Q&A: Treatment strategies and emerging therapies for canine forelimb lameness

Forelimb lameness is a common presentation in dogs, with causes ranging from osteoarthritis to shoulder tendinopathy that can require different treatment approaches. 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 her approach to multimodal pain management, rehabilitation strategies, owner education, and newer therapies, including shockwave and platelet-rich plasma (PRP).

Read Part 1 of this Q&A here: Diagnosing canine forelimb lameness: A Q&A on clinical clues and common pitfalls

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: Can you talk about pharmaceutical treatment strategies for managing forelimb lameness?

Alvarez: Treatment strategies should always begin with pain management, and you want a multimodal approach that includes pharmaceutical drugs and nonpharmacologic therapies.

From the pharmaceutical side, nonsteroidal anti-inflammatory drugs are often the first choice when you are dealing with osteoarthritis or another inflammatory joint problem. For more severe inflammatory conditions, I often combine additional medications. For example, amantadine pairs nicely with an NSAID, especially when dealing with chronic tendinopathy.

Shoulder tendinopathies are classic forelimb lamenesses that often do not respond well to NSAIDs. Tendons—especially relatively avascular tendons—do not have a great blood supply, and in chronic injuries there often is not an active inflammatory component.

dvm360: What nonpharmacologic therapies can help manage these cases?

Alvarez: In those cases, it can be helpful to rely on therapies that bring blood flow back to the affected tissue. Shockwave therapy and platelet-rich plasma injections are good examples.

These treatments can stimulate the healing response in the tissues and help restore blood supply. The approach to treatment can be very different depending on whether you are dealing with an osteoarthritic problem or a soft tissue injury, which underscores the importance of reaching a definitive diagnosis.

dvm360: What role can nutraceuticals play in managing forelimb lameness?

Alvarez: Nutraceuticals can play a role as part of a multimodal management strategy, particularly when you are dealing with osteoarthritis or degenerative conditions that are expected to progress over time.

Supplements should be exactly that—supplemental to primary treatments—but they can be very complementary. I almost always include them as part of my treatment plan.

For soft tissue injuries, I like products that support collagen and connective tissue health to help tendons and ligaments heal. Eggshell membrane is a good example.

For osteoarthritic patients, antioxidants can also be helpful because many of these patients are older. I tend to look for supplements that support the entire joint as an organ—not just the cartilage—so they provide support for muscles, tendons, ligaments, and help address oxidative stress in the joint.

dvm360: For general practitioners, what practical steps can help improve outcomes for dogs and cats with forelimb lameness?

Alvarez: Improving outcomes is really dependent on owner compliance. That means spending time on owner education.

One of the reasons forelimb lameness—especially shoulder tendinopathy—can be frustrating is that many of these dogs are very active. They are jumping on and off furniture, pulling on the leash, and doing things that contribute to recurrence of their lameness.

Tendons and ligaments do not have great blood supply, which makes them susceptible to reinjury. Much of the success of treatment depends on activity restriction. That means no off-leash activity, no jumping on or off furniture, and implementing strengthening exercises at home.

So the key to success is owner compliance, and that starts with educating the owner.

dvm360: Are there any new or emerging treatments that you find promising in managing forelimb lameness?

Alvarez: I think the most exciting advances in treating forelimb lameness are the modalities. Shockwave therapy, in particular, has really revolutionized how I treat shoulder tendinopathies.

Before I had that tool available, it was frustrating because these lamenesses often recur. The key is restoring blood supply and bringing healing cells back to the tissue.

Introducing shockwave therapy and PRP—which brings growth factors to the tissues—helps stimulate that healing response again. Those are probably the two biggest advances because they allow you to target the injured tissues directly and make a significant difference in outcomes.

dvm360: Is there anything else you would like veterinarians to take away?

Alvarez: Do not be intimidated by forelimb lameness. If you follow a systematic approach, it is very doable. It is something you can become good at and feel proud of, and you can be the person in your practice who can diagnose and effectively treat these cases.