Diagnosing canine forelimb lameness: A Q&A on clinical clues and common pitfalls

Because dogs carry most of their body weight on their front limbs, forelimb lameness can be challenging to pinpoint and diagnose. In this Q&A, Leilani Alvarez, DVM, DACVSMR, CVA, CCRT, head of the Integrative and Rehabilitative Medicine Department at the Schwarzman Animal Medical Center in New York, New York, shares clinical clues, common diagnostic pitfalls, and practical strategies veterinarians can use when working up difficult cases. This discussion comes from a follow-up interview on her session at the 2026 Veterinary Meeting & Expo in Orlando, Florida, where she offered practical tips and clinical pearls for evaluating and managing forelimb lameness.

Editor’s note: This dvm360 Q&A has been edited and consolidated from a verbal interview to better fit a written format while retaining the substance of the original conversation.

dvm360: Why is forelimb lameness such a challenging orthopedic condition to diagnose?

Alvarez: Forelimb lameness is a much more challenging part of the body to diagnose compared [with] pelvic limb lameness. One reason is that the primary weight-bearing forces in a dog are on the forelimbs. About 60% of a dog's body weight is carried by the forelimbs, which means there is a much higher mechanical load on those front legs compared with the hind limbs.

That means the joints and soft tissue structures are experiencing much greater stress compared with the pelvic limb. The shoulder joint also is not attached to the body by bone—dogs don’t have a clavicle—so it is supported entirely by soft tissue. That makes the shoulder more susceptible to complex soft tissue injuries.

The types of diseases we see in the elbow compared with the shoulder are also very different, and that adds to the complexity. Many people will call it the elbow because it is difficult to differentiate between elbow and shoulder lameness. In the pelvic limb, it is easier to differentiate between hip and knee, but in the forelimb, it is more complicated, partly because dogs rely so heavily on those front limbs for weight-bearing.

dvm360: What are some practical tips to help differentiate elbow, shoulder, carpal, and digital issues?

Alvarez: One of the main takeaways from my lecture is that although forelimb lameness can seem complex, if you follow a systematic approach, it becomes much easier to differentiate.

Your eyes are really great tools. Observing how a dog walks, how they stand, and how they transition between positions can give you a lot of information.

Shoulder lameness, because the dog is avoiding extension, will often produce a shorter stride when the dog is walking. Elbow lameness, especially when it is more advanced, may show external rotation of the elbow when the dog is standing. When transitioning, they will also avoid flexion of the elbow. For example, when a dog goes into a down position—when the elbow should be completely flexed—they may keep it slightly more extended.

For the carpus, the primary injury we see is a hyperextension injury, often from a jump-down injury. If you are not sure whether hyperextension is present, a simple trick is to lift the other leg. That will usually cause the dog to collapse more onto the affected limb and make the hyperextension easier to see.

For the metacarpophalangeal joints—the knuckles—if there is osteoarthritis, they will often look raised. Again, it is a simple observation that you can make just by using your eyes.

dvm360: What are some common pitfalls veterinarians should watch for when evaluating forelimb lameness?

Alvarez: One pitfall is forgetting about neurologic causes of forelimb lameness. For example, you may see a dog with a head bob and assume it is an orthopedic problem. But dogs with neck pain can also show a head bob.

Typically, dogs with neck pain will hold their neck lower compared with dogs that have orthopedic lameness. That is why it is important to include a neurologic exam as part of your forelimb workup.

dvm360: Do you have advice for veterinarians who are struggling to localize a difficult forelimb case?

Alvarez: If you have a forelimb lameness and you just cannot figure out where the problem is, I recommend taking [a] video at ground level of the dog walking toward you. That lets you really see what is happening in the front limbs.

Take the video in slow motion and at different speeds. Have the dog walk and trot. Walk the dog in a circle. Have them walk downstairs. Those things can accentuate the lameness and help you localize the problem.

You should also observe transitions—have the dog go from sitting to lying down to standing again—and watch how they compensate. Once you can localize the issue, you can direct diagnostic imaging to that area.

Often, the reason we get frustrated with forelimb lameness is because we have not been able to localize the problem. Once you localize it, imaging can confirm the diagnosis.

If you are localizing to the shoulder, MRI is the gold standard, although musculoskeletal ultrasound can also be helpful. If you are localizing to the neck, you want an MRI of the neck. If you are localizing to the elbow and radiographs do not provide answers, pursuing a CT scan can be helpful.

dvm360: What were the key points you hoped attendees would remember from your session?

Alvarez: The key takeaway is to have a systematic approach to working up forelimb lameness. I described 5 steps.

First is history. Second is gait and posture evaluation—using your eyes to localize where the problem might be. Third is the orthopedic and soft tissue exam. Fourth is a neurologic evaluation. And fifth, which is very important, is diagnostic imaging to reach a definitive diagnosis.

Once you follow that systematic approach, you can develop a treatment plan that is much more likely to be effective.