FAQ and Useful Tips

Icing the Injured Joint.

When the injury is fresh, cold can slow down the swelling that accompanies this kind of injury. In this way, cold can reduce pain and lessen tissue damage. Do not apply ice directly. Wrap ice (or a cold pack, or a bag of frozen vegetables) in a dish towel or other cloth, and press this lightly against the area for 15 or 20 minutes. Be aware of the dog's reaction. It is possible that the cold could be too cold and be uncomfortable. Remove the cold if the dog is bothered by it. It is helpful to cool the injured area in this way every few hours for several days after the injury. After several days icing is no longer helpful.

Is there a schedule I can use for how much activity to allow as Fido improves?

There is variation in the severity of these injuries, and there are differences between the dogs themselves. Each dog's recovery must proceed at its own pace. It is not good to set up a timetable in advance such as "10 minutes walks 4 times a day beginning with week 9" and then try to fit Fido into that pre-determined schedule.

---- It is best to have an unregimented approach which has as its primary rule that you will always avoid too much activity. It is important to be cautious. The most common error people make is to push forward with activity increases too quickly.

---- Start the recovery with a minimum of activity. Watch for a little improvement. Increase activity slowly & cautiously once you see improvement. Reduce activity to a minimum at any sign of a problem. A decrease in use of the leg or an increase in limping or stiffness after resting or other symptoms tells you: "Too much activity. Too-much-too-soon for that recovering stifle." Decrease activity to a minimum if symptoms increase. Then, when the symptoms lessen, introduce increased activity more slowly.

---- It is important that increases in activity be eased into slowly. Increasing slowly and watching carefully for indications of trouble will usually give you the ability to prevent a serious re-injury. Always be careful to prevent those high-stress events like taking off in a run after a squirrel which can cause major setbacks in recovery!

---- Recovery will take months. Your role is to maintain the careful restriction and supervise the slow incremental increases in activity and provide the high-quality food and supplements your dog's body needs.

---- As you look for improvement in your dog, it can be frustrating to compare today with yesterday. Improvement usually comes so slowly that the difference between one day and the next is not apparent. Keep track of your dog's condition with written notes or video so that you can compare today's condition to two weeks ago / a month ago. This will let you see if slow progress is taking place.

Pain Medication? Inflammation Reducing Medication?

Drugs which are anti-inflammatory, usually NSAID drugs (Non-Steroidal Anti-Inflammatory Drugs) like Rimadyl, Deramaxx, Metacam, etc, are commonly prescribed for dogs with ligament injuries. While these drugs may relieve the pain and reduce the swelling that accompanies a sudden traumatic injury, there are good reasons to minimize their use.

---- Inflammation is a necessary component in the healing process. The body responds to injury with a sequence of events that begins with an influx of inflammatory cells and blood. The inflammatory cells remove debris and recruit cytokines and other growth factors toward the injury site. This inflammatory phase is partly mediated by the same prostaglandins that are blocked by NSAIDs. In a healthy healing process, a proliferative phase consisting of a mixture of inflammatory cells and fibroblasts naturally follows the inflammatory phase. The fibroblasts build a new extracellular matrix and persist into the final phase of repair, the maturation phase, where functional tissue is developed. Each phase of healing is necessary for the subsequent phase. By blocking the inflammatory phase, anti-inflammatory drugs including NSAIDs can inhibit healing and cause a less desirable end result. There are numbers of studies showing that these drugs negatively influence healing / recovery in various kinds of injuries.

---- Also, NSAIDs all have risk of stomach ulceration as well as liver and kidney damage.

---- These drugs have a place in treatment because they are effective at reducing the pain of injury. But vets often fail to inform people of the drugs' undesirable aspects. I recommend that use of anti-inflammatories be minimized. Give these drugs to your dog in the lowest effective dose for the shortest time possible. Your vet may be handing out NSAIDs without warning of their risks, leaving you with the impression that these drugs are safe & good for use 'just in case' Fido might be feeling some discomfort. This is not true.

"But Max, My own doctor as well as Fido's vet prescribe NSAIDs all the time for all kinds of sports injuries and other trauma."

----- In the past, the extent of the negative aspects of these drugs was not well known, and they were prescribed without the caution we now know is appropriate. If often takes a long time for medical practice to catch up to current knowledge. While there is some conflicting evidence, it is well established that these drugs have serious risks. Use them with care.

---- Also, It is important to remember that the pain Fido feels when he puts pressure on that leg is nature's way of saying "Don't do that!" If you've ever had a sprain or other joint injury to an ankle or knee, you know that after the injury the pain soon eases to being mild except when you try to stand on the foot of the injured leg. Then the pain tells you in no uncertain terms "Don't do that! Don't try to bear weight on that leg!" If I had a sprain or other joint injury and took a pain reliever which completely stopped the pain, I could walk using the injured leg much more than I should and might do serious further injury to the joint by using it too-much-too-soon. We need to keep weight off an injured joint to give the body time to work on healing, and the pain we feel when we try to use the injured joint to bear weight sees to it that we do that.

---- So you see we do not want to try to medicate away Fido's limp. Pain medication is helpful right after traumatic injury (when pain may be bad even when Fido is at rest) because the drug allows a dog to rest comfortably. But extended ongoing use of pain medication can easily become counterproductive. We want to alleviate pain Fido feels when at rest, but the pain Fido feels when he stands on the leg and puts pressure on the joint encourages him to be gentle with the injured joint, which is good.

---- People often do not know that NSAIDs have an adverse effect on healing, as well as risks of severe liver & kidney damage, so they may cheerfully go on giving their dogs these drugs long after it would have been better to stop. Many vets do not inform clients about the negative aspects of NSAIDs, and may prescribe NSAIDs for dogs who are not feeling significant pain.

---- I would prefer to stop pain medication as soon as that can be done without Fido being too uncomfortable when at rest. If a dog is able to sleep comfortably after pain medication is removed, that indicates his pain is not too bad and he will be fine without pain medication. Being unable to sleep would indicate that pain medication should be resumed. Then try removing medication again in a week or so. If you need to continue pain medication after the first several weeks, and the original medication is a NSAID, ask your vet to prescribe a non-NSAID pain medication like Tramadol (Ultram, Tramal, others). Be sure he understands you want a non-NSAID, non-anti-inflammatory drug for pain. (Many times people ask for a different drug because their dog is having trouble with the specific NSAID originally prescribed, so the vet might not clearly understand your intention is to stop giving anti-inflammatories and could automatically respond to requests for a different drug by prescribing a different NSAID.)

---- Aspirin is a non-prescription NSAID drug. Regular aspirin is much more likely to cause stomach trouble for dogs than is Buffered Aspirin. Like all NSAIDs, Buffered aspirin should always given with food. Never on an empty stomach.

---- Buffered aspirin is not enteric-coated aspirin. Enteric-coated aspirin is not useful for dogs.

---- The suggested aspirin dosage for dogs is 5-15mg per pound twice a day. (One 325mg buffered aspirin tablet per 30 pounds is slightly over 10mg per pound).

---- Be watchful when using any pain drug for indications of a problem. With buffered aspirin, watch for signs that your dog's stomach is upset. If he stops eating, stop giving him the aspirin. Using buffered aspirin and giving it only with food should prevent a stomach problem in almost all dogs, but there are exceptions of dogs who are extremely sensitive to aspirin.

---- Aspirin, Rimadyl, Deramaxx, Metacam, etc, are all NSAID drugs. Don't ever give two different NSAIDs at the same time, nor switch to any NSAID from another NSAID until the body has had time to clear the previous drug. How long this takes depends on the particular drugs. When switching to buffered aspirin, wait at least one day.

Be Watchful When Using prescription NSAIDs

Rimadyl, Deramaxx, Metacam, etc, can cause health problems including very bad kidney and/or liver problems in a small percentage of dogs. These can be useful drugs, but they have this risk. Some dogs take these drugs for years and it helps them with pain they have from some condition. But for a small percentage of dogs these drugs can be deadly. A bad reaction can come immediately, or after a few days or a few weeks or longer. Usually dogs recover well if the drug is stopped soon enough, but not all recover. While the rate of deaths for dogs given Rimadyl etc is small, these drugs are nevertheless not something you want to use unless there is a good reason. If you are giving a dog any pain medication and see any changes that could indicate internal difficulties, stop giving the drug immediately. Here's the list of signs that a dog is reacting badly to a NSAID drug. If you see any of these, stop the drug immediately:

Adverse reactions may include decreased appetite, vomiting, diarrhea, dark or tarry stools, increased water consumption, increased urination, pale gums due to anemia, yellowing of gums, skin or white of the eye due to jaundice, lethargy, incoordination, seizure, or behavioral changes.

---- It's always a good idea to do a websearch on any drug and become as knowledgeable as possible about the risks involved in its use. Don't just search the name of the drug and stop after reading the first few informational pages. Add 'complications' 'risks' 'adverse effects' to the drug name in your searches.

What is meant by 'Activity Restriction' ?

Restriction during non-surgical recovery or after surgery means preventing all overly stressful activity and greatly reducing all activity. Only very short leashed walks to empty bladder & bowel at first, increasing to short 'sniff & stroll' walks which gradually lengthen as recovery proceeds. Permit only gentle activity which puts little pressure on the injured joint(s) for at least several months and perhaps longer with severe injuries. All excessive stresses must be avoided. 'Excessive Stress' is caused by any activity which puts more than minimal pressure on the legs, such as running or jumping. Even gentle walks can be excessive if they go on too long. A short walk every few hours is preferable to a longer walk once a day.

--- But 'Restriction' does not mean 'Immobilization'. Research shows that moderate gentle use of the joint leads to a better long-term result than immobilization of the joint. Sometimes people assume that keeping the dog crated all the time or in some other way preventing almost all use of the leg is the best way to prevent re-injury. But this doesn't lead to the best possible recovery for the joint. Moderate use of the leg during which the dog can move the leg through its normal range of movement without excessive stresses is the ideal. Swimming is great. Slow walking on a soft surface like grass for short distances is good. Being able to move around inside the house at will is good. Always provided that running and jumping etc are prevented. Some dogs are so high-energy that crating them is the only way to prevent jumping and other over-stresses. You know your own dog best and how best to prevent excessive stresses while allowing very moderate, gentle use of the leg.

---- With some high-energy dogs, attempts at proper restriction may seem hopeless because the dogs are so bouncy. Do your best and judge by whether they are improving. If a dog is improving over time--- limping less / putting weight on the injured leg / etc --- then the recovery is succeeding. The stifle(knee) is being made stable by the build-up of new tough, fibrous supporting scar tissue.

How Can I Tell How Much Activity To Allow? As My Dog Improves, How Do I Know How Long A Walk Is Too Long?

---- With a less-than-severe injury, or after a severe injury has improved somewhat, you don't need to restrict gentle activity nearly as much as is appropriate in the early period just after a severe injury, but that doesn't mean that restriction should end. You must still avoid all running & jumping & other activities which put too much pressure on the joint. When improvement is seen it is good for a dog to be somewhat active in gentle ways such as short leashed walks, but it is still possible to overdo gentle activity and caution is needed. Activity is good provided it is not excessive.

------ Activity can be excessive in basically two ways:

-- Anything that puts a lot of pressure on the joint like running, jumping etc

-- Any low-stress activity which goes on too long.

Here's why: The joint is held together by muscle and other joint structure as well as the ligaments. Different dogs have different muscular ability to hold the joint tight. (This is why vets may find with some dogs that they cannot manipulate a joint to try to discover 'drawer' movement at the joint. The dog may tense the musculature around the joint and the joint is held firm, regardless of the condition of the ligaments. When a vet finds that the dog does this he will want to use an anesthetic to make the dog unconscious for the manipulation.) But these muscles aren't able to do all the work of continual stabilization without the ligaments there to do their job, and are only able to maintain stability for a short time before they are exhausted. Once they reach exhaustion on too long a gentle walk, the joint will become loose. Therefore more subject to further injury to joint components or damage to the developing scar tissue buttressing. This is why longer periods of gentle activity are not appropriate.

-- However, shorter periods of gentle activity are helpful for the recovery. Proper gentle joint movement cyclically compresses then releases the meniscus, pumping nutrient-bearing synovial fluid around inside the joint capsule. Moderate gentle activity minimizes overall muscle atrophy from inactivity and encourages proper scar tissue development to support the injured stifle. So short periods of gentle activity like short sniff-n-stroll walks are very good, but longer walks are not good. How long a walk needs to be to be 'too long' depends on the dog and the condition of the joint. It is a judgement you need to make based on Fido's symptoms during activity, after activity, and following rest after Fido's activity. Basically, during recovery it is best to make walks quite short and do more of them, leaving time between for resting the recovering joint.

-- Here's an example for comparison: For a dog beginning to improve from stifle ligament injury, a four minute walk 6 times a day would be the same amount of walk-time per day as a 24 minute walk once a day, but the 4 minute walks would be very much preferable. I'm not recommending that specific schedule. It's just an example to illustrate the point. Each dog's activity as he moves through his recovery must be determined individually for that dog. Dogs with minor injuries or dogs further along in recovery from more severe injury will be able to have longer walks than dogs with greater instability / vulnerability to excess.

---- You should always be cautious and do less than your dog wants to do. Dogs will always want to do more that they should. Be cautious about activity and if you see improvement over time, you will know that the joint is becoming more stable. Improvement is usually slow. Improvement can be seen over the weeks & months by comparing the dog's condition to his condition several weeks previous.

---- All running & jumping put too much stress on the joints and must be avoided during recovery. A gentle walk is excessive which goes on so long that it causes or increases symptoms during a walk, after a walk, or after rest after a walk. Walking on a soft surface is greatly preferable to pavement. Grass or other soft surfaces offer less impact-stress to the leg than a hard paved surface, and the slight unevenness of a lawn or leafy path is better for the recovering joint than a flat hard surface like pavement.

---- All that may sound more complex than it really is. The important thing is just this: Reduce stresses on the joint to a minimum, and be patient.

Months have gone by since Fido's injury. He has not been restricted. Is it too late now? Would surgery be better now because so much time has gone by since the injury?
It is never too late. Begin restriction now. While it would be best to begin restriction immediately after the injury, this seldom happens. Most people facing this problem for the first time do not recognize the nature of the problem at first. They don't know that restriction is required. Sometimes the ligament slowly degrades and there is no sudden injury event. When there is a sudden injury event they may mistake the ligament-related symptoms for some other kind of injury. For these and other reasons it is very common for there to be a length of time pass before the problem is understood to be ligament-related and restriction begun. But most dogs do respond well to restriction even when the problem has existed for a long time. It is never too late to begin restriction.
---- Surgery does not become a more appropriate treatment option because time has passed since the injury. Restrict the dog carefully starting now, regardless of how long the problem has existed.

Tigger swimming in pursuit of geese

Tigger thought it was unsporting to wait for a goose to be shot before retrieving it

Swimming as Therapy ---- If possible I would have a dog swim as therapy during recovery. Many people have written me that swimming was very helpful in their dogs' recoveries. Swimming is great for dogs with ligament injuries because:

1) The non-weight-bearing nature of swimming puts much less stress on the joint than walking, and the water offers only limited resistance to movement. Swimming lets the dog get exercise which helps maintain muscle with little risk of injury to the recovering stifle.

2) While the dog is swimming the joint can travel through a normal range of movement. This encourages the newly forming joint-supporting tissue to develop in such a way as to allow a greater range of movement after healing is complete. And the gentle, low-stress movement also helps with healing other joint components by circulating the joint's synovial fluid.

3) Swimming gives the dog a safe outlet to burn-off that dog-energy.

---- But Use Caution -- When you take your dog on a trip to go swimming, be aware of the risks of excessive stresses when he is not in the water. Don't allow running into or out of the lake. Nor jumping into or out of the car. The stresses involved in getting Fido into the water and then getting him home must not be excessive.

---- Swimming has been great therapy for many dogs during recovery without surgery, and swimming is also good post-surgically. Many people who have used swimming as therapy during recovery are very enthusiastic about it. But if swimming is not a possibility then a dog can still succeed in recovering without it. Swimming is great, but not a necessity.

---- Being able to move the joints without bearing full weight is the reason swimming is so desirable. The next-best activity to swimming is wading in water that comes up over Fido's body so that he can keep his feet on the bottom but doesn't need to swim. The water supports a large part of the dog's weight, lessening the burden on the joints. For dogs who are non-swimmers and for old or sick dogs for whom swimming would be too strenuous, wading is a good alternative to swimming.

Hydrotherapy could be helpful if there is no body of water available to you for simply swimming.
I would prefer free swimming at the dog's own pace to any other therapy. But if this is not an option for you and Hydrotherapy using an underwater treadmill is available, Hydrotherapy can be helpful. However, you need to be aware that there are therapists who are too aggressive. An overly aggressive hydrotherapist might set the speed and time for Fido's underwater treadmill session too fast and too long, or in some other way push the dog too hard. This is not unusual. If your dog's symptoms are worse after hydrotherapy or worse the day after hydrotherapy, that should alert you that there is a problem with the therapist being overly aggressive. A good therapist understands that a joint injury is very different from a muscle injury. The joint needs gentle treatment as it gradually re-establishes stability after a joint injury. If you interview a therapist and her description of what she intends as therapy focuses on 'building strength' or 're-building muscle', then she is the wrong therapist for joint injury recovery therapy. Re-building atrophied muscle is part of recovery, but not the correct principal goal. When the joint is stable, the dog will know that it is stable and will use the leg. This will re-build muscle. You couldn't stop it if you wanted to. The primary goal of a joint injury recovery must be regaining stability and resistance to further destabilizing injury. This requires gentle moderate use and time. In recovery from a muscle injury or other situation where rebuilding strength is the goal but there is no joint instability problem, muscular strength and mass are increased by exhausting the muscles. This muscle exhaustion sends the message to the body that increased muscle is required, and the body responds by building muscle tissue. But if you exhaust the muscle tissue around a de-stabilized joint, you cause the bones to grate and grind against each other at the joint. This can easily result in permanent damage. Gentle use of the leg which provides a near-normal range of movement without any kind of excess stresses is the ideal therapy for joint injury recovery. Swimming at the dog's own chosen pace is the perfect exercise therapy for joint injuries.

Boredom can make the long days of recovery even longer for a dog.

---- Find things to do that don't require a lot of use of the legs. Bones are very nice! Fido probably enjoys a ride in the car. Toys can fill the hours for some dogs. Some like to watch out the window or watch TV. Make Fido's short walks 'Sniff-N-Stroll' walks. Slow meandering walks at the dog's chosen pace which include stopping to sniff at this and that. A ride in the car to someplace where a dog can have a liesurely 'Sniff-N-Stroll' on the grass among trees & shrubbery will be a high point in the day and help Fido keep up in good spirits.

What About Overweight Dogs?

Many dogs who have ligament injuries are overweight dogs. While it is important in the long run to get that excess weight off the dog, it is very difficult to lose weight while activity is severely restricted as it must be for the early weeks of ligament injury recovery. To lose weight in a safe and healthful way requires exercise. So it is best to make the first priority the joint's recovery, and the secondary goal the weight loss. The dog needs proper nutrition to heal that injured joint. Once the recovery is underway and you see improvement in the use of the leg, it is appropriate to slowly increase exercise. At that point it is possible to begin to work on the weight problem. One thing you can do from the beginning that will help with weigh loss even while the dog is sedentary is to switch to a no-grain diet. There is more about this on this website's 'Nutrition & Supplements' page. Also, it is possible for a dog to get exercise by swimming while recovering from a ligament injury. Swimming is great exercise and great therapy for joint injury too. Overweight dogs can recover from ligament injuries, but it is important for long term joint health to lose that excess weight. All the dog's joints are stressed by that weight. As a dog ages, problems will arise in the weight-bearing joints for overweight dogs.

What might go wrong during recovery?

The biggest risk for a dog is doing too-much-too-soon and re-injuring the joint. The most common mistake people make when they see that their dog is improved and no longer limping is to decide that the dog must be almost fully recovered. So they increase activity too much or even allow normal activity to resume abruptly. A setback in recovery often results. The dog may not have been limping, but that stifle was far from fully recovered. It will take months more before it is as secure from re-injury as it can be, and meanwhile it is the weak link in the leg. The only way to know how much stress it would take to overwhelm the vulnerable recovering stifle would be to push it to the point of failure. The wise course is to be cautious and slow in increasing activity. Many dogs have had re-injuries because their people went too quickly in increasing activity. The risk of re-injury is minimized when you increase activity prudently.

When is recovery complete? After how many weeks of restriction? When the limp is gone? When?

Once the original 8 week period of restriction has indicated by improvement in Fido's condition that non-surgical recovery is underway, don't try to regulate or judge the dog's recovery by the calendar. Don't think "It has been X weeks of restriction so this recovery is complete and Fido can now be free to run." Improvement during the early weeks of restriction shows that the joint is re-stabilizing. This indicates that the dog can almost certainly re-stabilize the joint without surgery. But it is not possible to say how long this will take. Continue to slowly and watchfully increase activity until you have reached normal levels. Watch the dog, not the calendar. A few dogs recover well relatively quickly, while most others take much longer.

---- Sometimes people want to set up a schedule of exercise weeks in advance. I believe this is a mistake. I think the best strategy is to take it one day at a time, deciding as you watch your dog how much activity is right. Always being cautious. Cautious and patient people do best. People who push for their dog to do more and do it sooner are much more likely to have setbacks / re-injuries. Sometimes it takes a setback to teach someone the value of a slow, cautious, incremental approach to increasing activity during a ligament injury recovery. I was like that, as have been many others. Learn from our mistakes. Patience and caution and careful attention to proper restriction are the keys to success.

The vet says to "rest" Fido four weeks, then bring him back in to see the vet again. If Fido hasn't recovered in the four weeks, the vet says he will need surgery.

---- Some vets will recommend surgery for a dog who has not recovered after two weeks or four weeks. While minor injuries will have resolved in this short time, in cases where there is more than slight ligament damage four weeks is far too little time to judge if the joint is capable of re-stabilizing without surgical intervention. I know of many instances where no improvement was apparent in the first month, but then slight improvement was clear at two months and the dog went on to a good stable recovered stifle without surgery. If your vet tells you two or four weeks after beginning restriction that surgery is necessary, please remember that this is far too soon to make that judgment, and that there is no good reason not to wait 8 weeks before considering surgery provided proper restriction is maintained.

---- Noticeable Improvement is what you are looking for at 8 weeks, not full recovery. The fullest possible recovery will take longer, perhaps much longer, but improvement shows clearly that Fido is slowly stabilizing that injured joint.

The vet said "Rest Fido 4 weeks, and if he is better then he can be free to run & play." So we did that, but then Fido was limping again a few days after being let off restriction and the vet now says he needs surgery.

---- Fido re-injured that joint because even though his symptoms had improved in four weeks that joint was still the weak link in his leg. Four weeks is much too soon to resume normal activity. The new supporting tissue at his stifle(knee) was still fragile and easily torn up by the stresses of normal activities. Fido needed very slow careful incremental increases in activity over at least several more months.

---- After a re-injury like this Fido may be starting over on his recovery, but he is not any more likely to need surgery than after the original injury. If he is carefully restricted and improves over the next eight weeks, he almost certainly does not need surgery.

The vet says my dog has a 'full tear'(or 'complete rupture'). He says a 'partial tear' might recover without surgery, but 'fully torn' ligaments must have surgery. Is this right?

---- Decisions about treatment should never be based on any vet's 'partial tear' or 'complete tear (rupture)' diagnosis. Going straight from diagnosing an injury as a more severe ligament injury to a recommendation for surgery is not justifiable.

-- In the first place, the facts an exam can determine about a dog's stifle's post-injury internal condition are limited. Although some vets commonly state with apparent confidence that there is a complete rupture, this is a far-from-certain deduction on their part, rather than a direct observation. They can't see ligaments on x-rays. They are making a guess about the ligament's condition based on the post-injury looseness of the stifle.

-- More importantly, the stifle is a complex joint. The degree of damage to the ligament is only one of a number of variables that influence whether a dog can re-stabilize the joint without surgery. Whether or not the ligament is completely torn, a dog's ability to re-stabilize the joint can be surprising. I receive a lot of emails about successful recoveries without surgery that followed vets' assurances that there was a complete rupture of the ligament and surgery was the only choice.

---- With some other types of injuries, making a decision for aggressive surgical treatment in a haze of uncertainty may be necessary because delay could cause harm, but this is not one of those situations. With little risk involved in trying a non-surgical recovery, it is not wise to rush to surgery based on any vet's estimate of the degree of the injury to the ligament. The careful restriction of Conservative Management will act as the best possible diagnostic tool while it minimizes the risk of further injury. Improvement or a lack of improvement over 8 weeks of careful restriction will tell you whether the dog needs surgery with far more certainty than any vet can tell you based on a post-injury exam.

---- Also, I think it wise to bear in mind that while there are many good, honest vets in the world, there are others who are trying to sell the highly profitable TPLO for every dog who comes through their door. If a person sees a surgeon like that, the profiteering surgeon may say "Oh, well, Fido has a complete tear, for sure! TPLO is absolutely necessary. We'd better schedule that now." Thereby presenting his own interpretation of the degree of injury as proof-certain that the surgery he sells is required. This is a sales tactic, not sound medical advice.

--- To be clear, it is true that dogs with a more severe ligament injury are more likely to require surgery than dogs with a less severe injury. But each dog's injury is unique and the only way to know if CM will work for a particular dog is to try the careful restriction of CM for that dog.

What about high-energy, difficult to restrict dogs?--- Don't think that if your dog is difficult to restrict then surgery will be the answer. Careful restriction of activity is the foundation of all dog ligament injury recoveries, whether or not surgery is necessary. Restriction is just as important after surgery as in a non-surgical recovery. If a dog has surgery and is not kept from excessively active behavior for months after surgery, the result can be disastrous.

--- It can be really difficult to restrict some dogs. It is important to start out restriction with the resolution that the dog is going to be restricted properly. This is no time to be a soft-heart who can't resist giving in to the dog's desire to run or play. Nor to take half measures which allow excessive activity in some situations. Failure to restrict properly could result in terrible consequences for the dog.

--- It can be risky leaving a recovering dog alone and loose in a large area including leaving the dog with the run of the house while his people are away. Sometimes a dog will be very quiet for many hours but then some little noise or disturbance will set the dog off to go running back and forth for a few minutes, possibly causing a re-injury. I dislike crates, and the idea that I hear many vets advance of closing the dog in a bathroom or other very small room seems worse than a crate in some ways. But some means of limiting movement is necessary. If there were no other way I would use a crate or a small room, but only as a last resort. First, I would consider getting an ex-pen and setting it up wherever the family spends time in the house. There are a number of makers & sellers of these ex-pens (or x-pens). The pens are generally constructed of 8 wire-mesh panels, each of which is two feet wide and connected to the panels beside it with a hinged attachment. They come in various heights. An ex-pen is large enough to allow the dog to move around freely and be comfortable, but not big enough to allow running, jumping, etc. I'd get the highest-sided type and roof over the top with some cardboard or other material if the dog were likely to try a leaping escape. The big advantage of an ex-pen is that the dog can see out and is right there in the place where the family lives. Not shut into a small room staring at blank walls or confined to a crate barely big enough to turn around in.

--- Some very difficult dogs are going to break down an ex-pen. They are going to need a more secure confinement. I would get a dog like that the biggest fold-down cage I could find. I know these are made as large as 48 inches X 30 inches, and perhaps larger.

--- When dealing with a high-energy dog, I would also consider getting a brace. I usually suggest waiting a few weeks after starting proper restriction to see how things go before ordering a brace. In most cases a brace is not necessary. But for high-energy, very active dogs who are difficult to restrict, I think a brace is often a good idea. You are the best judge of whether your dog is so difficult to restrict that ordering a brace immediately is appropriate. The brace helps with preventing potentially damaging movements, but you still have to restrict the dog properly as best you can. The brace isn't 'instead of' restriction. But for many dogs the fact of wearing the brace settles them down somewhat. They won't be as inclined to try to run etc with the brace on. In this way the brace aids in the restriction. Braces aren't cheap. But well worth the money in situations where a brace is helpful. There is a section on braces lower on this page.

--- I suggest that you not speak harshly to the dog for being too active, but instead physically prevent inappropriate behavior without making any attempt at training the dog to not be excited and playful. Don't yell at the dog or say that running & jumping around is bad. Just prevent the behavior with physical restraint. It may be possible to train a dog to not be a bouncy, happy dog, but the chances are the dog will become depressed and just feel unloved. Much better to let physical restraint do the restricting by getting down to hug / hold the too-bouncy dog, and by restraining with a cage or a pen, and by using a leash with pull-preventing collar, blocking off stairs, etc. I would use methods like this to prevent excessive stresses on the injured joint. Be loving toward the dog while using physical restraint to restrict activity appropriately.

Should the 8 weeks of original diagnostic restriction ever be extended? Or is every dog who does not start to improve within the first 8 weeks in need of surgery?

--- Eight weeks should be seen as a guideline, not a hard-and-fast rule. While most dogs will begin to show improvement within that 8 weeks unless they do need surgical intervention, some dogs will take longer. Older dogs and dogs with other health issues or medications which could interfere with healing, for example. Sometimes dogs for whom surgery is not a possibility for some reason will begin to improve after more than 8 weeks, showing us that the 8 week mark is not firm. And in a few instances people have written me about young healthy dogs who showed no sign of improvement at 8 weeks and were therefore scheduled for surgery but who then began improving while awaiting their surgery date.

--- Since some dogs do begin showing improvement after more than 8 weeks, or show only minimal improvement at 8 weeks, I would not disagree with anyone who wanted to wait longer before deciding surgery was appropriate for their dog, especially when the dog was old or there were other reasons to expect a slow recovery. However, I think the great majority of dogs will show some improvement by 8 weeks if they are going to be able to re-stabilize the joint. So a decision in favor of surgery after 8 weeks without improvement would usually be appropriate.

--- Bear in mind that any setback re-injuries during the original 8 weeks put you back at day one in counting the 8 weeks.

Enlarged Stifle Joint?

"My dog has improved well with Conservative Management, but his knee is larger than the knee of the un-injured rear leg."

----- The method the dog's body uses to stabilize the joint after a ligament injury is to build a buttress of tough scar tissue at the injured joint which prevents the bones from moving against each other inappropriately, but allows most proper movement. This buttress development happens with recoveries after conventional surgery as well as with non-surgical CM stabilization. The buttress can be seen and felt at the stifle joint. It is especially apparent when the joint is compared to the other leg's stifle joint.

---- People seeing this enlargement may think it is something they should be concerned about, such as a swelling from inflammation. But in fact it is normal, healthy tissue serving a useful purpose. Dogs who have had ligament injuries and have re-stabilized the stifle joint will almost always have 'big knees' like this.

What About Braces?---- Most dogs recover well without a brace, but sometimes a brace can be helpful. If a dog's stifle is very badly damaged and unstable after injury, the new supporting tissue cannot get a start before there is re-injury from even slight activity. In such cases a brace is appropriate. A brace can help support the injured stifle to prevent further injury and hold the leg while new supporting tissue develops. Or in the case of a very energetic dog with whom it is difficult to maintain restriction, or for very large or old dogs, a brace could be the best way to prevent repeated re-injury during recovery. But bear in mind that a brace is not a substitute for proper restriction. You can't put a brace on a dog and then let him run & jump. And remember that recovery from these injuries is expected to be slow. If Fido is a little better and slowly continuing to improve after 8 weeks, he doesn't need a brace.

---- While a brace can be useful for some dogs, don't rush to get a brace. I would wait a while after beginning restriction in almost all cases to see how things go before considering ordering a brace. If Fido is improving with careful restriction, I would not order a brace. But if he was showing no improvement, or had repeated re-injuries even though properly restricted, I'd consider ordering a brace.

---- The majority of people who tell me they have used a brace for their dog say they have been pleased with the braces, but others have not found the brace helpful. Some dogs will not accept wearing a brace. People sometimes describe the braces as too cumbersome for their dog or in other ways not useful. But if a dog is having a difficult time getting started on recovery, or repeatedly re-injuring the joint, a brace is definitely worth trying.

---- You can find the websites of dog brace makers with an internet search. There are several different types of braces. The kind I would very much prefer would be like the ones made by 'Orthopets'. There are photos at their website:

http://www.orthopets.com/index.html

There are other bracemakers who use the same method to custom fit a brace. The bracemaker sends you a kit which you use to make a casting of Fido's leg. You send the casting to the bracemaker and the brace is made. I do NOT recommend other types of braces which are made differently.

Brace Question:

"Max, You advise waiting before deciding whether to get a brace. Why not go ahead and use a brace from the beginning just in case it would help?"

The nature of braces is that they restrict movement. That is why we use them, of course. But it is not possible to make a brace which prevents the movement we want to prevent while offering no resistance to appropriate normal movement of the leg at the joint. This burdening of proper joint movement is something we would rather avoid if possible. When the injury is severe the joint may be so loose that it requires a brace's assistance to keep the bones in place while the new supporting tissue builds up. In that situation we must accept the negative aspects of the brace along with the useful joint stabilization the brace provides. But most dogs show us by improving with no brace (just careful restriction) that they are able to hold things together well enough to re-stabilize without outside assistance from the brace. When a dog improves and slowly continues to improve without a brace and does not repeatedly re-injure the joint, a brace would potentially be a detriment to recovery by preventing full proper movement at the joint, or altering the contact between the bones disadvantageously, etc.

---- Also, the dog can't comment on the fit or action of the brace. If you or I were wearing a brace, and there was a problem, we could say "At this point in the brace's movement it seems to give me a little pain / seems to tighten up in its movement / pulls funny " or whatever, but the dog can't do that. The dog is unable to adjust the brace or ask for adjustments or describe glitches in the brace's working. So I believe it is better to not use a brace unless your dog undoubtedly needs one.

---- If I tried the recovery without a brace and my dog couldn't get a start on re-stabilizing the stifle, I would certainly get a brace. Or if my dog was a super-active bouncing-off-the-walls kind of dog who was at high risk of repeatedly re-injuring the joint, I'd go straight to a brace. But remember, a brace is not a substitute for proper restriction. You must do your best to restrict properly so as to prevent excessive stresses to the injured joint with or without a brace.
---- People love their dogs and want to do everything they can to help their dogs recover. This makes it tempting to buy things which it is hoped will help. But it is easy to do harm with the best of intentions. Don't buy your dog a brace to make yourself feel better. If Fido's situation fits the description above of when a brace is appropriate, get Fido a brace. It he is slowly improving without repeated re-injuries in spite of proper restriction, don't get a brace.

What About Elastic Wraps?

Vetrap; Coban; Ace; etc elastic wrap-type bandages:

An elastic bandage wrap could perhaps be a good thing on your own injured joint, but there are serious potential problems with using an elastic wrap on a dog. It has to be pretty tight to do any good, but if it is a little too tight it cuts off the blood to/from the lower leg. If you or I have it too tight on ourselves we can feel that it is too tight and re-do the wrap more loosely so it is OK. But used on a dog, the dog can't tell you the wrap is too tight. So it is possible to do serious damage from cutting off the circulation.

---- I advise you not to use a wrap. The potential for making it too tight and doing serious harm is too great.

Emptying Bladder & Bowel

---- Be sure that your dog has plenty of opportunities. If she can walk on her own, that is fine, but don't rush her. Let her move at her own pace. If she cannot walk on her own, or needs assistance, help her with a towel-sling. (Towel-slings are described lower on this page under the heading 'Stairs'). Take her out regularly. Don't just wait for her to tell you she wants to go out. Be sure she has clean fresh water easily available to her at all times.

---- The 'gastro-intestinal reflex' is simply the tendency to feel an urge to defecate(poop) shortly after swallowing something. The practical use of this is to give a dog a treat just before going out when you hope the dog will have a bowel movement. And to always take a dog out right after a meal.

---- It is usually better not to try to be helpful to the dog by holding her up while she tries to squat to pee or position herself to take a dump. Most dogs are sensitive about being interfered with while they are emptying bladder or bowel. Let the dog work out the best way to position herself. She will take time to figure out how to do this, but almost all dogs will manage best alone working this out for themselves. If she needs to be carried out or supported with a towel-sling to get outside, once there leave her alone standing in an appropriate location. Don't watch her directly since that is also often off-putting for dogs. Watch her out of the corner of your eye while you face in another direction examining the tree leaves, the clouds, whatever. Don't rush her. Praise her for successful completion of the task!

---- If she cannot stand at all due to bilateral severe injury, you will have to encourage her soothingly while holding her in an appropriate position using your towel sling or perhaps just your hands. It will probably take some time to work out a way to do this that she will be comfortable enough with to relax and get the job done. Be patient.

Slippery Floors? ----A slippery floor is a hazard to a dog who is trying to recover from a ligament injury. Just like you or I, when a dog slips he will automatically try to recover from the slip with a quick move of whatever limb is likely to save him from falling. This can be the injured limb, and this can cause a further injury. The dog needs a floor he can walk on without his paws slipping. If you have floors that your dog could slip on, you need to do something to make footing more secure for him. Rubber-backed scatter rugs are one option.

---- Here is another method which some will find too extreme, but it is very effective: Dissolve a cup of sugar in a bucket of warm water and mop the floor with it. Allow it to dry and the floor will be slightly sticky. The stickiness will adhere a small layer of dust and the floor will no longer be slippery.

Stairs?

Going up stairs puts more stress on a dog's rear legs. A sling made from a towel is a very good way to handle going up stairs. Just loop the towel under the dog's belly so you have both ends above his back and can lift his rear. Then walk beside him and pull up on the towel as he goes up the stairs, taking the weight off his rear legs. You don't have to actually lift his rear end into the air so that his feet don't touch. Just take a good bit of the weight off those rear legs. Many dogs are inclined to take stairs leaping which is especially bad for the injured leg. So the sling is a good way to control them and take stress off the injured leg at the same time. Going down stairs shifts a dog's weight forward so you probably won't need the sling, but no running!

---- When you place the sling under the dog's belly & lift, you should move forward yourself & move the towel-ends you are holding over Fido's back forward as you say "Here we go!" or whatever Fido will recognize as indicating forward movement. Don't just stand there expecting Fido to understand what that towel is all about and that you want him to start up the stairs. You need to let Fido know what you expect him to do. Your moving forward with the towel-sling moving his butt forward will cause him to step forward himself with his front paws. Practice using the towel-sling on a flat surface before doing stairs using it. As he first moves forward with the towel-sling in place, tell him "Good! That's right! Here we go!" to encourage him and he will soon catch on to the idea. Proceed slowly & cautiously in this, as in all things related to the recovery.

Muscle Atrophy?

Very often dogs' leg muscles shrink markedly in size after the injury and during the early weeks of recovery. This happens because the muscles are not being used. Don't be too worried. What the dog needs first of all is to regain stability in the stifle. Once he can feel that the stifle is stable he will go back to using the leg more and more and the muscle will build back up naturally. You couldn't stop it if you wanted to. Sometimes people are too anxious about the muscle because they see it has reduced in size and they want to do something about that. They start doing too much weight-bearing exercise too soon which results in a less-than-optimum recovery for the stifle. I think the right approach is to just make the stifle your priority and the muscle mass and strength will return when the stifle is restored to its stable state. Using swimming as therapy will help minimize muscle atrophy without undue risk of furthering the injury.

Pulling at leash?

If a dog is pulling on the leash that is not good. I would want to prevent pulling at the leash since that is putting much more pressure on the stifle joints than would be there if the dog were not pulling. I hear good things about a kind of head harness that prevents pulling by redirecting the pulling force. One brand is "Gentle Leader". Another is "Halti".

Adequan Injections? --- Another thing you might want to consider is a series of Adequan injections. Sometimes Adequan seems helpful and with other dogs it doesn't seem to make any difference. Take a look at the 'Adequan' maker's website:

http://www.adequancanine.us/about/en/product_description.shtml Adequan is a 'polysulfated glycosaminoglycan'. They market this as an arthritis treatment, but it also can possibly be useful in situations where joint damage has occurred and the dog's body is in the process of repairing and maintaining the damaged joint. The injections are given twice a week for 4 weeks, intramuscularly. This is easy enough to do. You can probably do it yourself. You do need a prescription to get Adequan in the United States, but if your vet is a reasonable person he will give you the prescription. Before asking him, figure out how much you need and research the different on-line vet medication supply dealers for price.

---- Horse people use a lot of Adequan so the horse-focused suppliers are likely to have it and be competing with each other on price.

There are three different Adequan products:

-- Equine, for horses;

-- Canine, for dogs;

-- and a special type intended to be injected directly into the joint. You don't want that one.

You want one which is injected intramuscularly. I believe the only difference between equine & canine Adequan is that the canine has a small amount of preservative added to it since the whole vial will probably not be used at once. Adequan comes in a 2-pack of 5mL vials. At the time of this writing, this series of injections, done at home, would cost around $100 total for the 8 injections for a 62 pound dog (.02mL per pound per injection, Fido = 62 lbs, so 1.24mL per injection times 8 equals 9.92 mL, almost exactly 2 vials). When you find the best price on-line, call or go see your vet. Tell him you'd like to try a series of Adequan injections for Fido. The vet probably can't match the best on-line price, but I'd buy the Adequan from him if he would come close to the price I found on-line. If he can't get close enough to the on-line price, ask him to write you a prescription so you can get the Adequan on-line. A vet who is trying to maximize his own income may refuse to do this and insist that he needs you to come into his office for him to give the injections. This would be a red flag that you need to find another vet who will work with you to minimize your costs.

---- Cartrophen? Cartrophen is very similar to Adequan. Adequan is sold in the US. Cartrophen is sold in Australia, Canada, the UK, and other places. I like both Adequan and Cartrophen. However, there is a potential for confusion since the generic name of Rimadyl, a NSAID drug, is very close to the name Cartrophen. Rimadyl is Carprofen. Since Carprofen (Rimadyl) is also prescribed for joints, there is a risk of a misunderstanding. Except for short-term limited situations, I advise against the use of Carprofen (Rimadyl)for the reasons explained above under 'Pain Medication? Inflammation Reducing Medication?

Improvement Slows or Stops?

"My dog was slowly improving but after about 12 weeks he seems to be staying about the same for a couple of weeks now."

A dog may improve nicely for a few months, then have a period of time where improvement seems to slow or stop. If this is the case, first try reducing activity for a few weeks to see if you might have moved ahead too fast and need to cut back so that improvement can resume. If this reduced activity does result in improvement re-starting, then the previous level of activity was too-much-too-soon.

---- If reducing activity does not result in improvement, then you must choose between accepting the degree of improvement already attained as the best it is going to get, or having a conventional stabilizing surgery. This will be a difficult decision in many cases.

How Close To Full Pre-Injury Ability Is Achievable?

---- All dogs eventually reach a point in recovery where the joint is as good as it is going to get. Whether or not surgery is part of recovery, only a small proportion of dogs recover to near pre-injury capability. The joint, once damaged, is probably never going to be all that it was before the injury. On average probably about 85% of ability is recovered.

---- The best thing you can do for your dog after recovery is to avoid activities that cause limping or other symptoms which indicate the joint is being pressed beyond its limits. For example, perhaps pre-injury the dog could go for 10 mile hikes, but now he limps after 5 miles. You need to make walks less than 5 miles.

---- Avoid excessive activity or any high-stress activity which causes symptoms to resume, and give your dog plenty of joint support supplements glucosamine & chondroitin, and he will have the best possible joints for a long and active life.

---- Sometimes vets promote TPLOs by saying that after recovery from this surgery the dogs will be able to engage in high-stress sports without trouble. This is only TPLO sales-promotion talk. Dogs who have had TPLOs need to avoid high-stress activity. They are especially at risk for tibial tuberosity fracturing and should avoid any activity which involves impact stresses.

Re-Injury Months After Conventional Surgery Done With Nylon Monofilament Ortho Suture?

It sometimes happens that a dog who has had a conventional surgical stabilization (usually done with 80lb monofilament ortho-suture) will have symptoms recur after some months have passed and recovery has been going well.

---- It always happens that the monofilament will eventually stretch or break. How long this takes depends on the dog's size and activity. Usually before the ortho-suture fails the joint will have built-up sufficient new stabilizing scar tissue so that the loss of the stabilizing influence of the monofilament will not result in a big problem. If there is a recurrence of symptoms of stifle instability, the symptoms will usually not be severe since the joint now has new scar tissue support. But it doesn't have full support yet. Careful restriction begun when you see limping will give the joint the conditions it needs to further develop the tough fibrous scar tissue stabilization. This scar tissue development will happen slowly, over the course of several months. I would treat a re-injury which occurred months after surgery with careful restriction, just like a new injury.

---- However, in a minority of instances it is possible that a piece of the broken monofilament may intrude into a place where it causes trouble. If that happens it will need to be removed. Or the dog may not be able to successfully restore stability on his own for some reason. Then surgery may be needed. But certainly I would expect most dogs to do well without surgery after this kind of post-conventional-surgical-recovery renewal of symptoms. It would not be wise to rush to surgery before first trying 8 weeks of careful restriction.

---- Re-injuries can occur to dogs who have recovered non-surgically too. In all these situations the best first choice is restricting activity carefully just as you would for a new ligament injury.

---- Some vets want to sell TPLOs or TTAs to people whose dogs have had a re-injury after conventional surgery. I would be strongly opposed to either TPLO or TTA in most such cases. If your dog has this kind of problem, and it turns out that your dog cannot improve when carefully restricted, I would want a new surgery to be some form of the conventional LSS stabilization in most cases.

---- It could happen that the joint does not need stabilizing surgery but does need to have suture debris from the original surgery removed.

---- Dogs who have re-injuries are often dogs whose restriction wasn't maintained long enough or seriously enough.

How long is this recovery going to take?

---- Whatever the treatment method, remember that recovery from these ligament injuries is slow, and that months after recovery seems complete the stifle will still be vulnerable to re-injury from too much stress. Oftentimes vets who are trying to convince people that the surgery they are recommending is preferable will tell them that recovery is quick after the surgery. It is true that some weight-bearing is often seen more rapidly in the period just after TPLO or other surgery. But that is only the very beginning of recovery, not a long-term successful result.

---- A few years ago I interviewed roofing contractors about putting a new roof on my house. Several boasted that they would have the new roof on in a very short time. But what I wanted was the best roof, not the roof that went on the fastest. If TPLO surgery will have a dog bearing weight on the leg in the shortest time, is it therefore the best choice? No, because we want our dogs to have the best long-term recovery, not the fastest time to the first step in the recovery process.

That joint is going to be the weak link in the dog's leg's ability to handle stresses for a long time to come, whether or not surgery was part of his recovery. Return to normal activity should be accomplished very slowly and cautiously over a number of months.

Activities involving jumping and landing with twisting movement, such as catching things in the air, or other very high-stress-to-the-stifles activities, should be avoided forever, regardless of treatment option chosen.