Treatment and Prognosis for ACL (CCL) Injury in Dogs
Goals of Treating Canine CCL Injuries
When a dog suddenly comes up lame in one or both hind legs, its owner should take it to a veterinarian as soon as possible. Left untreated, damage to the stifle (knee) joint usually is progressively degenerative; any chance of reasonable recovery wanes without treatment. A dog that favors an injured leg for a long period of time also runs a significant risk of eventually damaging some part of its “good” leg, because it is being over-used. The goals of treating canine cruciate ligament (CCL) injuries are to relieve pain, improve stability and function of the stifle joint and minimize the progression of degenerative changes.
Dogs that injure their cranial cruciate ligament suddenly (acutely) should start medical management as soon as the injury is diagnosed. “Medical management” means treatment with medication and other sorts of supportive care. Conservative medical management of CCL injuries includes administration of non-steroidal anti-inflammatory drugs (NSAIDs), subcutaneous or intravenous fluids, rest, exercise restriction and possibly corticosteroid therapy. Steroids should not be given at the same time as NSAIDs, because severe gastrointestinal and other adverse side effects can occur when these two types of drugs are combined. Sometimes, medical management without surgery is all that is needed for small dogs, older dogs or dogs whose CCL is only stretched or partially torn. However, in most cases, surgical stabilization of the stifle joint is the only effective way to treat this injury and reduce the risk of future degenerative damage to the joint. Torn or ruptured cruciate ligaments will not re-attach or re-grow without surgical intervention.
There are a number of surgical options for stabilizing the stifle joint, and more are being developed all the time. Some of the current techniques include intra-articular grafts, extra-capsular suture stabilization, tibial plateau leveling osteotomy (TPLO), tibial tubercle advancement (TTA), arthroscopic reconstruction and medial meniscal release. A detailed description of these surgical techniques is beyond the scope of this article. A dog’s veterinarian is the best one to assess its injuries and select the best surgical procedure in any given case. Frequently, a general practitioner will consult with or refer the dog to a veterinary orthopedic specialist, because selection of the “best” surgical technique remains controversial even among experts.
After surgery, the dog normally will be managed medically with non-steroidal anti-inflammatory drugs, and possibly other drugs or supplements to promote healthy cartilage repair (these are called “chondroprotective agents”). A number of chondroprotective supplements are available, both over-the-counter and by veterinary prescription, to help keep cartilage and joints well-lubricated. These include polysulfated glycosaminoglycans, glucosamine, chondroitin sulfate, hyaluronan, Vitamin C, omega 3 and 6 fatty acids and MSM, among others. These can be quite effective in reducing inflammation and relieving pain.
In many cases, good dietary management and weight loss alone can dramatically reduce the pain and other symptoms that accompany CCL damage, as overweight dogs tend to suffer more from this injury than do fit dogs. Moderate, regulated exercise and/or exercise restriction can stimulate cartilage growth and help delay joint degeneration, and long controlled walks in early or mild cases of CCL damage may help prevent loss of rear muscle mass. Physical therapy, hydrotherapy (swimming and other water exercises), passive flexion and extension of the affected limb and controlled low-impact on-leash walks often are incorporated into the recovery process. It takes a long time – often months – for a dog to heal from CCL surgery. During much of that time, the dog should be strictly confined and only walked outside on a leash to potty.
Other, less traditional techniques that may or may not benefit affected dogs, in addition to medical treatment, might include: massage therapy to stimulate blood flow to the stifle area and reduce joint stress; application of acupuncture and/or acupressure techniques; use of herbal or other non-regulated supplements or homeopathic “remedies”; and other forms of supportive care that may help to ease pain, increase circulation, speed healing and otherwise promote wellness, relaxation and comfort. Some of these adjunct approaches lack controlled studies of their effectiveness and may not have established quality control methods or ways to assess their benefit to dogs with partially or totally torn or ruptured cranial cruciate ligaments. Chiropractic adjustment or manipulation of dogs with musculoskeletal conditions is highly controversial among veterinary professionals, unless it is performed by or under the direct supervision of a veterinarian with orthopedic expertise.
Dogs that undergo surgical correction of injured cruciate ligaments have a very good prognosis for return to long-term, pain-free function. Stabilization of the stifle joint, post-operative treatment with non-steroidal anti-inflammatory medications, and judicious rehabilitation typically result in rapid resolution of the pain that caused the lameness. If joint effusion (swelling) and discomfort persist, some dogs respond well to steroid therapy at immunosuppressive levels (but not at the same time as NSAIDs are being administered). Owners should know that following damage to the CCL in one leg, the other leg is at a greatly increased risk of suffering a similar injury – even if the first injury is surgically corrected. The contralateral (or “good”) limb is forced to bear an unusually large amount of additional weight, stress, wear and tear before surgery on the “bad” limb takes place, and also during the long recovery process, which typically takes months.