Recovery from ligament injury can usually be accomplished by restricting the dog's activity as described below. Minimizing
stresses on the joint by allowing only limited gentle activity avoids further injury and provides the dog's body the conditions
it needs to recover. Surgery is seldom appropriate. Unnecessary surgery is often recommended.
cases of canine ACL / CCL ligament injury, careful activity restriction will provide the conditions needed to restore
stability and normal functioning to the injured joint. Some severe ligament injuries in dogs require surgical
intervention, but the vast majority do not. Unneeded surgeries which will not improve outcome are often done on dogs. These
surgeries increase the risk of complications and poor outcomes as well as increasing costs.
When a ligament injury causes looseness in the stifle(the knee), if activity is carefully restricted the dog's body will slowly build
tough fibrous scar tissue which will provide support for the stifle joint. This is a natural healing process.
Before the injury, the ligament helped hold the bones in place at the joint while allowing proper movement.
After the injury, with the ligament not performing this function any longer, a dog's body will respond to the looseness at the joint by building-up this tough fibrous
new scar tissue to hold the bones of the leg at the stifle joint so that near-normal movement is possible while inappropriate
movement is largely prevented. This new supporting scar tissue is what permanently stabilizes the stifle in the future
whether or not surgery is done. Conventional surgery can provide temporary stability enhancement by installing strands of orthosuture (similar to fishing line), but ultimately
it is this tough fibrous scar tissue which provides permanent stability in recovered stifle joints. I emphasize
this because it is something that is often misrepresented by vets who recommend immediate surgery upon diagnosis. It is
common for these vets to call the orthosuture strands "Artificial Ligaments" and to give people the impression that the surgically installed ortho-suture strands become a permanent replacement for the torn ligaments. This is not true. The orthosuture always stretches or breaks within several months. The orthosuture strands' purpose is to help the joint get a start on re-stabilization. The orthosuture holds the bones temporarily while the scar tissue starts to develop. If the joint can begin to re-stabilize simply by restricting activity, there is no need for the orthosuture strands. No need for surgery. Most dogs will re-stabilize the joint without the aid of the orthosuture if their activity is carefully controlled. The installation of orthosuture as a temporary stabilization is unnecessary for them. If a vet tells you he will install an "Artificial Ligament" without explaining that this is a temporary stabilization while Fido's body is building permanent stabilization, he is trying to deceive you.
the page 'Conventional Stabilization Surgery' for more detail.
How Can You Tell If
Your Dog Can Re-Stabilize the Joint Without Surgery?
Carefully restricting activity for 8 weeks as described below acts as a diagnostic tool which will tell you whether
your dog needs surgery. If you see gradual improvement in symptoms begin within these 8 weeks, this indicates that the dog's body is building up tough fibrous scar
tissue as stabilization for the joint. When a dog cannot begin to improve in 8 weeks,
then either a brace or a conventional stabilization surgery is probably appropriate. (Please read the FAQ page section on braces before you order a brace. Sometimes people want so badly to help Fido in every possible way that as soon as they hear braces exist they rush to get a brace that Fido doesn't need and which might do harm. Please don't do that. Read about when braces are appropriate on the FAQ page. The FAQ page is linked in the column on the left side of all tiggerpoz website pages.)
The suggested 8 weeks is the time to wait (with proper restriction) before deciding whether the dog is
re-stabilizing the injured joint. If he is starting to improve by the end of 8 weeks, he will almost certainly continue to improve
in the following months as you carefully and gradually increase activity. ---- Eight weeks is not the total time
of restriction. Recovery is not complete in eight weeks. Recovery from joint injuries can be very
slow. Even vets who recommend non-surgical recovery may fail to appreciate that activity should be increased gradually and watchfully. They may tell people to resume normal
activity after some number of weeks. Abrupt increases in activity like that can easily result in re-injury. There is no certain length of time for
recovery. The time needed varies with the severity of the injury and the size and age of the dog. By increasing
activity gradually, watchfully, and cautiously, you will eventually come to the best possible recovery, but no one can know in advance
how long that will take. Cautiously lengthen walks and increase activity while watching for indications of trouble at the joint. Be patient. Some dogs will be back to near-normal levels of activity in a few months. Others will take longer. You should start out assuming the recovery will take months, and possibly more months after that.
---- Some who are reading this will be thinking "Months and months! The vet said just a few weeks restriction after surgery." Surgery is not really a quick fix. Vets may paint an unrealistic picture of post-op recovery. The re-stabilization and strengthening of the joint require a similar amount of time whether there is a conventional surgery done or a non-surgical recovery. A vet may have described to you the most optimistic view of recovery after the surgery he wants to sell you. The blunt truth is that with or without surgery, recovery is likely to be slow and if you try to increase activity too aggressively re-injury is likely. You need to be cautious about activity and have patience with or without surgery. Perhaps your dog will recover relatively quickly. Some do. But most recoveries are slower and require months.
Beginning Restriction of Activity--
In the earliest period of the recovery,
to begin restricted activity properly you should take only the necessary trips out every few hours on leash to empty bladder
& bowel. No walks longer than that, and no play which puts stresses on the joints.
'Proper Restriction' does not necessarily mean crating. We want to limit activity but do not want to immobilize the dog or the leg. You know your dog best
and are the best person to decide on the method of restriction. It will be fine to allow most dogs to move freely
inside the house when a person is there supervising. But if a very active dog would be over-stressing the
injured leg with running, jumping, or stair-climbing if free to roam the house unrestrained, then it would be best to restrict movement in the house with child gates at doorways or
get an ex-pen and set it up where the family spends time in the house. (Ex-pens are described in more detail on the
FAQ page here at this website.) Some very high-energy dogs are going to need a
more secure confinement and will need to be crated or caged. You must impose whatever degree of restriction
is needed to prevent all running, jumping, and other high-stress-to-the-stifle activity.
I must warn you that you are likely to be given bad advice by a loved one. Your dog himself is going to tell you he is recovered enough to be ready for longer walks and running and squirrel chasing and ball playing and other activity long before his recovering joint is really able to handle stresses. Dogs are much too optimistic about these things. Don't accept your dog's evaluation of what types and amounts of activity are OK. Much greater caution is needed about activity than your dog will believe is needed.
Don't Isolate Fido!
For dogs who are recovering from illness or injury, just like for people who are recovering, it is important for healing that a positive outlook be encouraged. Like most people, most dogs are social creatures and may become depressed if isolated. A despondent dog shut away in a back room is not going to do as well as he would with his family around him. If your dog is too energetic to be allowed to roam the house freely, use child-gates to block off doorways or an 'ex-pen' to restrict Fido's activity without isolating him away from his family.
is covered more extensively
on the FAQ page, but I want to mention here that while we all want to spare our dogs pain, the pain Fido feels when he uses
that injured joint to bear weight is nature's way of telling him to treat that joint gently while it is healing.
You are not
helping your dog if you medicate away his inclination to avoid putting pressure on that injured joint. When Fido's limp improves because he has been given a pain drug, this does not
indicate that the joint's condition has improved.
Pain-on-pressure is Fido's friend in helping him heal. Pain medication is appropriate in the first few days after
a traumatic injury to the joint in order to make it possible for Fido to rest comfortably. Please see the FAQ page for
more detail on pain & anti-inflammatory medication.
Proper activity restriction
provides the conditions the dog's body needs for new supporting scar tissue to be built-up at the joint, restoring stability.
As time goes on after you start the activity restriction, you will probably
see Fido start to use the leg a little bit, then a little more. This will begin sometime during the first 8 weeks.
Once you see this improvement beginning you can very slowly & cautiously increase activity.
Increase walk times and allow swimming if possible, but continue to avoid all running, jumping, and any other activity which
puts more stress on the joint.
---- Slowly and cautiously is the way to handle activity increases during recovery. As
you gradually increase activity over the months of recovery, observe Fido carefully during and after activity and later
after resting for any sign that the activity was excessive for the recovering stifle. Is there any indication that the
activity was too much? An increased limp? A decrease in use of the leg or an increase in stiffness after resting?
Other symptoms? No? Good! Then after several days you could increase a little bit more. On and on like
this until, over the course of a number of months, you come to the point where the best possible recovery has been achieved.
Be patient! Be cautious about activity!
Any increase in lameness or other symptoms during the recovery says: "Too much activity.
Too much too soon for that recovering stifle." Decrease activity sharply if you see an increase in symptoms.
Then, when the symptoms have improved, introduce increased activity more slowly. It
is important that the increases in activity be small. Increasing activity slowly and watching carefully for indications of
trouble will give you the ability to prevent a serious re-injury since you will see that activity is too much when it is just
a little bit too much.
During the recovery, when dogs first arise from resting you should expect them to be stiff and to
'loosen up' over a few minutes as they move around. If that after-rest stiffness is worse than it was
before his most recent activity increase, that is a warning to you that activity may have been increased too-much-too-soon.
Don't assume that if Fido's symptoms aren't
worse during the walk then the walk length is OK. Too long a walk or other excessive activity may not show up as an increase in symptoms until after rest.
are seeing gradual improvement when you look back weeks & months, the recovery is going fine.
the new supportive scar tissue develops over the months of recovery, the stifles become more and more capable of resisting
stress. They are less and less easily re-injured. Most dogs with ligament injuries recover well with this method. They do not require surgery to recover. Nor would their
recovery or future joint condition be improved by surgery. Don't let yourself become too concerned that the recovery is progressing slowly. Many thousands of dogs have had non-surgical recoveries and most of their recoveries were also slow. Be cautious and patient and the odds are very much in your favor for a fine recovery.
FIDO'S LIMP WILL BE GREATLY IMPROVED LONG BEFORE THE JOINT DEVELOPS THE CAPACITY TO RESIST NORMAL LEVELS OF STRESS. ACTIVITY INCREASES MUST BE GRADUALLY AND WATCHFULLY DONE EVEN AFTER FIDO APPEARS TO BE RECOVERED.
As recovery proceeds, sometimes people see that their dog is much improved and
assume that the dog must be almost completely recovered. They then increase activity too rapidly or even end
all restriction abruptly. But increasing activity too quickly can easily result in a re-injury. This is the most common error people make with these recoveries. The
tough fibrous joint-supporting scar tissue takes months to develop and firm. Limping will be improved while the joint continues to be vulnerable to damage
from excessive stresses.
of Gentle Activity Are Good For Fido's Recovery, But All Forms of Excessive Stresses Must Be Avoided Completely.
When a dog fails to
improve, the first question to ask yourself should be "Is Fido being properly restricted?" When
a dog with a ligament injury gets a little better, then worse, then better, then worse, this may be because Fido's people
are not restricting properly. The dog may be doing things that over-stress and repeatedly re-injure the joint.
Think of a fence surrounding a horse pasture. It is no good to have a fence that is 99% secure but has one opening the
horses can get through. It has to be 100% secure. Likewise, a dog's restriction to prevent excessive stresses
to the leg has to be complete. If a dog is kept from excesses all day & night except that for 15 seconds when the
mailman comes to the door the dog races around frantically barking and leaping, all the good done by the restriction may be
destroyed in those few seconds.
Activity can be excessive
in two ways:
1) -- Anything that puts a lot of pressure on the joint like running, jumping etc.
2) -- Also any low-stress activity
which goes on too long.
Here's why: The joint is held together by muscle and other joint components as well as the ligaments.
Different dogs have different muscular ability to hold the joint tight. This is why vets 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. But these muscles 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. Then the joint will be more easily subject to further injury of joint components
and damage to the developing scar tissue. This is why longer periods of gentle activity are not appropriate.
---- However, shorter periods of gentle activity are helpful for the recovery. Relatively short periods of gentle activity like 'Sniff-n-Stroll' walks* or swimming 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. Walks should be
quite short in the beginning while having a number of them daily, leaving time between for resting the recovering joint.
Here's an example of what I mean:
---- For a dog beginning
to improve from a severe stifle ligament injury, a four minute walk 5 times a day would be the same amount of walk-time per
day as a 20 minute walk once a day, but the 4 minute walks would be good, while the 20 minute walk could be harming the joint because the walk continues past the point in time where the muscular stabilization of the joint becomes exhausted. I'm not recommending that
specific schedule. It's an example to illustrate the point. Your dog's activity should be based on
your observations of his symptoms and changes in his symptoms. Don't have walks so long that there is an increase in symptoms during the walk, after the walk, or after
rest after the walk. You should always be cautious and do less than you think would be OK. If you see improvement
over time, you know that the recovery is progressing. 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. Walking on a soft surface is preferable
to pavement. Grass or other soft surfaces put less impact-stress on the joint 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 unyielding surface. *The ideal walk during recovery is what we call a 'Sniff-'N-Stroll' walk. A 'Sniff-'N-Stroll' walk is done at a park or other area where the surface Fido walks on is not pavement and there are sights and smells that are interesting to dogs. On-leash, Fido is allowed to walk at his own pace, meandering around wherever his interests take him and stopping to sniff and examine whatever he likes. Of course it will be necessary to insist that he stays away from some objects of interest. 'Sniff-N-Stroll' walks provide gentle exercise and relief from the boredom of restriction. Gentle use of the injured joint encourages development of the new fibrous scar tissue which stabilizes the joint. And low-stress activity is good for the recovery in other ways as well. Whenever the joint flexes the meniscus is compressed and then compression is released, pumping synovial fluid in and out of the meniscus. (see the page 'The Dog Meniscus' linked in the column to the left) This lubricates the joint surfaces as well as moving nutrients and oxygen in the joint capsule to where they are needed and removing carbon dioxide and metabolic wastes. So you see that in a number of ways gentle movement of the joint is desirable during the recovery. We don't want to immobilize the joint. But don't overdo activity! It is far more common for people to allow too much activity than to be too cautious. I can almost guarantee that your dog will want to do more than he should. He will tell you he is ready for longer walks and more activity long before he really is. Don't trust Fido to know how much activity is OK! This recovery requires 'tough love' from you, rather than 'indulgent love'. Your job is to be the one who limits activity to less than Fido thinks would be OK. These joint injuries have slow recoveries. Be cautious and patient.
Setbacks-- Sometimes a dog who is
recovering has a re-injury. This could be caused by doing too-much-too-soon, or by an accidental over-stressing of the joint.
Sometimes there is no cause that you can point to, but the dog's symptoms are suddenly worse. While these setbacks
cause concern, the dog will usually resume improving soon. When a dog has one of these setbacks, activity must be greatly
reduced. Then, after you see some improvement from the condition after the setback, slowly and cautiously resume gradual increases.
A setback could be minor or severe. Some dogs have several setbacks in the course of their recoveries. A setback occurence
does not mean surgery is necessary. An inability to improve, as described at this website on the 'When
Is Surgery Appropriate?' page, is not the same as a setback. After a severe setback re-injury, assume you
are back at the beginning of recovery and restrict accordingly. Sometimes recovery after a setback is relatively quick,
and other times it is like starting over from the beginning.
If a dog is re-injuring
the stifle repeatedly in spite of careful restriction, a brace could be appropriate. (See the brace section on the 'FAQ'
In the above section setbacks during non-surgical
recoveries are the subject. Re-injury after surgery may require additional surgery. If a post-conventional-surgery recovery
has gotten a good foothold on stabilization, and then the dog has a setback, it is usually reasonable to see how the
dog does by simply restricting activity rather than assuming another surgery must be needed. But be aware
that there may be debris from the surgical installion which could cause trouble in the joint. This is not usually a problem,
but occasionally it is. Restrict activity and see how the situation develops over the following weeks. If there is no improvement at all within several weeks or symptoms worsen, see your vet. Suddenly worsened condition after a bone-alteration (TPLO, TTO, TTA) is a situation requiring immediate intervention. If there is a sudden worsening of symptoms during recovery from one of the bone-altering surgeries TPLO, TTA, or TTO, see the ortho specialist immediately.
---- Are you considering having a vet re-examine your dog who is improving because you want to get a vet's
opinion of the progress of the recovery?
Don't do it! More manipulation of the joint is NOT a good idea.
Unless there are special circumstances I would not allow any more exams. Manipulation of the joint trying to elicit 'Drawer'
movement serves little or no purpose after the original diagnosis, and there is considerable risk to an improving dog that
the vet will damage the vulnerable partial re-stabilization. If Fido is improving, don't let anyone manipulate the
injured joint. We get many emails from people whose dogs were improving nicely until a vet manipulated the recovering
joint causing damage to the developing fibrous scar tissue and setting back the dog's recovery or worse. Please do not allow anyone to handle or manipulate your dog's leg in any way. No vets' exams. No handling of the leg by anyone.
Physical Therapy (PT) is not a necessity for recovery but
can be helpful if done properly. There are some good canine physical therapists, but some therapists push dogs to do
more than they should. Some physical therapists fail to properly distinguish between the appropriate PT for a dog with a joint injury as opposed to a muscle injury. Joint injuries require a gentle approach from a physical therapist. With a muscle injury, PT activity which exhausts muscle inspires the body to build more muscle. That's fine. But with a joint ligament injury the dog is depending on existing muscle to help with joint stability while the new stabilizing fibrous scar tissue slowly develops. If the muscle is exhausted by exercise the joint becomes loose and vulnerable to further injury. So while we want to have some moderate non-exhaustive exercise because movement of the joint is good for the recovery, and we want range of movement to be gently encouraged, treating the leg as though the primary goal is muscle-building is not good. Repeated 'Sit-Stands' and other supposedly helpful exercises which are often recommended are actually potentially harmful to the joint. Many therapists have either been improperly trained or have mistakenly transferred human post-op rehab techniques to dog ACL / CCL situations.
---- When the time comes for redevelopment of muscle-mass, this will happen as a natural consequence of the increased use which will follow re-stabilization of the joint. You couldn't stop it if you wanted to. Dogs with joint instability do NOT need you to force muscle-building activity. They need restoration of the stability of the joint and the gradual increase in the joint's resistance to de-stabilizing injury that will gradually develop. All that the recovery needs from you is careful control of activity which prevents excessive stresses. And patience. A dog will increase use of a stable leg without any special encouragement. Fido senses the recovered leg is dependably stable and increases his use of it.
---- If you want to use a therapist, talk with physical therapists before you hire them. If a physical therapist says her goal in working with your dog is to re-build muscle, she is the wrong physical therapist for your dog's joint injury recovery.
---- Physical Therapy is not a necessity for recovery, but if you want to
try using a professional physical therapist, always stay with your dog during a therapy session, and insist on gentle cautious
treatment. A session with a therapist should not result in increased lameness or other symptoms afterward.
---- It isn't necessary, but if you'd like to you can do 'Range Of Motion' PT at home with your
dog. ROM consists of having Fido lay on his side relaxed while you gently move the joint through its normal range
of movement. Don't force! Only gentle movements which are not painful and which the dog accepts.
What About Alternative Therapies?
Such as Acupuncture? Prolotherapy? Stemcell? Chiropractic Adjustments? Laser? Massage? Platelet Therapies? Etc etc?
People love their dogs and want to help their dogs recover, but this urge to be helpful can sometimes result in people doing things which are not helpful and may be harmful. Good intentions don't automatically bring good decisions. If you find yourself unsatisfied with just patiently and cautiously controlling activity for Fido, and feel an urge to take a more aggressive approach to Fido's recovery, you may be on the verge of making a mistake. Perhaps a big mistake. In considering treatments that are recommended to you, you need to bear in mind that vets are not saints who are only concerned with what is best for Fido. They are in the business of selling treatments. They need to have profits. This influences their view of treatment options. They are easily convinced that treatments which are profitable for them are good for their patients. There are many 'alternative' treatments for ligament injuries which are being sold by vets. Unsupportable claims are often made for these treatments. Over the course of the decades these treatment ideas come and go. Some of these alternative treatments are a waste of your money but harmless. Others may be harmful. A few may turn out to be useful when real research into their efficacy is eventually done, but that research has not happened yet for any of the alternative treatments that will be suggested to you. (By 'Real Research' I mean double-blinded Class I or II studies. A vet may tell you that research has been done but what he is pointing to are just subjective articles written by other docs who are also selling the same treatments.) The history of new treatment ideas in general is that very few turn out to be good ideas. New treatments are embraced enthusiastically by some docs and then time eventually shows that most of these ideas were ineffective or harmful. So at this point in time there is no solid reason to use these treatments, and plenty of reasons to be suspicious of them. When a vet tells you how wonderful the alternative treatment he recommends is, the vet's claims are salesman's-talk, not
objective advice from an expert.
---- In medical treatment for animals and people, there are instances of serious injury / illness for which there are no proven effective treatments and the prognosis for the patient is grim. In such situations it can be reasonable to try unproven treatments even though they have risks. But that is not
the kind of situation we have with Fido's stifle(knee) ligament injury. We have available a highly successful approach for Fido which does not
involve unproven treatments. Simply give Fido's body the gentle conditions and the time it needs and it will re-stabilize the joint. It is incorrect to believe there is a need to buy special treatments for Fido's recovery. Fido's body has thousands of generations of experience at dealing with these injuries and will successfully re-stabilize the joint without any of the alternative treatments. You may see claims from well-meaning dog owners who are sure that one of the alternative treatments healed their dog. These people are failing to give credit for Fido's recovery to the real hero of the recovery-- Fido's body. If a person was told to feed their dog peanut butter to recover, and did feed peanut butter, and the dog recovered, that person might be convinced that peanut butter heals ligament injuries and shout that from the housetops. But they would be wrong. Their dog recovered because all our bodies have an inherent ability to heal and recover from injury. There are ways we can assist in Fido's recovery-- proper activity control, top-quality food, joint-support supplements-- but it is the body which re-stabilizes the joint using the inherent abilities we all have to recover from injury. If you break an arm or leg bone we can put on a cast but we cannot cause the bone to heal. It is your body that knows how to heal broken bones. If you have a cut or a crush injury or a burn or sprain a joint, it is your body that knows how to heal, and will do so if the right conditions are provided. Doctors are just assisting your body in recovery. The body is the expert at healing. Fido's body has the ability to re-stabilize that injured joint. His body doesn't need acupuncture or prolotherapy or stemcell treatments or any other alternative treatments. It is the people selling those things who need Fido to have those treatments so they can make their boat payments.
The Best Therapy By Far Is Swimming! Swimming
is great for injured joints! Being able to move the leg in a way that provides gentle exercise and joint movement without weight-bearing is the reason swimming is so desirable. If your dog doesn't like to swim, a flotation vest may be a good idea. Flotation vests are helpful for poor swimmers and for older dogs who prefer less exertion. But be sure to get one meant for dogs to wear while swimming. There are flotation vests for dogs which are intended to simply keep a dog afloat if he falls off a boat. These are not good for swimming because they restrict leg movement. The 'Ruffwear K-9 Float Coat' is one example of a good flotation vest for a dog. There are several other brands which also allow full leg movement and provide well-distributed buoyancy. Another possibility for non-swimmers is wading in water that comes up high on Fido's body. For wading-as-therapy we want the water as deep
as Fido finds acceptable with his feet on the bottom. While he is wading in deep water 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,
deep wading like that is a good alternative to swimming.
How Long Does Recovery
Take? --- Some injuries are worse than others and require much longer periods for the best possible recovery.
And there are differences between individual dogs themselves that influence how much time is needed. Larger & older
dogs usually take longer. Some dogs recover well in a few months, while the most severe injuries in very large older dogs
could require restriction for as much as a year. By cautiously controlling your dog's
activity you will attain the best possible recovery, but it is not possible to plan on recovery taking some certain length of time.
Caution and patience are the keys to success.
'Conservative Treatment' or 'Conservative Management'
are terms used by doctors to refer to any non-surgical treatment.