Non-Surgical Treatment

In most cases of canine ACL / CCL ligament injury, careful activity restriction will provide the conditions needed to restore stability to the injured joint. This will result in the best possible recovery in most cases. Ligament injuries are 'sprains' by definition. Just as in humans, some severe ligament injuries in dogs require surgical intervention, but most do not. Unneeded surgeries which will not improve outcome are often done on dogs. These surgeries increase the risk of surgical complications and poor outcomes as well as increasing cost to the dogs' people.

Ligaments are not re-grown by the body when they rupture. When a ligament injury causes looseness in the stifle, the dog's body builds tough fibrous scar tissue which will provide support for the stifle joint. This is a natural healing process. Before the injury, the ligaments helped hold the bones in place at the joint while allowing proper movement. After the injury, with the ligaments not performing this function any longer, a dog's body will build-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 stabilizes the stifle in the future whether or not surgery is done. Conventional surgery can provide temporary stability enhancement, but ultimately it is this new supporting-tissue which provides stability in recovered stifle joints. I emphasize this because it is an aspect of recovery that is often not made plain by vets who recommend immediate surgery. It is common for vets to give people the impression that the surgically installed ortho-suture strands used to temporarily stabilize the stifle become a permanent replacement for the torn ligaments. This is not true.

See 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. Continuing improvement in symptoms indicates that the dog's body is building up new supporting tissue as stabilization for the joint. When a dog cannot begin to improve in 8 weeks, and show slow ongoing improvement, then either a brace (see the FAQ page here for more on braces) or a conventional stabilization surgery is probably appropriate.

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 improving by the end of 8 weeks, he will almost certainly continue to improve in the following months as you carefully & gradually increase activity. Eight weeks is not the total time of restriction. Recovery is not complete in eight weeks. Recovery from joint injuries is very slow. Even many vets who recommend non-surgical recovery fail to appreciate how slow, and tell people to resume normal activity after 8 weeks or 12 weeks. This will often 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 how long that will take. Be patient.

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.

---- Inside the house, 'Proper Restriction' does not necessarily mean crating. 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 get an ex-pen and set it up where the family spends time in the house. Ex-pens are covered in more detail on the FAQ page here at this website. An ex-pen is large enough to allow the dog to move around freely a few steps, and be comfortable, but not big enough to allow running, jumping, etc. Some very high-energy dogs are going to need a more secure confinement and will need to be crated or caged. Remember that we are not aiming for immobilization. It is good for the dog to flex the joint and move around gently. But you must impose whatever degree of restriction is needed to prevent all running, jumping, and other high-stress-to-the-stifle activity.

Pain Medication 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. 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 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 the dog 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 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 the dog 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 in a few 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 symptoms 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.

As 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.

Very many dogs with ligament injuries recover well with this method. They do not require surgery to recover. Nor is their recovery or future joint condition improved by surgery.

Less Severe Injuries--

With less severe injuries which have only mild symptoms it is not necessary to begin by restricting to a bare minimum of activity. But you should still prevent all running, jumping, and any other high-stress activities, and have only relatively short leashed walks.

Be Watchful!

Any activity which causes or increases limping or increases after-rest stiffness is excessive. When dogs first arise from resting, they will always be stiff and will 'loosen up' over a few minutes. If that after-rest stiffness is worse after Fido's nap today than it was previously, it is a warning to you that activity may have been increased too-much-too-soon. If a walk is too long, you probably will not see increased symptoms during Fido's walk. Don't assume that if Fido's symptoms aren't worse during the walk then the walk length is OK.

---- If you are seeing slow improvement when you look back weeks & months, the recovery is going fine. If you don't see slow gradual improvement, the first question to ask yourself should be "Has Fido's activity been sufficiently reduced?". In this situation you can significantly further reduce activity to see if that causes a reduction in lameness or other symptoms. If reduction in activity results in improvement, this shows that the former level of activity was too-much-too-soon.

Be cautious about activity!

When you see improvement during the 8 weeks after beginning restriction, you will know that the dog has begun re-stabilizing the joint. Then, with that improvement as a foundation, you can begin to gradually increase activity. Always increasing slowly and cautiously as described above.

---- Many dogs with less severe injuries have a special kind of disadvantage because the milder nature of their symptoms causes their people to be less concerned with the problem and allow too much activity, or to restrict for a short time but then remove all restriction as soon as the symptoms improve. This can easily result in repeated re-injuries and damage to the joint.

As recovery proceeds with either a severe or milder injury, sometimes people see that their dog is much improved and decide that the dog must be nearly completely recovered. They then increase activity too rapidly or even end all restriction abruptly. But increasing activity too quickly can result in a serious re-injury and a return to the beginning of recovery. This is the most common error people make with these recoveries.

The tough fibrous joint-supporting scar tissue takes months to build-up sufficient strength so that the joint is secure from re-injury. During this recovery period, while the new support is incomplete, the joint continues to be vulnerable to damage by excessive stresses.

Different activities cause different stresses on a dog's joints. Running is more stressful on the stifle than walking, for instance. With the ligaments ruptured, actions which put too much stress on the joint overwhelm the weakened resistance of the stifle to improper movement. Some activities should be avoided altogether and other less-stressful activities moderated. Running and jumping put too much stress on the stifles and can damage the newly-forming supporting tissue, so these activities must be avoided. Swimming or walking calmly for short distances are appropriate activities because they stress the stifle much less.

---- Small amounts of gentle activity are appropriate, but all forms of excess 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 buttressing. This is why longer periods of gentle activity are not appropriate.

---- However, shorter periods of gentle activity are helpful for the recovery. Joint movement cyclically compresses then releases the meniscus, pumping nutrient-bearing synovial fluid around inside the joint capsule. Moderate gentle activity also minimizes overall muscle atrophy from inactivity and encourages proper scar tissue development. 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. 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.

-- 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.

It can be difficult to decide 'How much activity is right?' during these recoveries. You should manage your dog's activity during his recovery based on the principle of avoiding all symptom-generating or symptom-increasing excessive stresses while allowing gradual increases in non-excessively stressful activity. Don't rely on any hard-and-fast schedule. Your judgments should be made based on observing the dog's symptoms & changes in his symptoms. Don't allow 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 is possible. If you see improvement over time, you 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. Walking on a soft surface is preferable to pavement. Grass or other soft surfaces put less impact-stress on 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 on which every step is identical to the previous step. 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' page)

---- 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 sometimes it is.

---- Are you considering another exam of 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. I get emails regularly 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.

Physical Therapy?

Physical Therapy (PT) is not a necessity for recovery but can be helpful if done properly. There are some great canine physical therapists, but some therapists push dogs to do more than they should. Joint injuries require a very gentle approach from a physical therapist. 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 symptoms afterward.

---- You can do Range Of Motion exercises at home with your dog. ROM consists of having the dog lay on his side relaxed while you gently flex the joint through its normal range of movement. Don't force. Only gentle movements which are not painful and which the dog accepts.

The best therapy is swimming. Swimming is great for injured joints! Swimming as therapy is covered further on the 'Frequently Asked Questions' page. 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 high on Fido's body. We want the water as deep as it can be with his feet on the bottom. 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, possibly requiring much longer periods for re-stabilization. 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 large older dogs could require restriction for as much as a year. By cautiously & watchfully handling decisions about your dog's activity you will eventually attain the best possible recovery. Don't 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.