Ruptures and partial tears to one or both Cranial Cruciate Ligaments (CCL) is a remarkably common injury in our doggy friends. While certain breeds seem to have significantly more frequency of injury, I see it in a wide variety of breeds, ages and sizes of dogs.
Traditionally, it has been believed that typically only small dogs, under about 15kg, fare just as well with conservative management as they do with surgical repair options. This belief is based on a study which showed very positive outcomes for the small dogs and not so much resolution of lameness in the bigger dogs. Some practitioners, however, have been questioning the assumptions since.
Dr Narda Robinson DVM is one practitioner who has been quite vocal about the lack of options many pet owners are given when faced with a CCL injury. She has compiled some good evidence here to endeavour to debunk many commonly held beliefs around why surgery should always be the primary option for sorting out our dogs dodgy knees.
So, when an owner makes the decision to give the surgical option a miss, even on a trial basis, what actually are the conservative options?
- Weight management – The first step is to ensure the dog is at a healthy weight or slightly underweight. Evidence is mixed but several well designed studies suggest that advancing age and increased body weight are two of the big factors influencing the likelihood of degenerative lesions in CCLs and also risk of of full ruptures. Obviously there isn’t much we can do to stop the clock, but body weight is absolutely one of the most manageable risk factors. This makes a lot of sense from a physiologic perspective as fat cells are inherently inflammatory, and become more so as fat accumulates. As such, it’s not only the mechanical effects of extra weight itself, but even more significantly the systemic inflammation that is created when a dog is carrying excess weight that aggravates the situation.
- Rest and control exercise – This one is huge, and plays an enormous role in the outcome whether managing CCR conservatively or with surgery. Complete crate rest was once advised however studies have shown it to be not necessary in most cases. Restriction to a space that minimises excitement, but has room for gentle movement is ideal. Provide good surfaces which eliminate the risk of slipping. Eliminate opportunities for jumping up or down from vehicles, bedding or step/verandas. Incorporating frequent short controlled leash walks which are more aimed at providing mental stimulation – a good sniff is amazing at calming the stir-crazy pent up energy that can build when dogs are relatively confined, is the ideal for 6-8 weeks.
- Reduce inflammation and pain – Finally, the use of anti-inflammatory or analgesic medication as required. In the early weeks veterinary prescribed medications might be required, however there is a fine line to walk as far as the potential for reducing pain to such a degree that the dog becomes far too active for the stage of healing. We certainly don’t want our animals sitting through strong pain, however a small amount of awareness that they aren’t quite 100% can sometimes help during the crucial rest period. This is a topic to discuss on an individual basis with your veterinary professionals, as each dog will be very different and many factors play into this balancing act!
From an osteopathic and allied perspective it is possible to boost the effects of this conservative management firstly by recognising that it is, in most cases, strongly likely that biomechanical restrictions and asymmetrical movement in the dog’s body have contributed to uneven weight bearing through the hind legs and the stifle joint. This asymmetry and dysfunction can be addressed using Osteopathic techniques which are gentle and generally largely pain free. By allowing the dog’s musculoskeletal system to function to the best of it’s ability, it is possible to greatly reduce the overloading of individual joints and enhance the circulatory, lymphatic and nervous system function around the joints and tissues and hence allow the body to achieve optimal healing.
One of the big risks with CCL rupture is that around 50% of dogs will present with rupture to the other CCL within 6 months of surgery to repair injury to the first. This suggests two possibilities. Firstly, the obvious one that during recovery, the ‘good’ knee will be taking more than its fair share of workload. Secondly, the likelihood that there are underlying biomechanical and physiological factors that haven’t been addressed in the first instance which are continuing to compromise the healthy functioning of the joint. Whether post-surgery, or opting for the conservative option, it is therefore crucial to ensure the dog’s body is actually able to work symmetrically, as well as to then formulate a thorough rehabilitation plan to help ensure the dog begins to use themselves evenly. This rehab can begin within the first few weeks post-surgery or during the rest period if managing conservatively.
Allied therapies including dietary changes (examples here and here) and nutritional supplementation and herbs, hydrotherapy, acupuncture, laser, orthoses, stem cell therapy and cryotherapy (cold) are some of the many that may be useful within the management plan for CCL rehabilitation.
Prevention is better than cure! From a preventative point of view, again it is crucial to ensure dogs are able to use themselves as symmetrically as possible and carry as low an inflammatory load in their body as possible. This can be achieved by taking a few routine steps to ensure your dog is as healthy and strong as possible whatever the stage of life.
- Osteopathic preventative/maintenance visits from a young age, to thoroughly examine and uncover any dysfunctional regions of the body and remove these restrictions before they begin to significantly alter the way the dog is moving.
- Regularly assessing dietary needs, both for weight management as well as for minimising systemic inflammation that can develop due to unbalanced or overly processed diets.
- Ensure that dogs are given consistent, relatively controlled activity that builds progressive strength and condition for their daily activities and specific sporting activities minimises the risks of injury significantly – avoid the weekend warrior approach of relatively little or no exercise during the week followed by manic ball chasing or frisbee catching at the weekend. Make intentional exercise a big part of your daily routine so your dog has a good baseline level of fitness and strength to help cope with the inevitable extra fun at the weekends or on holidays.
- Specific range of motion/position exercises are particularly worthwhile for building great proprioceptive and core control in all dogs and can be built from simple routines to very complex movements depending on training levels and the needs of the individual. Chat to your Osteopath or canine conditioning expert for ideas!
- Make sure nails are kept trimmed regularly, both to avoid slipping risk and also to help avoid changes in limb posture which may occur if the dog is feeling discomfort during activity from overly long nails.
If you are noticing your dog has uneven movement patterns or is occasionally showing signs of stiffness or soreness there is plenty you can do at home to improve their comfort by introducing a routine of safe stretches and exercises. I have compiled a comprehensive range of these within my eBook – The Canine Athlete Warm-Up and Cool-down Manual, which is a safe way for you to start exploring better musculoskeletal health for almost any dog. Check it out HERE or get in touch if you’re uncertain how to get started for your specific dog’s problems.
Working with excellent vets in my own local area, I am by no means anti-surgery – a well stabilised knee followed by dedicated and thorough rehabilitation is often the ideal option, however if you would like to discuss options, please don’t hesitate to contact me to discuss whether conservative management might be appropriate for your dog in the task of preventing, managing or rehabilitating a CCL injury.