not just the peripheral nerves. It’s the central nervous system as well. It’s the spinal cord and brain. So with chronic myofascial dysfunction there is a peripheral and central sensitization associated with a conglomerate of pathophysiologic events. These include local and remote inflammation, as well as locally acidic milieu, which further sensitizes the nerves there, and hypoxia, as well as tissue stiffness. So it all kind of works together.

And then number seven. A hyper irritable nervous system may contribute to referred pain patterns, which confuse clinicians and lead to diagnostic dilemmas or enigmas. And so for all those surgeons that don’t even know what a trigger point is, don’t care about myofascial dysfunction, see muscles as just a means that you have to get by to get to the interesting joint and hard stuff, then then you, they can’t even understand your language. But for example, what I see in human medicine is the infraspinatus. So in your shoulder blade. But when there’s a trigger point there, it refers strongly to the shoulder joint.

So I’ve had people come to me as human patients because I’m an osteopathic physician as well as a veterinarian, and they’re sure that there’s something going on in their shoulder. And I ask them what they’re doing and think about precipitating causes. And then when I palpate them, if I find that trigger point in the infraspinatus, so right in in here. And that and they go “oh yeah that’s the pain.” That’s not in their shoulder. That’s in their muscle and it’s in a really readily treatable zone in that infraspinous fossa which is the infraspinatus. And it might be the middle of the muscle belly. It might be the attachment sites. It might be that myotendinous junction. It’s hard to tell until you palpate and identify that.

So when we think about the consequences of central and peripheral sensitization over the long term that can lead to the fear, anxiety and stress, that if you’re doing Fear Free practice, that you’ve heard of that. But that is particularly excitatory in the limbic system where we have the anterior cingulate gyrus, the insula, and the amygdala. So with or without surgery, unaddressed myofascial dysfunction impacts quality of life and impedes movement. So we have a mental, physical and just quality of it all that we’re addressing.

And so the final point here is that the diagnosis of myofascial pain syndrome is based on anatomically informed palpation. Which then allows us to put together a picture of what’s going wrong with this individual. Where are the key areas of significance? But also where are the secondary ramifications from the biomechanical compensatory patterns? And what can we do in a sort of triaged or tiered state to address the worst issues that are bothering them now? But to create a plan that works for them and their caregiver, the client or whoever it is that’s caring for them, so that we can make changes in the short term and long term. And those changes aren’t just having treatment but they could be adjusting the flooring, the exercise program, the nutrition, supplements, stuff that’s happening at home, whether that’s some home laser treatment or LED care, maybe an Assissi or other pulsed electromagnetic field loop or bed.

And so for the focus of what we’re doing today, we’re going to study muscle anatomy, the mnemonics that remind us about what these muscles do or don’t do when they’re dysfunctional, and referred pain patterns.

So let’s begin with our exploration of anatomy and the referred pain patterns. And we have a handout for this that is downloadable from the curacore.org website. If you don’t have a link to it and want to access it, just email us at info, so i-n-f-o at curacore.org c-u-r-a-c-o-r-e-dot-o-r-g and we’ll send you the link that you can download the handout on this for.

So rectus femoris is one of the quadriceps group of muscles. And they’re on this front, the extensor aspect of the stifle. And it’s called the “two-jointed puzzler.” Well, why would that be? Well the rectus femoris is the only one of the quadriceps group that actually crosses two joints. So that’s the hip and the stifle. So it can cause referred pain that is above the stifle, coming up or below it. So you see here on the right side of your screen, you can see that the pink area is more strong over the stifle actually, because that rectus femoris is going to join with the other quadriceps tendons and muscles. But become tendons after the patella and then insert there on the tibia. So that’s probably the worst area of referred pain that we suspect they might have with myofascial dysfunction of the rectus femoris muscle. But yet instead of worrying about “oh what did the diagram show me ?” you can see it roughly follows the area in which the rectus femoris travels.

Now let’s look at vastus medialis which is called the “buckling knee” muscle. So again this is from the biped study where if your knee tends to buckle a lot, then definitely check out the vastus medialis. So that’s just medial to the rectus femoris. And I’ll put little Roxy down. She’s our rehab animal model. But so vastus medialis is medial to the rectus femoris, which was over here and that’s not crossing the hip joint. That’s just crossing the stifle And again if you’re just coming around the top of the animal and not doing circumferential palpation, you’re going to miss these. And so this referred pain pattern here, you see again, this is the anterior or cranial aspect of the stifle area, and the referred pain pattern, at least for humans, that we’re extrapolating to dogs, is right over that patella region, right over the stifle, right in here. But also can occur and range a little bit medial. So it’s cranial medial, but that’s why if you’re palpating there too, the dog may be, or cat, or whoever, may be experiencing the pain, the referred pain, down into the patella and stifle region. We don’t know that. But you should be able to palpate that vastus medialis from end to end.

Another one that gives pain, referred pain patterns to the cranial aspect of the stifle, is the adductors. Now in the humans we have them more separated out. In the dog it’s more of a conglomerate. But this is part of the “obvious problem maker” group. And so I call this “obvious problem maker one.” And so you see here, interestingly, that the referred pain pattern is going all the way up to the ilium, that wing of the ilium, and then down that cranial aspect of the thigh. And then continues on when it’s less dark in, or less intense of the coloration, that is just some more stippling, that’s not as common a referred pain zone. But it can go all the way down that medial aspect of that pelvic limb. And for those of you that know acupuncture, you can see, well, that’s kind of that Stomach line on that cranial lateral thigh. And then it goes into the Spleen line here. So that’s something that you can remember.

The adductors gracilis is another one of the “obvious problem maker two.” And here I’m just conglomerating the ones that are referring to the stifle. We have many other muscles in the pelvic limb but they don’t all refer to the stifle. They might go to the thigh or more down the crus or to the foot. But I’m just now using this window for the stifle as though the dog came in and say “hey doc my knee hurts” right. But and so I’d say well “where does it hurt?’ And if they’re speaking English in full sentences they might say “oh in the front, but it comes around the side,” or “the front, it comes down the middle,” or “it’s way in the back, and either I found my knee buckles, or I can’t go upstairs well, or downstairs, or my knee gets locked.” So I would use that verbal feedback from the human. But with the dog we’re going to emphasize more on palpation and observation.

So the gracilis. That’s “obvious problem maker two” because it’s obvious, because it follows the muscle but with the adductor. Yeah okay. It extended further with the gracilis. It’s really over the gracilis region and more proximal than distal usually. But you can see that that’s attaching here. This is the medial aspect of the limb. And remember that the gracilis is one of the three muscles that attaches at the distal medial tibial condyle at that pes anserine, where the surgeon is going to cut into the bone there and elevate all those soft tissues. But when you have the confluence of the sartorius coming around attaching to that distal, to the tibial plateau, tibial condyle right in there. Spleen 9 for those of you that are acupuncturists. But you have the sartorius coming around. You have the gracilis from the medial aspect, and you have the semitendinosus coming around this way too. So around the back. So it’s a hamstring. So you’re getting proprioceptive information from the attachment sites, from the sartorius. So lateral and cranial pelvis down here to the gracilis, which is the medial aspect, and the semitendinosus, which is the caudal aspect.

And all those three are conjoining to form that pes anserine, pes anserinus, “goosefoot” because it’s looks like a webbing there. But that’s bringing in neural proprioceptive input from the femoral nerve, which supplies the sartorius, from the obturator nerve, which supplies the gracilis and the tibial branch of the sciatic nerve, which supplies the semitendinosus. So it’s so rich with important information that the brain and spinal cord need in order to help the stifle remain strong and contained, and have that joint integrity from a muscular and myofascial neurologic standpoint, that when we disrupt that, when we just cut it, when we tear it, when we lift it away, whatever we’re doing to injure that, we are disordering or disappearing the impulses that are coming from that section, and should be going into the nervous system. Anyways, so the referred pain pattern is an “obvious problem maker” with the gracilis.

Vastus lateralis gives you a stuck patellar feeling. And again we’re translating bipedal information to quadrupedal. But when you feel like your patella is not moving well, yeah there might be a tracking problem. But when the vastus lateralis is dysfunctional, and so this means that you’ve got chronic acetylcholine release, you’ve got the nerves just sending out these impulses to the muscles to contract, contract, contract. And so these taut bands that we were feeling before, that that happens because the nerve impulses are saying to the muscle yeah, in this little segment of it, it might not be the whole muscle, it might be certain parts of it. But it’s like you just need to keep contracting and wearing yourself out because I’m getting these impulses from above. It’s like the CEO is just driving the employees, you know, work harder, work harder, work harder. And they’re going to exhaust themselves. There’s going to be stress. There’s going to be strain, and just dysfunction, and things can break down. But look at the extensive referred pain pattern here of the vastus lateralis. And so whether they’re feeling a stuck patella or not, this is the referred pain pattern for the vastus lateralis.

So you see here the muscle attaching to the greater trochanter. And then down onto the patella, which then becomes that conjoined tendon, down onto the tibia. But look at the extensive extensiveness. Look how extensive the vastus lateralis referred pain pattern is. And it’s all the way down that area that in us we’d call the iliotibial band. And maybe there is a difference, if you don’t have one, because dogs just have the fascialata. But it’s still a lot of intense connective tissue there. And so you can see if that was tight, and it’s not only that the muscle gets tight by itself, it’s bringing all that fascia and the dysfunction, and the shortening, and just that reaction from the nervous system. It’s making all that pretty tight.

Now again, for those of you that do medical acupuncture, think about what acupuncture channel is that? And you should know. And that is the Gallbladder channel. Okay hamstring group. Now most of you are probably sitting down, unless you’re at a chair or a movable desk, where you’re standing, or you might be on the bus, or whatever you’re doing, probably not driving, unless you’re just listening to the audio here. But whenever you sit. Now again dogs don’t sit in a chair, but if they become tense, and many do in their hamstrings, especially that biceps femoris, that’s been deemed the “chair seat victim” because just that pressure on those muscles and potentially the sciatic nerve causes these referred pain patterns. So with the, so with the referred pain pattern from these hamstring muscles, it goes strongly to the caudal stifle and then follows the location of the biceps femoris muscle. And then when we have the semimembranosus and semitendinosus muscles, then we see that together that they create this more medial referred pain pattern that starts strongest at that ischial tuberosity region, and then goes distal to the caudal stifle as well. So these are again just areas we’re going to be palpating circumferentially, and pick up where they are tight and dysfunctional.

Now a commonly overlooked muscle is the popliteus. And that’s been called the “bent knee troublemaker” and it might be worth looking at. You’re heightening your suspicion of the popliteus if that animal is sitting and then seems to have trouble getting up. And I’m not sure how many of you even remember learning about the popliteus in vet school, or even if it was taught, but it’s a small muscle. And even though it’s small, it’s important because sometimes it’s those small ones that have the richest innervation of muscle spindles, and so proprioceptors. And so it’s really important because what that, if you see here that popliteus muscle attaches just to that outside of the stifle, and that’s going to help rotate it a little bit, rotate the femur out a little bit so that it gives that stifle an ability to extend. So especially if you have problems, you’re sitting down and you just can’t extend your knee when you’re getting up, check out the popliteus. That can be a real troublemaker.

And what I’ve seen in my human patients is usually if a person has this problem that they’re telling me, and I’m thinking the popliteus, they’ve been talking to an orthopedic surgeon about getting a knee replacement, when just if I can use manual therapy and laser and acupuncture, we can take care of that, and then that knee moves more functionally. But you see it really focuses that referred pain. So it’s almost like not referred pain, it’s just over that region, but it’s vague and unless you palpate it specifically that might not be noticed. Gastrocnemius, “calf cramp muscle,” gastrocnemius, “calf cramp cramp muscle.” Say that three times. Cough cramp muscle. No that doesn’t help. Calf cramp, calf cramp. Calf is a funny word isn’t it. Anyway the referred pain pattern from the gastrocs. We have a lateral head pattern which makes sense. It’s over the lateral head. And a medial head pattern. Now this one extends further down. And for those of you that do acupuncture you can see it goes along the Bladder line a little bit and the Kidney mainly, those two. So it’s not always just over the muscle. But the fact that from our focus here, that it can go to the stifle, where the gastroc is actually you know, it’s more of a calf muscle, but it can cause dysfunction in the stifle and that’s what we’re looking at here.

The last one, like its little counterpart the popliteus, plantaris, skinny little muscle, you might never have thought of it. You know sometimes in human medicine it’s used for grafts for the anterior cruciate repair. But again small muscles mean lots of proprioceptors. And so the plantaris you can see attaches from the femur down to the foot. And in humans that’s been dubbed “joggers heel” because it can cause problems that you think about in the Achilles tendon. But for our purposes the stifle related referred pain pattern can be here right at the caudal aspect of the stifle.

So just some ways to increase your awareness about where the problems can arise when you have pelvic limb lameness, and where you can target your medical acupuncture, photomedicine, medical massage, your stretching, your movement therapy, and therapeutic exercise, all these things. But it begins with your hands because if that muscle is not having any dysfunction, it’s not going to send referred pain. So you can identify that without imaging, without sending them to the orthopedic surgeon who’s going to schedule the TPLO and find that in your office, get it fixed and then go from there.

So the key takeaway points are, do a better examination that includes the comprehensive and focused myofascial palpation evaluation. We’re going to do less traumatic assessments. So we’re not going to have three people holding the dog down and forcing that stifle and oh do we have a drawer or don’t we. And if we didn’t, we’re going to have one after the hour of me doing this. But instead use our thinking fingers, our whole hand, our informed palpation, put together that picture of what’s going on with the tissue mechanically. What’s the communication health or dysfunction with the nervous system? What’s the postural balance like? What kind of movement patterns do we have? Are they dysfunctional? Are they eufunctional? What do we need to bring to bear to the hardware and software of this individual? And what are the non-invasive options that we can offer?

And in addition, we can talk about the pros and cons of surgery. And the different types of surgery. And let that client understand it, and be informed, and make their decisions consequently. But the better exam, less traumatic assessments, and non-invasive options are our gold standard. So taking the time to know what to palpate, and why, can improve patient care and your professional satisfaction.

If you’d like to learn more, we have our Integrative Rehabilitation and Physical Medicine certification program for veterinarians called MOVE, and that’s on our website if you want to learn more. And our certification as a veterinary medical acupuncturist through our MAV course, or Medical Acupuncture for Veterinarians, we have small animal and large animal programs, as well as on-site courses at our CuraCore Academy facility in Fort Collins. Or the no travel option, which we call eMAV. But both programs get you the certification title, certified in veterinary medical acupuncture. So if you have questions you can just send a general email to info at curacore.org or to me specifically. Send it to Narda at curacore.org or just go to our website. Thanks for being here. Look forward to our next talk together. Thank you.