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Cranial Cruciate Ligament Injury in Dogs

Giving Dogs with Cranial Cruciate Ligament Disease a Reason to Jump for Joy

The bond and relationship we share with our dogs is unique so when our pet is in pain or gets injured, our initial reaction is to panic, stress and prepare for the worst. Sometimes lameness is caused by something as simple as a spike in a paw, while other times the reason may be indefinable. Careful observation of the actions leading up to the lameness and a detailed examination of the limbs, paws and back will help establish where the problem lies.

There are lots of causes of musculo-skeletal problems. An unexplained lameness or limping that won’t go away will need your veterinarian evaluation and in most cases an X-ray and possibly an MRI... Seek your vet’s advice and be open minded when it comes to treatment and rehabilitation options.

Remember you are not alone, take a deep breath, relax and smile - there is a lot of support around you and a reason to jump for joy!

WHAT YOU SHOULD KNOW ABOUT CRANIAL CRUCIATE LIGAMENT DISEASE

The knee is predisposed to multiple injuries both in humans and in dogs. Rupture of the cranial cruciate ligament (CCL) is one of the most common orthopaedic problems that affects dogs resulting in instability of the knee joint which leads to lameness. Dogs with partial tears will exhibit subtle clinical signs such as occasional lameness and/or stiffness on rising while a dog with complete tear will exhibit signs with variable degrees of lameness with altered movement in the hip, stifle and hock (ankle) joints.

A little bit of background on the Knee (or Stifle) Anatomy


The cranial cruciate ligament (CCL) is a band of fibrous tissue that attaches the femur (thigh bone) to the tibia (shin bone).

It prevents the tibia from moving forward in relation to the femur, helping to stabilise the knee and preventing the stifle (knee) from rotating. 

The cruciate ligaments are comprised of two ligaments that form a cross inside the knee joint: the Cranial (anterior) and Caudal (posterior) cruciate ligaments. Typically, it’s the CCL that ruptures. 

WHAT IS THE CAUSE OF CRANIAL CRUCIATE LIGAMENT INJURY

Traditionally it was thought rupture of the cranial cruciate ligament (CCL) was as a result of slipping, twisting, falling or jumping off furniture. For most dogs, the CCL ruptures due to chronic joint degeneration as a result of weakening of the fibres within the ligament. Trauma induced rupture of the CCL results in knee instability and is often supplemented by a sudden non-weight bearing lameness. 


Other factors such as individual conformation, obesity, hormonal imbalance and specific inflammatory conditions of the joints may also play a part.

HOW IS CRANIAL CRUCIATE LIGAMENT INJURY DIAGNOSED


Dogs with partial tears will need to undergo orthopaedic examination (palpation) and diagnostic tests such as; X-rays or MRI scans. Dogs with complete rupture of the CCL will need to be examined by a Veterinary Orthopaedic surgeon through comprehensive knee manipulations including investigative tests. For optimum quality Arthroscopy (keyhole surgery) might also be used to verify diagnosis and investigate potential cartilage tears and other problems.

WHAT ARE THE TREATMENT OPTIONS AVAILABLE?


Cranial cruciate ligament (CCL) disease can be treated either surgically or conservatively. Treatment options will depend on patient weight, severity of rupture, pre-existing disease and cartilage tears. 

Although few dogs do well with enforced rest and physical therapy, most vets recommend ruptured CCL be repaired surgically. In instances where the ligament hasn’t torn completely, long term rest and anti-inflammatories may be sufficient. Holistic support beforehand and following surgery will help your best friend be more comfortable, recover quickly and gain mobility.

#1. Conservative Management

Conservative treatment for CCL rupture by stringent confinement for four to eight weeks may be endeavoured, however the progression of Osteoarthritis is greater. An external brace can be used to support the knee, although there are no studies to document their effectiveness in dogs (Levine & Millis, 2014).

#2. Surgical Management

Conservative management isn’t suitable for all dogs with ruptured CCL and the majority will require surgical intervention. There are several common surgical techniques available, however none proven to be superior.

  • Tibial Plateau Levelling Osteotomy (TPLO) 
  • Tibial Tuberosity Advancement (TTA)
  • Extra-capsular Stabilisation 

#3. Regenerative Medicine

Fast forward to 2017 and you’ll be thrilled to know that your beloved friend can now be treated with regenerative medicine (Stem Cells) as long as they are diagnosed in the early stages and only have a partial tear.

WILL MY DOG NEED REHABILITATION AND WHAT WORKS BEST?

It has been established that a reduction of activity, such as confinement to a cage, may affect ligament and tendon properties. An intense rehabilitation program following TPLO surgery yielded good results and more rapid muscle mass recovery. One study concluded that training before immobilisation and remobilisation had a positive effect on muscle mechanical behaviour compared to being inactive. (Levine & Millis, 2014).

Likewise, it has been recognised that ongoing muscle atrophy after CCL surgery is a common obstacle. Furthermore, the non-inured limb can undergo hypertrophy (enlargement) possibly due to increased loading on that limb during recovery. Joints can develop arthritic changes; surgical procedures can result in adhesions and muscle spasms which may cause restriction of Range of Motion (ROM).

Therefore, get yourself organised - rehabilitation begins prior to surgery! early involvement can help reduce pain, improve ROM and ligament strength. A pre-operational plan allows yourself and your dog to de-stress, prepare for surgery, practice new techniques and trial new modalities.

Post-operative rehabilitation should start immediately after surgery. It should consist of variety of approaches such as:

* Cryotherapy or Thermotherapy – cryotherapy is useful immediately after surgery to control inflammation and thermotherapy has been used for centuries as a means of managing chronic conditions.


* Massage – massage is one of the most commonly used physical therapy modality encompassing a wide variety of techniques, each can produce different effect. Major massage techniques are: Stroking, Pressure, Friction, Percussion and Vibration.

* Passive movements – it’s a movement of a joint by external forces and is usually utilised when a patient is unable of shifting the joint on its own or when active motion is distressing to the patient.

* Hydrotherapy / Underwater treadmill 
Hydrotherapy is one of the most beneficial forms of rehab and is prevalent in recovery from musculoskeletal and neurological conditions. Once the initial acute phase is over, your dog would benefit from short periods in the hydrotherapy pool or on an underwater treadmill, this will get him used to the water and begin the process of limb usage and muscle strengthening. Underwater treadmills are also very valuable for managing obesity.

Transcutaneous Electrical Nerve Stimulation (TENS) – electrical stimulation may help prevent muscle wasting caused by immobilisation.

* Laser Therapy – the term laser stands for light amplification by stimulated emission of radiation or LLLT. Laser therapy used worldwide for treatment of numerous injuries in humans and animals. It’s effective for wound healing, sprained & strained ligaments, soft tissue injuries and aids with pain relief and inflammation.

* Therapeutic Exercise – therapeutic exercise is one of the most significant part of rehabilitation post injury, surgery or disease and represents the final step in the rehabilitation program. 
It encompasses a wide range of physical activities designed to enable your dog to enhance function, improve cardiovascular fitness, increase flexibility and strength.

It also prevents long term physical impairment and reduces the risk of injury during unrestricted exercise. 
Therapeutic exercises include dancing, trotting, cavaletti rails, standing on the gym ball, weight shifting, wheelbarrowing and much more.

Ask your vet to give you a detailed pre/post-op rehabilitation plan or ask for a referral to an animal physiotherapist


An effective preoperative rehab period can result in better and faster functional outcome.

HOME THERAPY CARE: HOW LONG IS RECOVERY TIME AND HOW MUCH EFFORT IS NEEDED?

What you do before and after surgery is extremely important. The time and effort necessary for recovery will depend on how strictly you follow your vet and rehabilitation practitioner instructions and how much physical therapy your dog embarks prior and post-surgery. A suitable home therapy program should include:


  • Reinforcement of commands prior to surgical procedure.
  • Pet confinement to a small quiet area or crate for six weeks (rest period) post-surgery.
  • No off-leash exercise for 4 months. Your dog should be on a leash at all times when outside, even in the backyard. 
  • No stairs which can overstress the joint and no jumping under any circumstances during recovery, overextension of the knee could compromise tissue repair and extend healing time. 
  • Keep away from slipping on wet or smooth surfaces as this places strain on the recovering limb – lay a rug or soft covering on tiles or floorboards. 
  • Mental enrichment using mind games, food tricks and puzzles during crate rest will stimulate their brain and avoid risking further injury.
  • Larger dogs should wear a harness and use ramps to get onto vehicles. 
  • Weight loss can be extremely effective as part of management of dogs with cruciate conditions. 
  • Progressive exercise programme monitored by a physiotherapy or rehab professional. 

ADDITIONAL NUTRITIONAL & JOINT SUPPORT

It’s likely that after surgery your veterinarian may recommend a dietary change which will need to be gradually introduced over a seven to ten-day period. 


If your pet is overweight, your vet possibly will recommend special food to help return your pet to its ideal weight which will reduce stress on the knee joints and prevent arthritis development. 

Avoid harmful foods that have excess sodium, phosphorus, calories and include foods that contain sulfur such as eggs and asparagus to help support repair and rebuilding of tissue as well as Vitamin-B, Calcium, Zinc, Manganese and other minerals since they are important in tissue healing. 

Include supplements such as Omega-3 fatty acids to reduce inflammation in muscles or joints as well as Glucosamine, Chondroitin, green-lipped mussel supplements to protect joint cartilage and help with joint lubrication. 

Herbs such as turmeric and ginger can also be sprinkled onto your dog’s meals since they possess anti-inflammatory effects.


POSSIBLE COMPLICATIONS AND THINGS TO KEEP IN MIND

Complication rates are fairly low when cruciate ligament repair surgery is performed by experienced vet surgeons. The two most common complications are infection and mechanical problems. Infection is treated with antibiotics.The majority of mechanical complications are treated with rest or a surgical intervention.

It’s not unusual for dogs who rupture their cruciate ligament in one leg to develop a tear in the other leg. Arthritis or Osteoarthritis may also develop or may already be present. In some dogs, the meniscus can also get damaged in cases of cranial cruciate rupture.

A vital part of your dog’s recovery and continuing wellbeing is ensuring that you choose the right veterinary care, treatment options, rehabilitation program, an appropriate home therapy program alongside a positive and joyful mind set!

To assist preserve long term good health of your dog’s musculoskeletal system, careful attention to diet and exercise are essential, avoid obesity by monitoring their weight and body conditioning score and encourage daily exercise to keep joints supple, muscles and ligaments strong which in turn will help prevent further injury. 

Melina Grin from Pet Nurture love of animals began in childhood, when she would care for sick or stray dogs and cats while dreaming of becoming a vet. Today, her passion has become her profession. 

Melina has many years of experience handling animals: her own of course, as well as pet sitting, dog walking and caring for her clients’ beloved companions. In addition to her qualifications, Melina is a member of many professional associations including: Small Animal & Equine Naturopathic Association (SAENA), Veterinary Nurses Council of Australia (VNCA), DOGS NSW, Feline Nutrition Foundation

Melina is currently studying to become a qualified Veterinary Nurse with a view to progressing to Canine & Feline Rehabilitation Therapy. She also volunteers regularly at Monika’s Doggie Rescue and gives her time and expertise to several animal rescue events and festivals.


A helpful resource for owners is the Facebook Group Canine Cruciate Recovery (TPLO, CM)

References

1. Allegretti, J., & Sommers, K. (2003). The complete holistic dog book Home health care for our Canine Companions. Berkeley, California, United States of America: Celestial Arts.
2. Clair, D. J. (2011). Retrieved from Top Dog Health: https://www.topdoghealth.com/home-rehab-guides/cruciate-home-rehab-guides/
3. Fitzpatrick, N. (2017). Fitzpatrick Referrals cranial cruciate ligament injury. Retrieved from Fitzpatrick Referrals: http://www.fitzpatrickreferrals.co.uk/orthopaedic/cranial-cruciate-ligament-injury/
4. Hourdebaigt, J.-P. (2004). Canine Massage: a complete reference manual (2nd Edition ed.). Wenatchee, WA., USA: Dogwise Publishing.
5. Levine & Millis, D. a. (2014). Canine Rehabilitation and Physical Therapy (Second ed.). Philadelphia, USA: Elsevier. Retrieved August 2017
6. Monk, M. (n.d.). http://www.dogsinmotion.com.au.Retrieved from Dogs In Motion: http://www.dogsinmotion.com.au/wp-content/uploads/7-Mistakes-Rehab-Generic.pdf
7. Practice, T. V. (2017, July 07). The Revolutionary Way to Treat Partial CCL Tears in Dogs . Retrieved from The Vet Practice: http://www.thevetpractice.com.au/new-treatment-partial-ccl-tears-dogs/
8. Watson, S. L. (2010). BSAVA Manual of Canine and Feline Rehabilitation, Supportive and Palliative Care. (S. a. Penny, Ed.) Gloucester, England: British Small Animal Veterinary Association. Retrieved May 12, 2017

Disclaimer

Individual blogs are based upon the opinions of the specific author, who retains full copyright. The material is not intended as medical advice, it’s intended as a sharing of knowledge and information. We are not veterinarians and do not diagnose any conditions, perform surgery or prescribe medications. We encourage you to make your own pet health care choices in collaboration with a certified pet health care professional.
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