Assessment of Orthopedic

Ver s u s N e u ro l o g i c C a u s e s o f
Gait Change in Dogs and Cats
a b,
Sharon C. Kerwin, DVM, MS , Amanda R. Taylor, DVM *

KEYWORDS
 Forelimb  Lameness  Root signature

KEY POINTS
 The most common causes of thoracic limb lameness are orthopedic diseases.
 The elbow joint is the source of most orthopedic disease resulting in lameness.
 Neurologic disease resulting in a gait change often causes other changes in the neurologic
examination.
 Dogs may be affected by both orthopedic and neurologic disease, making determination
of the underlying cause of gait change challenging.

INTRODUCTION

A change in gait is a common cause for clients to present their pet to a veterinarian for
assessment. Determination of the underlying cause can be challenging even with full
investigation of gait change with examination and diagnostics. In this article, the au-
thors review examinations, both orthopedic and neurologic, specific to assessing
the thoracic limb (forelimb) for underlying causes of gait change. The causes are
reviewed in other articles included in this issue.

CLIENT HISTORY

Before examination, a discussion with the client regarding their pet is a helpful piece of
evidence in determining the underlying reason for a gait change. Orthopedic disease is
more likely to be present at all times and will look worse at faster speeds. Neurologic
disease may be more intermittent in presentation and tends to appear worse at slower
speeds. Clients should be asked whether they have noticed knuckling of the affected
limb or limbs, abnormal toenail wear, and sores on the toes or pads (Fig. 1). Home
video recordings provided by the client are a helpful tool, particularly for cats, and
for dogs that are uncooperative for examination in the clinic.

a
Department of Small Animal Clinical Sciences, College of Veterinary Medicine & Biomedical
Sciences, Texas A&M University, TAMU 4474, College Station, TX 77843-4474, USA; b Pittsburgh
Veterinary Specialty & Emergency Center, 807 Camp Horne Road, Pittsburgh, PA 15237, USA
* Corresponding author.
E-mail address: Amanda.taylor@bluepearlvet.com

Vet Clin Small Anim 51 (2021) 253–261

https://doi.org/10.1016/j.cvsm.2020.11.001 vetsmall.theclinics.com
0195-5616/21/ª 2020 Elsevier Inc. All rights reserved.
254 Kerwin & Taylor

Fig. 1. Lateral (A) and dorsal (B) views of thoracic paws with worn nails consistent with pro-
prioceptive deficits resulting in dragging of the limb.

GAIT EXAMINATION

A gait assessment is an essential first step for any cause of gait change and should be
performed before other examination of the patient. Dogs should be walked with a slip
lead on a surface with traction. Their gait should be observed from the front, back, and
side. Cat examinations may need to be more creative for gait assessment, but often a
cat will walk around a small, closed room as they explore their environment, finding
interest in following their carrier or a laser pointer. Gait should be assessed at a
walk and a trot, if possible, as different speeds can make a lameness more obvious.
When walking a dog for examination, it is important that the dog not be pulling at the
leash or diving off to the left and right. It takes some practice to gain experience at
walking a dog correctly so that the observer can see the gait from all angles and at
several different speeds. Adjusting the slip lead higher up the cervical region may
give the examiner more control; however, take care with dogs with neck pain. If there
is any discomfort, consider walking with a harness or leash looped around 1 forelimb
(Fig. 2). At the walk, one may observe a “head bob” with the head moved up as the
painful affected forelimb strikes the ground. Typically, the more proximal (and more
severe) the disease process, the more pronounced the head bob. Some lameness
may not show up at the walk but is more apparent at the trot; conversely, some lame-
ness may be most obvious at a slow walk.
The key differentiating factor between orthopedic and neurologic disease is assess-
ing whether the patient is aware of limb position in space. A digital video (smartphone)
camera is helpful, as the examination played back in slow motion can allow identifica-
tion of relatively subtle lameness, particularly for small dogs with long-haired coats
that obscure limb motion. While watching the animal move, the examiner should
note which joint or joints have an increased or decreased flexion/extension, evaluate
stride length for each limb, and compare right versus left. Circumduction in an affected
limb may be apparent when viewing from the front or rear. Orthopedic disease will
result in shortened stride, may limit motion of a joint, and may cause the weight of
the patient to shift to the sound limb. The examiner should also listen to detect drag-
ging toenails that may indicate a neurologic problem. Patients with decreased propri-
oception owing to neurologic disease may exhibit knuckling, scuffing, and crossing
over midline with the affected limb. Although a short-strided, shuffling gait can indicate
lower motor neuron disease (ie, polyneuropathy), it can also be indicative of orthope-
dic disease in multiple limbs (ie, hip plus elbow dysplasia or polyarthropathy) or
 Gait Change in Dogs and Cats 255

Fig. 2. Cranial (A) and dorsal view (B) of leash placement over 1 limb to avoid placing pres-
sure on cervical region in dogs with neck pain.

diffuse, severe spinal pain without neurologic deficits (discospondylitis). In addition,

limbs crossing over midline may also be observed in patients with orthopedic disease,
but will not be accompanied by ataxia.
When possible, the animal should be observed going up and down steps, circling,
going over curbs or small obstacles to detect subtle lameness, ataxia, or propriocep-
tive deficits. For the cat, observing the gait as it jumps down from a low chair or stool
may be valuable in differentiating orthopedic versus neurologic gait abnormality. An-
imals with proprioceptive deficits may miss a step or hit the dorsal surface of a paw
against the step as they go up.
Head and neck posture and mobility should also be assessed. Animals with
neck pain may hold the neck low and straight and will move their eyes only, while
keeping the head still, to observe things going on around them. Most animals
without spinal pain will hold their heads up and move the neck about freely while
observed on or off leash. If knuckling, scuffing, or ataxia is noted on gait evalua-
tion, the authors recommend that neurologic evaluation be prioritized over ortho-
pedic examination in cats and very nervous dogs, although typically they are
done concurrently.

ORTHOPEDIC EXAMINATION
Standing
With the animal standing squarely, the head restrained by an assistant, and the exam-
iner standing behind the patient, the examiner should carefully palpate and examine all
of the major muscle masses of both forelimbs (as well as the rear limbs and spine). One
256 Kerwin & Taylor

of the easiest ways to detect muscle atrophy is by comparing the infraspinatus and
supraspinatus muscles along the spine of the scapula. The triceps muscles should
also be compared as well as the muscles of the antebrachium. Occasionally, one
can detect more subtle differences, such as a difference in width or distension of
the elbow or carpal joints, and joint effusion in general is much better appreciated in
standing as opposed to lateral recumbency, while the joints are loaded. In challenging
animals that resent lateral recumbency, evaluating joint range of motion and palpation
of the long bones and muscles for signs of tenderness may be done with the animal
standing. Although uncommon, peripheral nerve sheath tumors may be palpable on
a standing examination as a mass in the axillary region or peripherally on the limb.
With the animal standing, proprioception should be assessed by flipping the foot
and observing the amount of time it takes for the patient to replace the foot in a normal
position (paw replacement reaction), making sure to support the patient under the pel-
vic limbs or chest to help them avoid falling or forcing all of their body weight on a pain-
ful or weak limb. In a normal dog or cat, the paw is replaced immediately.1 Although
orthopedic pain may slow this response, even in animals with orthopedic disease,
normal paw replacement should occur. Appropriate support of the patient should
allow even very painful animals to knuckle appropriately. Delayed or absent paw
replacement may indicate a proprioceptive deficit, and a complete neurologic exam-
ination should be performed.

Lateral Recumbency
A complete orthopedic examination cannot be done without the help of a competent
assistant to restrain the animal. Although most dogs and cats can be examined awake
in lateral recumbency, occasionally sedation may be needed to complete the exami-
nation, and for the cat, much of what can typically be done in lateral recumbency for
the dog can be done standing.
First, the nails and digits should be evaluated for abnormal wear or damage, saliva
staining, or swelling around the nail beds. The area between the toes and pads should
be closely examined for foreign bodies, draining tracts, skin lesions, and thickening.
Each interphalangeal joint should be individually flexed and extended. Many normal
dogs resent having their feet examined; however, this is usually an initial reaction,
and the dog will relax as the examination continues. Each metacarpal should be
palpated up to the carpus.
The carpus should be completely flexed and extended. In many (but not all)
dogs and cats, the carpal pad can be touched to the caudal aspect of the ante-
brachium (Fig. 3) and the carpus can be extended past 180 . However, some
dogs have more limited flexion of the carpus (eg, greyhounds); careful comparison
of both sides is important. Average flexion/extension angles for the Labrador
retriever have been reported as 32 /196 in dogs and 22 /198 in cats.2,3 The ten-
dons crossing the carpus should be palpated as well as the antebrachiocarpal,
intercarpal, and carpometacarpal joints for instability and effusion. The integrity
of the collateral ligaments is assessed by stressing the carpus medially and
laterally.
The radius and ulna should be palpated separately, traveling from distal to proximal
up the antebrachium, looking for bony changes or pain. The muscles of the ante-
brachium are also palpated separately from the bones, assessing for pain, hypertro-
phy, atrophy, or tendon thickening. Occasionally, small nerve sheath tumors or
other soft tissue masses causing lameness can be found with careful muscle
palpation.
 Gait Change in Dogs and Cats 257

Fig. 3. Complete flexion of carpus with digital and metacarpal pads making contact with
antebrachium.

The elbow is flexed and extended, and internally and externally rotated, which puts
pressure on the coronoid processes of the ulna. Average flexion and extension angles
for the elbow of Labrador retrievers are 36 /165 and 22 /162 in the cat.2,3 The joint
capsule should be palpated medially and laterally for evidence of thickness or effu-
sion. It may be difficult to differentiate elbow from shoulder pain, as manipulation of
1 joint may affect the other, particularly in extension. As for the proximal limb, the hu-
meral shaft should be individually palpated and the muscles of the upper forelimb
palpated separately, evaluating for muscle and bone pain or deformity.
The shoulder has a very wide range of motion, with flexion and extension reported
as 57 /165 in the Labrador retriever and 32 /162 in the cat.2,3 It is important to fully
manipulate the shoulder not just in flexion and extension but also in abduction/adduc-
tion and internal/external rotation. If shoulder instability is suspected, it may be useful
to hold the distal scapula fixed and attempt to manipulate the proximal humerus in a
“drawer”-type motion cranially and caudally. Although joint effusion is difficult to
detect in the shoulder, joint pain can be detected by palpating the caudal joint capsule,
particularly in dogs with osteochondritis dissecans of the shoulder. The best way to
find this area is to “walk” down the spine of the scapula until the acromial process
is reached; just below and caudal to this is the caudal aspect of the humeral head.
Carefully palpate the biceps tendon with the shoulder in extension but also in full
flexion, with the limb pulled almost parallel to the trunk to put maximum stress on
the biceps brachii tendon, which runs just medial to the greater tubercle of the humer-
us. There are several publications evaluating whether medial shoulder instability is
present based on measuring shoulder abduction angles in the dog; however, it is
not clear how repeatable this test is in general practice.4 Despite this, shoulder abduc-
tion can be helpful in detecting intermittent luxation, sometimes seen in toy breed
dogs. As a routine part of the examination, the axilla should be palpated deeply,
258 Kerwin & Taylor

checking for muscle atrophy and masses and attempting to palpate the brachial
plexus. A normal animal should not resent even deep palpation of the axillary area.
Although rare, scapular avulsion (separation of the scapula from the thoracic body
wall) has been reported in both dogs and cats. Excessive mobility of the scapula
may also be noted on gait examination.
Once the examination in lateral recumbency is completed, there are 2 more
important steps: spinal palpation and rectal examination. For spinal palpation, the
animal is restrained as above for standing examination. In a normal dog or cat,
the animal should be able to comfortably extend the cervical spine so that the
nose points up at the ceiling, can flex down to almost touch the chest, and extend
laterally from side to side to touch the thorax. Use caution with cervical flexion in
patients with neck pain, especially toy breed dogs, as instability associated with
atlantoaxial subluxation could damage the spinal cord. It is also important to deeply
palpate the bones of the cervical vertebral column, from the wings of the atlas back
to the ventral and lateral processes of C6-7. Animals with neck pain may have
noticeable muscle fasciculation or spasm. For the thoracolumbar spine, many ex-
aminers will locate the spinous process, and then put firm, even pressure with the
finger and thumb from T1 back to the lumbosacral space. The tail should be
elevated dorsally, and the lumbosacral space should be palpated on rectal exami-
nation (dogs) as well (reserve as needed for cats under sedation), while the pelvic
canal is evaluated for any masses, pain, or deformity of bony structures (pelvis,
hips) and anal tone is assessed.

NEUROLOGIC EXAMINATION
Postural Reaction Testing
Paw replacement (knuckling) reaction has been discussed above. Wheelbarrowing
(supporting the pelvic limbs just above the ground and moving the animal forward
to evaluate forelimb gait) can be helpful in detecting more subtle proprioceptive def-
icits, and many examiners will repeat that maneuver with the head up or with the
eyes covered. In smaller dogs and sometimes in cats, it is possible to test propriocep-
tion by bringing the dorsal surface of the paw gently up beneath the edge of examina-
tion table until it touches the table: a normal animal will place the paw on the table
automatically (placing test). The animal should also be hopped back and forth on
each forelimb individually, always with support to the rest of the body (keep in mind
that normal cats may just flop down and will not always play this game). Carefully eval-
uate the pelvic limbs as well. Some dogs with cervical spinal cord involvement pre-
senting for thoracic limb lameness will have proprioceptive or reflex abnormalities in
the pelvic limbs associated with spinal cord compression that were not detected in
the gait evaluation.

Forelimb Reflexes
Although the withdrawal reflex is the only consistently reliable forelimb reflex in small
animals, it can be worthwhile to do the others if only to better evaluate muscle tone
and orthopedic status and to compare between sides. These reflexes are typically
done with the animal in lateral recumbency along with that portion of the orthopedic
examination; however, the withdrawal reflex may be assessed with the animal stand-
ing and the thorax supported.
Extensor carpi reflex
With the limb supported and the carpus relaxed (it must be somewhat flexed or the
reflex is impossible to see), the proximal, central portion of the extensor carpi radialis
 Gait Change in Dogs and Cats 259

muscle is struck with the point of the reflex hammer, stimulating the radial nerve and
causing a brief extension of the carpus. Hand positioning can be seen as in Fig. 4.

Biceps brachii reflex

The shoulder is flexed, making the insertion of the biceps brachii tendon taut and
easily palpable at the level of the medial elbow. One or 2 fingers, depending on the
size of the animal, are placed directly over the tendon and the fingers struck with
the point of the hammer. The biceps muscle, innervated by the musculocutaneous
nerve, is usually observed contracting along its length from shoulder to elbow.
Hand positioning can be seen in Fig. 5.

Triceps reflex
Triceps reflex is the most difficult to observe. The elbow is flexed and slightly rotated to
make the tendon taut. The examiner places a finger over the tendon and strikes it with
the hammer or strikes the tendon with the flat side of the hammer, looking for contrac-
tion of the muscle belly and a brief elbow extension.

Withdrawal reflex
Withdrawal reflex is a general test of the entire brachial plexus and relies on both the
sensory and the motor components of the nerves stimulated to be effective. Finger
pressure can be effective, but some larger dogs may require pressure with a pair or
hemostats to stimulate an effective response. The degree of flexion of the shoulder,
elbow, and carpus should be assessed, and subjectively the strength of the limb
should be assessed as well. A normal limb should fully flex each joint with this stim-
ulus. Care should be taken not to apply too much counteractive force in small dogs
and cats, as this may prevent withdrawal.

Fig. 4. Positioning of hands and pleximeter for performing extensor carpi radialis reflex.
260 Kerwin & Taylor

Fig. 5. Positioning of hands and pleximeter for performing biceps reflex.

Cutaneous trunci reflex

Cutaneous trunci reflex may also be useful, as it originates from the lateral thoracic
nerve, which exits at the level of C7-T2 intervertebral foramen. The sensory arm of
the reflex is the individual dorsal spinal nerves, which travel from lateral to midline
and caudal to cranial, typically traversing 1 to 2 vertebral body lengths. The reflex
typically starts in the midlumbar region, and hemostats are often required to
generate sufficient sensory stimulus, particularly in larger dogs. The skin is
pinched, and if the reflex arc is intact, the cutaneous trunci muscle will quickly
contract bilaterally. Any lesion affecting the lateral thoracic nerve will eliminate
this reflex on 1 side as the efferent arm of the reflex arc is affected. It should be
kept in mind that occasionally there are normal dogs that do not have a cutaneous
trunci reflex.
Cranial nerve examination and Horner syndrome
Brachial plexus injuries involving the outflow tracts of T1-T3 may cause Horner syn-
drome (loss of sympathetic innervation to the ipsilateral eye), resulting in ptosis,
miosis, enophthalmos, and third eyelid elevation. A careful cranial nerve examination,
focusing on assessment of pupil size and position, should be included in the case of
forelimb dysfunction and is a part of a complete neurologic examination.

DISCUSSION

As a general rule, orthopedic disease is a far more common cause of forelimb gait ab-
normality in dogs and cats than neurologic disease. However, they often coexist,
particularly in older animals, and orthopedic disease may get most of the attention,
resulting in a lost opportunity for early diagnosis and treatment of important neurologic
disease.
 Gait Change in Dogs and Cats 261

Some disorders, particularly foraminal extrusion of disc with cervical intervertebral

disc disease, and disorders of the brachial plexus can look like orthopedic disease
early on and may present without any neurologic abnormalities. These cases eventu-
ally present for referral with multiple sets of normal radiographs of the bones and joints
of the affected limb, and advanced imaging and electrodiagnostics may be needed to
make the diagnosis. Many of these disease processes will eventually result in obvious
neurologic deficits.
Performing the orthopedic and neurologic examination simultaneously is an efficient
way of getting the most diagnostic information possible in 1 visit. With practice, a com-
bination examination can be done quickly and effectively, even in cats or challenging
dogs. When orthopedic and neurologic abnormalities are both present, the neurologic
problem should be prioritized when planning diagnostics to include imaging, although
a thorough knowledge of any orthopedic abnormalities will be helpful in setting owner
expectations for outcome and in designing and evaluating an appropriate treatment
plan.

SUMMARY

Diagnosis of forelimb lameness may be challenging, as it not only can be due to mul-
tiple common orthopedic diseases but also may occasionally be caused by neurologic
disease. A thorough orthopedic and neurologic examination is key to determining
which disease category is the likely culprit. Deficits identified on the neurologic exam-
ination, such as proprioceptive deficits, changes in reflexes, and presence of spinal
hyperesthesia, are key in identifying neurologic causes of forelimb lameness.

CLINICS CARE POINTS

 Combining all, or elements of, the orthopedic and neurologic examination for
every patient with thoracic limb lameness will improve diagnostic capability.
 Attention to whether the animal knows where the limb is in space (proprioception)
is key in differentiating neurologic versus orthopedic gait abnormalities.
 Orthopedic disease and neurologic disease often present together, with the
neurologic disease taking diagnostic precedence.

DISCLOSURE

The authors of this article have no commercial or financial conflicts of interest.

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