Front Matter

412 Canine Sports Medicine and Rehabilitation

Case Study 16.1 Flexor enthesiopathy

Signalment: 9‐y.o. M/C Border Collie, 25 kg.

History: Patient had past history of agility training, and

presented for an intermittent right thoracic limb lame-

ness that started 3 years prior to presentation without

evidence of trauma. At that time, an intra‐articular

(shoulder) injection of cortisone was performed, with

no evidence of improvement. In addition, arthroscopy

of the right elbow was done, with a report of synovitis.

Rehabilitation therapy was initiated with good initial

results.

Clinical examination: Patient showed 2/4 right thoracic

limb lameness, worse at trot. Muscle atrophy detected

in the affected limb. Patient reacted at flexion and

extension of the elbow (mild pain), but showed more

severe pain at pin‐point palpation over the medial

humeral epicondyle.

Imaging: Radiographs and CT scan of both elbows

were unremarkable. MRI was performed to evaluate

the soft tissue structures of the right elbow (Figure 16.5).

Radiographic diagnosis was enthesiopathy of the

origin of the flexor musculature at the medial

epicondyle.

A transverse ultrasonographic image distal to the

medial epicondyle was obtained during the intrale-

sional injection of autologous conditioned plasma

(ACP), with the same diagnosis (Figure 16.6).

Comments: Based on the diagnosis of flexor enthesi-

opathy at the origin from the medial humeral epicon-

dyle, an intralesional injection with ACP was performed

under ultrasound guidance. The dog was re‐evaluated

6 weeks after the injection and the lameness was

significantly improved.

Flexor enthesiopathy has been reported as a primary

injury or concurrently with other elbow pathologies

such as fragmented coronoid process. The flexor

enthesiopathy can be diagnosed with radiography,

scintigraphy, CT, MRI, and arthroscopy. The advantage

of MRI and ultrasound is the potential for earlier

diagnosis should mineralization not be evident radio-

graphically (de Bakker et al., 2013).

Figure 16.5 T1 turbo spin echo sequence with

spectral presaturation with inversion recovery for fat

saturation in a sagittal plane after i.v. injection of

gadolinium. The origin of the flexor musculature at the

medial epicondyle (gray arrow heads) is mildly

thickened and undergoing contrast enhancement.

cranial

axial

caudal

Figure 16.6 Transverse ultrasonographic image distal

to the medial epicondyle during an intralesional

injection of autologous conditioned plasma, revealing

that the origin of the flexor musculature at the medial

epicondyle (red arrow heads) is mildly thickened.

The organization of the musculature is reduced and

the echogenicity heterogeneously reduced.