The Best Treatment For Your Dog’s ACL Tear
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Is your dog limping on their back leg?
Have you just found out that they have damaged their cruciate ligament (or ACL) and are wondering what this means and the best treatment to give them?
On this episode of the Call The Vet Show, I talk with veterinarian Dr. Kristen Shaw, a specialist surgeon with a longtime interest in rehabilitation techniques, arthritis and cruciate disease, as well as the founder of Canine Arthritis Resources and Education (CARE), which provides evidence-based resources for vets and pet owners on how to treat arthritis in dogs.
Dr. Kristen and I discuss cruciate ligament disease, also known as an ACL tear, which is by far the most common orthopedic injury in dogs. There have been many developments in the treatment of ACL tears over the years, and Dr. Kristen gives some great expert advice on how you can help your dog recover.
We walked through what an ACL tear is and how they happen, plus a comprehensive run-through of all the different kinds of treatment available. We also discussed some alternative treatments for an ACL tear if surgery isn’t within your budget.
Listen out to learn how you can help your dog to recover from an ACL tear, how you can spot any warning signs of a returning ACL injury, and what to do to manage subsequent arthritis in your dog following this injury including the supplements you can give your dog to help them recover from ACL injuries and keep their joints as healthy as possible long-term.
This is a really detailed episode with a lot of expert knowledge on treating dog ACL tears, so be sure to listen carefully and share the episode with the other pet parents in your life.
[02:36] I invite special guest, Dr. Kristen Shaw, onto the show and she talks about her background in orthopedic surgery and rehabilitation
[04:38] What is an ACL injury and how does it happen?
[07:07] What are the treatment options for an ACL injury in dogs?
[10:01] Cheaper treatments for ACL injuries
[11:37] What’s the best kind of surgery to repair an ACL tear?
[14:34] How to help your dog heal after an ACL surgery
[16:51] Supplements to give dogs during their recovery time, and when to give them
[20:38] How to spot the early signs of an ACL injury return post-surgery
[22:13] Dr Kristen’s thoughts on using braces on dogs
[23:13] Where to go to find out more about Kristen and canine arthritis care
You have to really look at what that dog is doing, what their lifestyle is, and this holds true for any size dog.
If they’re a 30kg dog but they really don’t do much in their life, maybe surgery’s not right for them.
But if they’re a 10-kilo dog and they’re an agility dog or a little Papillon that’s doing agility, they’re still probably going to do better with surgery than with conservative rest
The Spectrum Of Orthopedic Disease
We’re going to dive into the world of cruciate ligament injury, surgery, treatment, and recovery but before we get into that, I’d be interested to hear about what brought you into this world of orthopedics of joint disease and of arthritis?
As a surgical resident, we get trained in both, what we call soft tissue surgery, which is general surgery, and orthopedics and I had a love for both. I did research on both sides but somewhere in my surgical training and my residency, I developed a particular interest in rehab, physiotherapy and that went along with the orthopedic side.
I will say that I spent several years actually doing primarily general surgery and then rehab on the side.
What really drove me to my passion for arthritis management and then the rehab and orthopedics that go along with it is caring for my own dogs with arthritis. I have probably learned more from them than I have from the hundreds and thousands of patients that I’ve taken care of.
It seems to be a common theme in people I speak to who are passionate about arthritis is it’s that their light bulb moment came when their own pet suffered from this really debilitating problem!
What Is Cruciate Ligament (ACL) Disease?
We’ll dive into the impact that arthritis can have no doubt later on, but talking about cruciate ligament disease, I guess we think of that as an ACL injury with people. What exactly does that entail?
Is it just one problem or is there a spectrum of issues that we’re dealing with?
That’s a great way to frame it. It really is a spectrum.
So just to go back to the basics, I usually do refer to it as ACL when I’m talking to pet owners as well. ACL in humans stands for anterior cruciate ligament. You may hear veterinarians say cranial cruciate ligament, it’s the same thing.
And to break it down, a ligament connects two bones together and in this case it’s connecting the femur or the thigh bone to the shin bone or the tibia and the job of a ligament is to prevent motion. It’s allowing a joint to move in just the right ways but not any more than that
In humans when we tear our ACL, it’s generally the result of some sort of trauma, so a skiing accident, usually some sort of acute injury that we tear that ACL.
In dogs, it’s quite different.
Partial Tear to Full Rupture
We consider it to be a spectrum of a degenerative process that the ligament is inherently or predisposed to starting to weaken and fray. If you think of that ligament like a braided rope, there are thousands of little fibers in there and they can start to fray.
Early on and when that happens, what we generally see is that you’ll see your dogs limp. But as veterinarians, we don’t necessarily appreciate any instability there or any extra motion in the knee
Over time that ligament continues to weaken and continues to fray and eventually it will completely rupture and then we can have the development of arthritis and we can have tearing of other structures in joints such as the meniscus.
The Injury Affects Both Knees
And the problem is that because it’s this gradual process and there is a predisposition of certain individuals that when one cruciate ligament breaks, there’s a reasonable chance that the other knee is also going to be affected.
Statistically, we say 50% but I feel like it’s more than that. I feel like more than 50% of the dogs that I see come back to see me for the other side but that’s a general reference.
Yeah, it may be that the other one isn’t quite so bad and frayed and maybe isn’t appreciated as being a problem when actually there is an issue there.
The Options For Treating ACL Tears
So it’s a pretty common injury that I see a lot in general practice and is seen across the world. But there’s quite a lot of confusion I think, among vets as well as owners, as to which the best treatment option is.
We’ve got our conservative management, we’ve got our surgery, there are all kinds of different surgery which have all kinds of acronyms so it can get pretty confusing especially as the costs can be fairly significant.
So what are our general treatment options for this disease?
There is the spectrum of options. Conservative management, which can include physiotherapy, rest, pain management, braces and then there’s surgery.
I’ll just share with you my experience in somewhat evolution in my approach to cruciate disease because when I finished my surgical residency and I was gung-ho about physiotherapy and rehab.
I was like, “I’m going to put orthopedic surgeons out of business.” We’re just going to rehab these guys, especially the early ones, the ones that didn’t have a lot of instability in that knee.
And so I spent many, many years treating patients with physiotherapy, a couple of them with braces, and we’ll come back to braces later, and ultimately we never knew when to say, “You’re good to go back and run around at the dog park.”
We never had that checkmark, even though it felt like it, and the couple of success cases that we had ultimately went on to tear their ligament years later.
At the same time, as my confidence grew as a surgeon and I realized that, “Hey, I can do a surgery pretty well.” This dog’s back to running around at the dog park three or four months later and the degree of arthritis is usually less if we intervene with surgery earlier.
Since, my approach has been surgery first and that I consider cruciate disease a surgical condition unless there’s a really strong reason not to do it.
I completely agree and we’ve been through an evolution as well. We used to just put a lateral suture in and that was the only option and something I was comfortable doing. Now we’ve moved to these osteotomies, which I’m not performing but I’ve seen a huge improvement in recovery as well as the end result.
Conservative Rest and Rehab
Yeah, absolutely I consider the result far superior to our rest and conservative management. I guess we think of traditionally the statistics being, I can’t remember what they were exactly, but it was dogs less than 15 kilos did reasonably well with rest. But I’m not sure that’s necessarily the case.
You have to really look at what that dog is doing, what their lifestyle is and this holds true for any size dog.
If they’re a 30kg dog but they really don’t do much in their life, maybe surgery’s not right for them but if it’s a 10 kilo dog and they’re an agility dog, or a little Papillon that’s doing agility, they’re still probably going to do better with surgery than with conservative rest
It’s more about the individual dog and not necessarily that size.
We’ll jump into the surgical options in a bit, but for those people who just really can’t afford surgery, because there is that financial barrier, what would the ideal conservative management plan look like?
Does it involve braces? Is it physiotherapy? If you can get that, hydrotherapy? What’s the ideal there?
I think it’s really important and I always talk about this with my surgical clients, that surgery is elective. This is not a life-saving surgery and so it’s important to understand what happens if you don’t do surgery.
There was a really nice paper that came out that showed 60% of dogs not having surgery had a reasonable recovery.
For those 60% of dogs, what the recommendation is, is first and foremost pain management. Because it is considered to be a painful condition, especially once arthritis sets in.
And then second equally important is weight loss or weight management. So dogs that are overweight are more likely to tear their cruciate in the first place, and having them lose weight can help them in that recovery process.
Then after you’ve done those two things, physiotherapy can be helpful for sure, but it’s really about a waiting game. It’s waiting for that body to scar down the knee and stabilize it on its own just like a dog would do if they lived on the streets and never got to see a veterinarian.
So for surgery, we’ve got a lateral suture, which is probably not being performed very much. Maybe in smaller dogs it’s still something that’s done more often. But now we’ve got lots of different osteotomy procedures where the bones are being cut and the angles within the joint are being modified.
But there’s a number of different techniques here.
Is there a better surgical technique? Is there something that’s definitely worth the top dollar, or is it too much of a compromise to be going for a lesser surgery?
So when we look at the two different types of surgery, the lateral suture type, the aim is to try and replicate what that ligament’s doing in the first place.
But the reality is when we put that lateral suture in, we don’t expect it to last forever. It’s going to weaken, it’s going to tear. And so what we’re trying to do is actually just speed up the body’s natural scarring down process.
TTA and TPLO
Versus when you do an osteotomy, and an osteotomy means to cut the bone, you can cut the bone in a whole lot of different ways. And once you cut that bone and you reposition it the goal of repositioning it is to change the forces and the biomechanics that work on that joint so that you don’t even need that ACL in the first place.
The beauty of working with bone is that once that bone heals it’s as strong as it was before you cut it. So once that healing occurs you don’t ever have to worry about that weakening.
To answer the question, is there a best osteotomy? What most surgeons will say is the best osteotomy is the one that, that individual surgeon is most comfortable with.
In my hands, it’s certainly a TPLO. I was trained with TTAs also but at this point in my career, I’m going to say TPLO is the best one. But there are other very reasonable options.
So in our clinic, the vet I work with, he’s doing a TTA. This is potentially a less technically demanding surgery, although there are more and more jigs available that make the different techniques a little bit easier in general practice.
And we’ve had some fantastic results with this procedure. And it’s really comparing night and day between a lateral suture, especially for these bigger dogs.
They’re weight-bearing really nicely the next day, almost sometimes without lameness which is just incredible.
When I was a surgical resident I had a dog, it had an amputated back leg and we had to do a surgery on the one knee it had. And actually I wound up doing a TTA for that dog and she got up the next day and was walking really, really well.
So surgical procedures do work well even when there’s not a lot of room for error!
The Recovery Period
Surgery isn’t the end of treatment though. I like to say that with any orthopedic surgery especially, the recovery period is 50% of the job. So what should that look like?
Although your dog may be walking really well, that can maybe trick us into letting them do more than they really should be.
The trick is to not let them do too much while the body is healing, especially if we’ve cut the bone and that bone needs eight to 12 weeks to heal back together.
Dogs are going to feel like they want to run around and jump and play and do all the normal things two or three weeks after surgery. If they do too much too soon all sorts of bad things can happen, ultimately leading to more surgery and potential infection.
What the recovery should look like is progressively increasing the controlled leash walks.
Adding physiotherapy in whether it’s underwater treadmill or swimming or other modalities, that can certainly be helpful and there’s some research to support it.
Really what physiotherapy is doing is speeding up that initial recovery. Two years later, we can’t tell the difference between dogs that had physiotherapy and dogs that didn’t, but for pet owners I find that it’s really helpful to help guide them through that recovery process if they have someone that’s really helping them more than the surgeon would be.
It’s maintaining muscle mass, because in that confinement they can become a little bit of a couch potato and potentially, like you say, we’ve got these bigger dogs that are often overweight in the first place so we should be hopefully be losing weight as well.
Whereas if you’re dog is stuck in a crate or a small room and not doing very much, then the weight can climb.
When I first started doing surgery, when I was a surgical resident, when we would finish an orthopedic surgery, we would say put your dog in a crate for two months. Take him outside on a leash to go to the bathroom, back inside and that’s it.
Thankfully we’re not doing that at all, we know we need to build up that muscle just in a controlled manner.
Then should we be starting on supplements or changing anything else with a view for the long term? Because we touched on it at the very beginning, a joint injury does predispose to arthritis and I think depending on the age of the dog, arthritis is pretty much a given in that joint.
What can we be doing to maximize joint health for as long as possible?
Given dogs that have an ACL injury a hundred percent of the time will develop some degree of arthritis, being proactive is vital.
We can keep harping on it, but weight management is the most important thing.
Omega-3 fatty acid, so fish oil, that’s my favorite supplement or my first line of supplements that I’m going to use.
Then I know there’s a lot of difference between supplements in different countries. The next one that I reach for is actually an injectable type of supplement. It’s a polysulfated glycosaminoglycan called Adequan. Another version is Cartrophen. And that would be my next line of supplement.
For Adequan, the regiment is twice a week for four weeks and then usually a once a month continuation there after.
Then there are all the other oral supplements. I think right now the one’s getting a lot of play and I’m curious to hear what your thoughts on is green-lipped mussel, which comes from your neck of the woods. It’s a huge industry in New Zealand.
I wonder how much of is just an Omega-3 fatty acid source, which is what we’ve got the best evidence of efficacy for, and whether there are a few other nice to haves.
The problem with the supplement industry is it almost seems like every week we get a new rep come in and say, “Look, we’ve got this, it’s got this proprietary chemical in it that is amazing and is wonderful.” And you go, “Well okay, well great, where are the studies?” And they go, “Well, here’s one from this one person or this one person’s done two papers.”
I have to say I’m a little bit skeptical in the sense that we know that the Omega-3 and the fish oil sources work or help. Because they’re not cheap either, a lot of these other supplements.
I couldn’t agree more. I would say when I give lectures anywhere or talk to veterinarians or pet owners, the number one question I get is what supplement do you recommend?
It is tough because I think if we as veterinarians don’t make a
recommendation for a supplement, most pet owners are going to go look for one that they saw an ad for on the Internet. So I do like to have something to recommend, but it is also having a discussion that, is it really financially worth it?
Yeah. So I mean, we’ve got Synovan EFA which is based on krill oil I believe, and I think there’s some green-lipped mussel in there as well.
And we also recommend Hills JD, the Joint Diet, which has got that all mixed in and good evidence of benefit.
One thing to touch on is we have a lot of flaxseed oil supplements as well and that’s something a lot of owners reach for because it is cost-effective. But in dogs it’s not particularly efficacious, is it?
Dogs don’t metabolize and process of flax seed oil the way that humans do. I take flaxseed oil, my dogs take fish oil and it really is worth investing a little bit more in the fish oil because it’s going to actually do its job.
It’s actually going to work, which is a big thing!
Keeping Watch For Problems
Into the future these dogs need monitoring for that other stifle, or knee joint becoming affected. Are there any telltale signs that the other cruciate is a problem?
Because some of the difficulty is that if they’ve got a bit of a sore knee in the one that we know is a problem, then they’re not necessarily going to manifest in the same way of carrying their leg as they did at the very beginning.
Some of the early signs would be, and pet owners may have noticed this for the first side, is the dogs don’t sit squarely. They sit off to the side.
Now, usually, if they’re recovering from a surgery on one knee, they’re still not going to sit squarely but monitoring that willingness to fully put that knee through normal range of motion. And one thing that a veterinarian can do is feel that knee and see if it is willing to go into full extension or fully straighten it.
If they’re not comfortable in that full extension or fully straight knee, that’s an early indication that that ligament is starting to fray and it’s starting to be abnormal and I would see this pretty frequently as dogs would be recovering from their first surgery. All of a sudden the clients notice that the other leg is not as good and they’re just off, just a little bit limpy on it.
And it’s always very difficult then, because when you spend several thousand dollars on one surgery, and even if you know that there’s the risk, you’d like to have a little bit of time to save up the money for the next one.
Do Braces Work?
I will say one point about braces because I do get asked about it frequently.
In my hands and my experience, I don’t recommend braces. Because if you’re going to use them they’re best to be custom made and, at least in the States, the custom made ones are going to run to a couple of thousand dollars. Even then they will inevitably cause rub sores and so then you’re dealing with irritation to the skin.
I’ve been able to be just as successful without a brace and a non-surgical management approach than with a brace, so that’s just my personal take on it.
The ones that you get for a hundred bucks are really not worth the cost of postage. And if you’re spending that kind of money on a decent brace then why not spend it on surgery. Because also that brace is going to be molded to the one side and not the other side when that also becomes affected.
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Breezing (relatively speaking) Through Nightmare of ACL Repair
My majestically athletic, exuberant Weimaraner Maisie made it all the way to age six before she tore her ACL ligament in May. I had been living in absolute dread of it tearing for months before it happened. I was doing everything I could to protect her sore knee — weekly acupuncture, bi-monthly chiropractic adjustments, TRP-Tri-COX joint supplement, Platinum Performance supplement, cold laser, and ElleVet Sciences CBD oil.
But she was an unstoppable force of nature when she revved her engines and — as an expression of pure joy at being alive and pleasure in the power and speed of her own body — she would take off in big, looping figure-of-eight circles at 25 miles an hour. She used her favorite humans as the center point of the circle, just barely grazing your leg as she whizzed past and changed direction to the next circle. (By the way, Healthy Paws pet insurance paid 90% of nearly every single one of those treatment modalities, including the MRI of her spine which was done early and x-rays of her leg. We’re talking close to $9,000 before her ACl even tore). [PLEASE get pet insurance for your pets, I beg you once again.]
Inevitably, her knee defied my efforts and two months ago, as I was gardening, she took off on her high-speed circles and her knee gave way. Suddenly, she had only three usable legs.
I was horrified by the prospect of the ACL surgical repair, which i have been through with more dogs than I care to count. The bone is cut, a lot of metal hardware is screwed into it, and the dog has a swollen leg too painful to step on for weeks and weeks, needing support just to stand and go out and relieve himself. With almost total house arrest for two months, except for bathroom breaks, eventually the leg heals and the dog is left with an “okay” knee joint after a total of 4 months recuperation. In 50% of cases, the dog’s other ACL tears, but I’ve always wondered if it was because of the additional stress and strain on it of supporting all the weigh for so many months?
However, happiest of happy news: we had a different and much, much better outcome this time. Maisie began putting weight on that leg within 10 days, “toe-touching.” Within two weeks she was carefully walking on it. I had to visit Dr. Bo Bergman at West Mountain Vet Hospital because part of the incision wasn’t healing, and he was really surprised she was putting any weight on the leg at all. On an extendable leash I walked her increasing amounts each day because she could, and wanted to — which is not common practice, as vets usually insist on pretty much crating/caging the patient for nearly the full 8 weeks post-surgery. I decided to let common sense by my guide and let her tell me how much she could comfortably do, while keeping her muscles strong.
At four weeks post-surgery I stopped the pain medication she had also been getting. She kept on walking and trotting on the leash and was not lame or limping at all. I believe this remarkable recovery had to be due to the ElleVet CBD oil. What else was different from the other five ACL surgeries I’ve lived through with previous dogs? The surgery has not changed in decades — although each year I have kept interviewing Dr. Rob Hart at the Animal Medical Center in New York City HERE, and HERE, hoping there would be a less invasive and easier-to-recover-from repair of the ACL, but it hasn’t happened.
I am giving credit for Maisie’s brilliant recovery to the large dose of CBD oil from ElleVet Sciences she’s gotten at both meals from the moment she tore the knee. I’d had her on the maintenance dose of a few drops per meal when her knee was just sore, but I learned from ElleVet Sciences (which is a sponsor of DOG TALK) that there was a new clinical trial studying pain management post-ACL surgery in dogs. I learned what that dose was and immediately put Maisie on it. My vet, who has just begun trying that CBD oil on patients, said they hoped Maisie would be their “poster dog” to convince themselves — not just owners — of how useful it could be to their senior arthritic or post-surgical dogs. At the 8-week post-op x-ray visit yesterday, my vet, Linda Morris at West Mountain Animal Hospital, was amazed at how much Maisie was using all four of her legs. “So she’s The Dog you can use as proof that CBD works!” I said.
I sure don’t wish this problem on any dog, but ACL tears are so common that I really hope if it happens to you that you will ask your vet to get you this CBD oil made and measured just for pets.
We’ll be off and running before long now!
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