Is your dog less than 15kg? Is it a partial or a full cruciate ligament rupture/tear?
This is one of the commonest questions that I get asked. Pet owners are not sure whether to operate or not? In the end you want to do whats best for your pet. There are times when one can avoid surgery but other times that avoiding surgery will be detrimental to your pets health in the long term. There are a few different types of surgeries and the one your surgeon recommends will depend on your pets weight, size and limb conformation. Each type of surgery has the same goal in the end to improve the stability of the knee by either mimicking the cruciate ligament or to change the joint angulation.
Cruciate ligament rupture is one of the most common causes of lameness in dogs. Usually seen in large breed, middle aged active dogs but it can be seen in any age and any size of dog. In some breeds such as the Newfoundland they have actually found it to be hereditary.
There are two cruciate ligaments a caudal and a cranial. The cranial ligament is the one that ruptures the most often and the ligament I will be writing about in this article. The cranial cruciate ligament (CCL) is responsible for preventing the tibia (bone in the lower limb) from moving forward. It can rupture due to wear and tear, over a period of time or as a result of an injury. Injury normally occurs due to the dog stepping in a hole, and doing a sharp turn at the same time.
The CCL, together with the muscles of the hind leg also prevent the knee from internally rotating. The cruciate ligaments are a vital component in the overall stability of the knee joint and without them the knee is unstable.
Now joint instability result in cartilage degradation and inflammation eventually leading to arthritis.
In the conservative approach, by building the muscles around the joint these muscles can help to offer dynamic support to the stifle until the joint capsule and the tissues around the knee can thicken and fibrose. The fibrosed tissue and the muscles take over the function of the cruciate ligament providing support for the knee although never to the extent that the cruciate ligament did.
The conservative approach will never be able to provide the same amount of stability as surgery and for this reason arthritis may progress quicker in the conservative approach in comparison to the surgical approach.
Even with surgery your pets knee will be predisposed to becoming arthritic.
I have had success treating cruciate ruptures conservatively but it depends if there is a full or a partial tear and if there is a concurrent meniscal tear.
The CCL can either rupture fully or their can be a partial tear. The cranial cruciate ligament has two bands. In the partial tear one of the bands of the ligament ruptures but the other is still intact. There will be some instability of the knee joint in either flexion or extension (bending and straightening) depending on which band ruptured.
There are two c shaped cartilage structures called menisci that offer support and cushioning for the knee joint. These menisci can become torn and injured when we have a CCL rupture and can be a continual source of pain to the pet and will prevent success in conservative treatments. Meniscal tears can be difficult to diagnose but one can sometimes feel or hear a click when bending or straightening the joint otherwise the only way to diagnose it is to go into the joint to have a look I.E arthroscopy.
In my clinic I have successfully treated cruciate ruptures conservatively in the following cases
- Full rupture in dogs less than 15 kg (With no meniscal tear)
- Partial rupture in all size dogs and weights (With no meniscal tear)
Dog greater than 15 kg do not respond as well to the conservative treatment for the full rupture because the heavier weight puts more strain on the knee joint.
When we look at treating the pet using a non surgical approach we want to achieve the following goals
- Decrease pain
- Build the muscles that help support the knee and function of the CCL
- Improve weight bearing of the affected leg
- Improve the range of motion or the ability of the joints to bend and straighten
- Maintain the rest of the body as there will be secondary muscle tension due to the dog compensating or altering the way they use their bodies.
This is my 30 day conservative approach to cruciate ruptures / full or partial.
- Acupuncture, TENS, Laser therapy, magnetic therapy , massage (Control the pain as naturally as possible)
- Traumeel oral ( Natural treatment for musculoskeletal conditions) Dose: <15kg 1/2 twice daily, >15kg 1 tab twice daily
- Kaprex ( Natural plant derived supplement to relieve pain and inflammation) Dose: <15 kg One capsule daily >15kg One capsule twice daily. Hint: Do not break open the capsule and mix it in the food. It is terribly bitter) Check out this video of a dog called Bailey who took Kaprex
- Pentosan polysulphate injections weekly (Clinical studies)
- Underwater treadmill and therapeutic exercises to strengthen the muscles that help with knee support
- Custom made knee orthotics (optional)
I take thigh circumference measurements, do a lameness score and take measurements of the knee joints movement (goniometry) when I start treatment and 30 days after starting treatment.
I want to be sure that I am achieving all the goals I set. Building the correct muscles is the most important part of the conservative approach as it is the only way to provide that initial stability for the knee joint.
I look for the following improvements
- Increase in thigh circumference measurements which will show an increase in muscle mass and strength
- Improvements in lameness score
- Improvements in the range of motion of the knee joint
If the pet has all three after 30 days of treatment then I continue the conservative approach. If they don’t then I recommend surgery. Usually these cases have a reason that the conservative approach is not working e.g. undiagnosed meniscal tear. If there is no improvement after the first month the likelihood of a successful conservative approach is doubtful. If your pet is not putting more weight on the leg, not moving the joint better then they are not going to be building the muscle they need to make the conservative approach successful. If the muscle keeps wasting away and your pet gets weaker and weaker you will eventually need to do the surgery. The outcome will be less favourable because your pet will be weaker and the arthritic process may have begun already in the knee. 66% of dogs that rupture one cruciate end up rupturing the other cruciate. This is due to increased strain on the other joint because of decreased weight bearing on the affected leg. This is another reason we need to see improvements in lameness and weight bearing otherwise your pet could end up with a contralateral CCL rupture.
If you are considering a conservative approach to your pets cruciate rupture find a trained veterinary rehabilitation therapist to assist you. You want to make sure you are doing this right.
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