I offer non-surgical treatment for cruciate ligament disease in dogs

SUMMARY
1) Well-performed surgery plus excellent aftercare gives the most reliable recovery. But surgery is expensive, requires one or more general anaesthetics, activity must be very strictly controlled for at least 6 weeks afterwards, and surgical success is not guaranteed.
2) I offer non-surgical treatment, a fairly novel programme that is not yet in the textbooks. Recovery rate within 6 months is 76%.
3) Non-surgical treatment includes some activity restriction (less strict than the restriction following surgery) plus a tailored programme of exercises. The exercises achieve dynamic stability for the injured leg.
5) During regular consultations, the dog is reassessed and the programme adjusted as needed. Time to recovery varies widely between dogs.
6) For non-surgical treatment, dogs aren’t allowed off-lead on walks until the leg is ready for this, typically 4-6 months after starting treatment (compared with a typical 6-12 weeks for dogs that have had a successful operation).
7) Non-surgical treatment involves a lot of care and attention from the dog’s owner(s). It works best for owners who are happy to take their dog’s recovery on as a project.

 

 What is cranial cruciate ligament disease?

For dogs, one of the most common causes of hind limb lameness is cranial cruciate ligament disease. You may hear the same condition referred to as anterior cruciate ligament disease, CCL or ACL disease, cruciate tear or rupture or injury, or just cruciate diease.

Some affected dogs have a mild lameness that seems to come and go, while others are very badly affected and cannot walk on the leg at all. Dogs typically hold the injured leg in a “toe-down posture” as in the photo below.

The problem involves damage to a ligament within the dog’s stifle joint (this joint is similar to our knee). Once the ligament is frayed or torn, the joint becomes unstable and “gives way” when the dog tries to walk on the leg. In many cases the lameness is first triggered by a burst of activity, e.g. chasing a squirrel. However, in most cases, the ligament had already been weakened by degeneration (wear and tear over time) before it snapped. Many affected dogs are prone to degeneration of both cruciate ligaments. For that reason, the problem may happen in one hind leg and then go on to affect the other hind leg, often within the next couple of years.

This is the typical standing position of a dog with cruciate disease. The orange arrow points to the affected joint. The blue arrow indicates the typical toe-down paw position that we tend to see in these dogs.

Treatments available for cranial cruciate ligament disease

Surgery is usually advised for cranial cruciate ligament disease. There are various operations available including (a) osteotomies such as TPLO and TTA, in which bone is cut and realigned so that the joint no longer gives way on loading and (b) extracapsular repair such as the lateral fabello-tibial suture technique, in which wire or strong suture material is used to hold the joint stable. Expert surgery followed by good post-operative care is likely to give the most predictable good outcome.

However, many owners are looking for a non-surgical option. Surgery is beyond the budget of some owners, and it involves a full general anaesthetic that is best avoided for dogs with certain medical issues. Patients do not come out from the operation with a “normal” leg, but healing occurs gradually, and patients need very careful restriction for at least six weeks after surgery, e.g. crate or pen rest or room rest. Orthopaedic surgery is  invasive, and success following surgery is not guaranteed. Some dogs go on to have further problems with the joint despite surgery. In many dogs, some osteoarthritis develops in the operated joint following surgery. 

Over the years I have been approached by many dog owners looking for a good non-surgical option. Therefore, as The Rehab Vet, I have developed a non-surgical recovery programme for these dogs. First we allow inflammation in the joint to settle down and then, over the following weeks to months, we strengthen key muscles until functional stability of the joint is achieved. 

How does the joint become stable without surgery?

During recovery, we focus on improving the strength and coordination of key muscles within the hamstring group. These muscles are connected to strong fascia that wraps around the joint. Once they are strong and well-coordinated, the muscles contract at just the right point of the step cycle to enable the fascia to support the joint in place so that it does not give way.  The recovered joint has “dynamic stability”, meaning that surrounding muscles contract or relax at just the right moment to keep the joint stable when the dog is moving.

Above: Illustration of a standing dog with some relevant muscles and fascia

What does non-surgical management involve?

Recovery involves input from the owner from start to finish. We need to restrict the dog’s activities to allow inflammation in the joint to settle down. This generally means a change in lifestyle for both dog and owner. Ball play and chasing games should be avoided right through recovery as they will cause a flare-up of joint inflammation. Running, jumping, stairs, hurrying over slick floors and sometimes even trotting also need to be avoided until the dog’s joint is robust enough to cope with these activities. From the practical point of view, this may mean setting the dog up in a recovery room, or in a pen or large recovery crate, with close supervision whenever outside the designated recovery area. Lead walks start off very short,  typically 5 minutes at a time. Dogs tend to do best if  free access to the garden is avoided until late in recovery. Having said this, advice needs to be tailored to each dog and depends on the dog’s typical behaviour and the nature of the home environment.

During recovery, the owner needs to help their dog with prescribed exercises to improve coordination and strength of key muscles. Most of these exercises are done during lead walks. For example, once the dog is ready for this, we use kerb steps and natural slopes, we get the dog to start and stop walking in a prescribed way, and we use harness and lead to encourage the dog to shift his weight over the affected leg in a specific way. The length and speed of walks is gradually increased depending on progress.

This isn’t a one-size-fits-all recovery plan. Different dogs (and their owners!) get on better with different amounts of activity restriction and different exercises, and each patient progresses at a different rate. I prescribe appropriate exercise for each patient’s current ability and strength. Prescribed walking time and exercises are adjusted at each follow-up consultation. Painkillers (analgesic tablets or liquid) are prescribed for most dogs during the first part of recovery. I check the dog’s diet and adjust if needed: overweight dogs are put on a weight-loss plan.

I supervise dogs closely on this programme. Before the coronavirus pandemic, each consultation was a home visit. Through the pandemic, consultations have continued very successfully over video.  One requirement of video consultations is that the owner needs to send me footage of themselves walking their dog before each follow-up consultation. The total number of consultations varies widely between cases. If the dog has an unexpected “flare-up” or if there is a big delay in the owner starting to follow prescribed advice, then the recovery process will be prolonged.  However, most of my patients have around ten consultations from the start of treatment to going off-lead on walks. Consultations start once weekly, and then reduce to once every two to three weeks depending on how much supervision and reassessment is needed. 

What success rate do we have with this non-surgical management programme?

Out of 27 consecutive cases, 21 dogs came sound (lameness resolved) by 6 months. Most of these were sound by 4 months. Here’s a summary:

  • 76% recovery rate (came sound) by 6 months. Most of these were sound by 4 months.
  • 6 of 27 dogs relapsed or had >6 months of ongoing lameness. One of the six “failures” continued the programme and came sound at 10 months and another came sound at 11 months. Three dogs were referred for surgery and went on to do fine. The sixth dog listed as a “failure” had improved to a mild lameness by 6 weeks, but her owners at that point decided to seek treatment elsewhere as the program did not fit in with their lifestyle. 
  • Of the six “failures”, three had concurrent patellar luxation in the affected stifle joint and one had suspected lumbosacral disease in addition to cruciate disease.

Above: Chomp at 10.5 years old. The video shows her eight months after starting non-surgical treatment for cruciate injury in her right hind leg.  Chomp was enjoying 30 minute walks by that stage, including some off-lead time. She had cruciate surgery on her right hind leg at age 4 years, recovery from that had been slow, and her owners were looking for another option to resolve the left hind limb lameness. 

 

Are there any studies to support the use of non-surgical management? 

Statistics for my own non-surgical programme are shown above (see “success rate”). These were compiled in Nov 2019, with my success rate having been similar since then. These statistics are not published. This is mainly because these patients were referred to me for treatment rather than for research, and presenting diagnostic information was therefore not standardised  between cases. However, if other veterinary surgeons are interested in collaborating with me on a future published study comparing the effect of my non-surgical treatment programme with surgery then I would be very interested to hear from you. 

There is a published study on cruciate disease comparing the effect of surgery with non-surgical management, but I must make clear that this looks at a different non-surgical management programme to the one that I use. That study (Wucherer et al 2013) looked at 40 overweight large-breed dogs. They were divided into groups, with one group having TPLO surgery plus physiotherapy and a weight loss diet, and the other group having physiotherapy and a weight loss diet but no surgery. The Wucherer et al study found that dogs managed surgically did better, though the success rate by 52 weeks was only 11.4% better in the surgical group than in the non-surgical group: The percentage of dogs in the non-surgical treatment group with a successful outcome was 47.1%, 33.3% and 63.6% at 12,24 and 52 weeks after enrollment in the study, respectively. The percentage of dogs in the surgical treatment group with a successful outcome was 67.7%,92.6% and 75% at 12,24 and 52 weeks after enrollment in the study, respectively. 

How long does recovery take with non-surgical management?

Time to recovery varies widely between dogs. There is usually very good early improvement with the dog becoming noticeably more comfortable through the first 2 weeks.  The dog’s gait then tends to improve to just a mild lameness by 6-12 weeks. This is with walks kept short and slow. From around 3-4 months after starting treatment, we are typically able to start introducing a few steps of trot at a time into walks . Trotting is then built up gradually. Most dogs are safe to go off-lead for part of each walk from around 4-6 months after starting treatment. A few take less or more time to recover than this. 

Are all dogs suitable for non-surgical management of cruciate disease?

Dog breed and size is not a problem: I have helped all kinds of dogs recover without surgery, from toy breeds and terriers to Labradors and a 70kg Newfoundland. We have also had success both with very severe lameness and with milder lameness that waxes and wanes. 

Non-surgical recovery is challenging for very active dogs who tend to choose to race about fast indoors, especially if they cannot be prevented from jumping on and off furniture. Success is possible with these dogs, but it requires us to find a way to restrict their activity through the recovery period. This may involve setting up a recovery room for larger dogs, or a recovery pen or crate for smaller dogs. 

If there is a second problem with the joint at the same time, such as patellar luxation, then this can also make recovery more difficult.

The photos here are of three dogs that did well following non-surgical management of cruciate ligament disease. 

Which owners get on best with this non-surgical treatment programme? 

Owners need to get involved in the recovery plan for it to be successful. Advice varies depending on the situation, but may include restricting the dog’s activities in the house and garden,  doing short timed lead walks, helping the dog with exercises and, in many cases, measuring out the dog’s food.

For this reason, success tends to depend more on the mindset of the owner than that of the dog! This recovery plan is best for owners who are happy to take their dog’s recovery on as a project. It doesn’t work so well in very chaotic households. Non-surgical cruciate recovery works best for owners who are happy to follow instructions, and happy to report back to me along the way with any problems or concerns. Owners also need to be patient and to bear in mind that each dog recovers at a different rate, and that dogs may have one or more little setbacks along the way.

“Non-surgical management works best for owners who are happy to take their dog’s recovery on as a project”

Recovery involves a lot of walking on harness and lead. This starts off as very slow walking (it may be slower than you usually walk). Lead walks start very short indeed, typically no more than five minutes at a time. If you cannot cope with lead-walking your dog, then this programme is unlikely to work for you. 

If an uncertain timescale of recovery sounds impossible to you, then it may be better to opt for surgical management. Following surgery, recovery occurs at a more predictable rate. Unless there are complications after an operation, most dogs are allowed to go off-lead for short periods from around 6-8 weeks. With non-surgical management, your dog won’t be allowed to go off-lead on a walk until he or she is assessed as safe to do so, and this timescale varies between dogs. In most cases the walks have to be on-lead for the first few months.

In summary, The Rehab Vet’s non-surgical treatment plan works best for those owners who are happy to try this fairly new approach to treatment, and who are keen to follow prescribed advice right through recovery. 

How to arrange referral to The Rehab Vet

Photo credit: Scott Murdoch

Here’s how to get in touch to check for appointment availability: To book ann appointment, please phone or text on 07852 625317 or get in touch using the contact form here. I’ll get back to you as soon as I can. Please note that this phone number is for appointments only. If you are looking for general advice, then I recommend that you check out the advice for dog owners section of my website. 

Through the coronavirus pandemic, most consultations are run remotely using zoom.  For owners who are happy to follow instructions, non-surgical treatment can be managed well using video consultations. Click here for further information on what to expect from a video consultation.

Home visits are an option for follow-up, but only for those who live local to me in North Herts, UK.  For now, any home visits are weather-dependent outdoor sessions in the owner’s garden.