We are not actually talking
two different approaches. I have survived two traditional repairs and one
with conservative management. The amount of time it takes to heal for both
approaches is exactly the same as it is dictated by the body, not
the surgery. There are two points I want to start with. First, when I started
in practice 20 years ago, it was the beginning of the move away from
rest and toward exercise, away from open chain exercises (leg lifts on the
bed,etc, where you isolate muscles and perform exercises non- weight bearing)
to close chain exercises (weight bearing, using groups of muscles
instead). Second, many doctors and vets are unaware of this transition and
still advocate rest when it is clearly contraindicated (and I will give
my reasons for the contraindications below). Remember that physical
therapists spend 4 to 6 years learning what most doctors and vets learn
in about a 6 week rotation...they are rehab specialists for a reason
and have a better understanding of these concepts than many doctors, not
including SOME orthopaedic surgeons who choose to stay on top of the field.
Ankle sprains used to be casted. Now they are not. Human cruciate
repairs used to be casted. Now they are not. Early weight bearing used
to be avoided. Now it is not.
The reasons for this are because we now understand that immobilization
of joints creates the following problems:
1. reduced range of motion 2. decreased afferent neural input 3. muscular atrophy 4. ligament shortening 5. reduction of water content, proteoglycans and glycosaminoglycans
(involved in the healing process) 6. bone loss 7. cartilage erosion (leading to arthritis) 8. reduced ligament weight 9. reduced ligament strength 10. adhesion formation which may restrict range of motion and create
pain at the end range (ie, sitting with their leg straight out in
extension) 11. increased ligament laxity (!) 12. joint stiffness related to synovial membrane adhesion.
The long-term detrimental effect on ligament-bone insertion sites is
irreversible and the effects of the above are normally noted between
4 months to 1 year after immobilization.
Now, ligaments can be surgically repaired or allowed to heal without surgery
and the necessary approach depends on the degree of injury and the involvement
of the supporting tissues as stated in my previous post. For those who don't
know, ligaments do not have terrific blood supply, so healing is normally
by way of scar tissue proliferation, rather than by true ligament
regeneration. Untreated ligament tears are biochemically inferior, possessing
a large proportion of collagen, and are not generally healed even after
40 weeks after injury. This is why we need to be proactive and use
more than rest to rehabilitate our dogs.
When deciding which approach to take, we must consider the severity
of the injury.
Grade 1: microscopic tearing of the ligament without producing
joint laxity (hardly ever appears in dogs as we fail to notice at this point)
Grade 2: Tearing of some ligament fibers with moderate laxity
Grade 3: Complete rupture of the ligament
Generally, grade 1 and 2 tears can be treated with appropriate exercise
to provide dynamic muscular support. Good to excellent results can
be seen in these injuries in 90% of cases.
Grade 3 or complete tears are GENERALLY more successful with surgical
repair but in relatively inactive individuals, a non surgical approach can
definitely be indicated. The other thing to consider is that grade 3 CCL
tears are very often associated with meniscal tears (the crescent shaped
cartilage inside the stifle) and untreated meniscal tears can and will
degenerate, break off, and cause articular damage which can result in greater
arthritic changes. Unfortunately, veterinary surgeons can not easily tell
if there is mensical damage without opening up the joint and this may be
one reason to consider surgical repair.
OK, so your dog hopefully has a partial tear and you are ready to embark
upon rehabilitation. I have already outlined that leaving him in his crate
is counter-productive. So what to do?
Well, let's outline the basic healing mechanisms and their timeframe.
Day 2 - 4
Collagen cells infiltrate the area. In this initial stage of scarring,
the tissue is very fragile and easily disrupted because of the unstable
collagen cells. Adhesion is by cellular attachments and stretching of the
scar easily causes tearing of the cells. Treatment during this stage
should consist of REST, ice, compression elevation, non weight bearing or
partial weight bearing AS TOLERATED. Limited range of motion exercises can
begin. We want to protect the ligaments from unwanted stress so a brace
is a very good idea at this point as it may protect the joint from end range
movement. We should also be doing contralateral limb exercises at this point.
Have the dog stand on his good leg for several seconds at a time,
for 10 or 20 repetitions. Why? Because working the contralateral limb actually
promotes healing and strengthening in the opposite affected limb.
Day 5 to 21
The scar increases in bulk. This is a very active stage of collagen synthesis
so it is very important that we do range of motion (ROM) exercises. If we
do not do ROM during this stage, the newly forming collagen will be short
and stiff and will be stressed at the end range of joint movement, making
it susceptible to further tearing. Treatment during this stage should focus
on continuing to protect the ligament but working toward progressive
weight bearing and this can be a challenge. During this stage, we work at
encouraging weight bearing with the exercises outlined in the rehab programs.
We have the dog take a treat from their unaffected hip, forcing them to
bear weight on their injured stifle. We progress toward putting a little
baggie on the unaffected limb as mention, to force a bit partial weight
bearing on the injured joint, then we begin slowly lifting the front legs
off the ground to encourage a greater amount of weight bearing, starting
for short periods of time and a small number of repetitions, increasing both
duration and repetitions each day. During this period, endurance-type exercises
are more effective in producing a better quality collagen in the joint, so
the type and duration of exercise is very important in determining how well
the ligament heals.
THIS IS WHY GETTING YOUR DOG OUT WALKING IS IMPORTANT!!!!!!
It is also important that we avoid activities and motions that will stress
the ligament such as jumping and twisting.
Walks during this stage should begin at three 5 minute walks per day and
progress to 15 minutes as tolerated (watch for limping or fatigue). Be certain
that the terrain is flat.
Day 21 - 60
The ligamentous scarring becomes well organized collagen and the tissue
gradually changes from cellular to a tougher fibrous composition. During this
stage, there will be a continuous decrease in the ability of the scar
to respond to treatment. Treatment during this stage is geared toward low-load
static stretching. Preheating the muscles will help to achieve a more
thorough stretch. We need to continue with the passive ROM exercises as well.
Walking our dogs over small jumps and obstacles (NOT high enough that they
have to jump, just lift will help build active range of motion as well.
Hydrotherapy is generally introduced in this stage. We also need to initiate
closed chain exercises to regain proprioception. These should start toward
the end of this phase and should include lifting the unaffected limb off
the ground, encoruaging full weight bearing. Walks during this stage should
15 to 20 minutes (watch for limping or fatigue). The last two weeks
of this stage should focus on walking on moderate inclines. From now on,
the brace should not be worn during exercises, but worn the rest of the day
and for walking.
Day 60 to 360
The collagen fibers begin to mature. During this stage, response to treatment
is poor. Remodeling and healing can take upward of a year to complete.
Treatment during this final stage consists of static stretching, switching
from ice to heat and increased efforts to restore proprioception and muscle
balance. In the early stages, we can have the dog stand on the affected
limb and begin gentle rocking to restore proprioception. We can walk our
dogs in more uneven terrain and continue with both uphill and sidehill walking.
We can begin to ask our dogs to lift from a sitting position to standing
on their hind legs as previously mentioned. We can also introduce small destination
jumps, ie, jumping onto small platforms and over small jumps. At this
point, the ligament has regained most of it's fuction and strength,
but resulting muscle imbalance and loss of proprioception, as previously
mentioned, MUST be restored in order to protect the joint and ligament from
shearing forces resulting from loss of stability and proprioception.
I hope that makes sense to everybody. Extracapsular repair is a form of
stabilization of the joint to protect it from lateral and rotational instability
until scar tissue forms. The same can be accomplished with a WELL FITTED brace
(although one must be careful here as most CCL braces are hinged so they
limited lateral movement but NOT rotation. But the moral of the story is
complete immobilization and inactivity are bad and well constructed, appropriate
exercises is good and must be started earlier rather than later to be effective!!!!!
Good luck with your dogs!
Dana
permission
to reprint this post from Orthodogs was given by Dana
Thank you
The above information is simply informational. It's intent is not
to replace the advice of a veterinarian nor to assist you in making a
diagnosis of your pet. Please consult with your own veterinarian for confirmation
of any diagnosis. Your pets life may depend on it.
