Canine Ligament Injury Diagnosis & Treatment

Diagnosis --The ligaments cannot be seen on x-rays. X-rays can be a useful diagnostic tool to eliminate the possibility that there are other non-ligament injuries such as a broken bone, but they do not show ligaments. Ligaments could be seen using MRI, but this is of limited usefulness, expensive, and usually not readily available. When the leg is examined by manipulation, damaged ligaments can be inferred by what is called 'drawer movement' at the stifle. It's called 'drawer movement' because the lower leg bone can be moved against the upper leg bone at the joint in a sliding movement like a drawer in a cabinet. This 'drawer movement' is the most reliable indicator that the ligaments are not holding the stifle properly. But it should be remembered that some dogs just naturally have looser stifle joints than others, and all puppies have loose stifle joints which may seem excessively loose, possibly up until as old as age 18 months. It does sometimes happen that 'drawer movement' is not present (or not clearly present) but a vet will diagnose the problem as a ligament injury anyway because ligament injuries are very common and he sees no other cause for the dog's symptoms.

Misdiagnosis-- Misdiagnosis is common. Dogs with a muscle injury or some other reason for their symptoms may be misdiagnosed as having ligament injuries and their people told ligament surgery is necessary. Dogs with tick-borne diseases may limp and be misdiagnosed as having ligament injuries. Paw injuries, bone cancers, and a host of other actual reasons for the dogs' symptoms have been overlooked and the dogs subjected to inappropriate surgery for a ligament injury they didn't have. Vets prefer to present themselves as confident and assured to their clients. They may claim to be quite certain about the exact nature of the injury even when their diagnosis is really guesswork. The possibility of misdiagnosis should be kept in mind when considering treatment options.

A Too-Rough Exam Can Do Further Damage -- Some vets are overly rough in their manipulation when examining the leg. I hear from people who watched a vet tugging and twisting their dogs' legs and then had the dogs come home limping much worse than before and in increased pain because of the roughness of the vets' examination. And I hear from people who left their dogs alone at the vets' for exams and when the dog came home his condition was much worse. Never let your dog be examined without being present yourself to stop the vet if it looks like he's being too rough with the dog's leg. There is no need for that degree of pressure and twisting to be used in the exam. Don't hesitate to stop a vet who is being too rough. Too much pressure can crush the vulnerable meniscus and damage other joint components in an already unstable stifle. If drawer movement cannot be felt with simple gentle manipulation, don't let a vet risk damaging the joint further in an excessively forceful examination.

Sometimes a vet wants to sedate a dog to manipulate the injured leg. The vet's reasoning is that the conscious dog may be tensing the leg muscles and preventing drawer movement from being apparent. When sedated the dog will not be able to tense the muscles, so the vet will be able to more easily elicit 'drawer' movement if the stifle is unstable.

---- I would not allow a sedated exam on my dog.

Here's why:

-- An unconscious dog will be even more at risk of being further injured by manipulation of the joint.

-- Even if the vet uses only gentle pressure in checking for 'drawer' movement, there is still risk involved in any use of anesthesia.

-- A sedated exam may yield a better understanding of the exact nature of the injury, but what is to be gained in terms of improved treatment? Once it has been determined that there are no broken bones, I would choose careful restriction of activity as the appropriate next step whether or not 'drawer' movement could be elicited.* It makes good sense to avoid diagnostic procedures which have risk in themselves but would not alter treatment decisions.

* Many different kinds of injuries respond well to restricting activity and giving the body time to heal & recover. If careful activity restriction does not result in improvement, then a sedated manipulation could be appropriate at a later date in order to determine the exact nature of the problem.

Restoring stability to the stifle joint is the goal of both conventional surgery and of non-surgical treatment.

TPLO and TTA surgeries use a different strategy. These bone-altering surgeries change the geometry of the stifle rather than restore stability to the joint.

If you are considering TPLO or TTA, please read the 'TPLO / TTA' page here at this website.

LINK=TPLO --Very Seldom A Good Choice

'Conservative Management' of Ligament Rupture

Non-surgical 'Conservatively Managed' recovery from ligament injury is based on restricting the dog's activities so as to avoid re-injury from excessive stresses to the joint while the dog's body restores stability. 'Conservative Treatment' or 'Conservative Management' are terms used by doctors to refer to non-surgical treatment of any injury. Preventing excessive stresses while the body builds new support for the joint is the basis of a 'Conservatively Managed' recovery from ligament injury.

---- Ligaments are not re-grown by the body when they rupture. When a ligament injury causes looseness in the stifle, the dog's body begins building 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, the 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. Except in very rare instances, none of the surgeries repair or replace the ligaments permanently. 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 leave people with 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 Ligament Surgery' for more detail.

LINK= Conventional Surgery / 'TightRope'

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, a conventional stabilization surgery is probably appropriate.

Beginning Restriction of Activity--

In general, when dogs are seriously disabled by a ligament injury you should restrict their activity to a minimum when first beginning recovery. Only the necessary trips out every few hours to empty bladder & bowel. Proper restriction does not necessarily mean crating. You know your dog best and are the best person to decide on the method of restriction. When a dog would be over-stressing the injured leg if not prevented from freely moving around, my first choice would be 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.

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, over the course of weeks. Be patient. Once you see improvement you can begin to 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 time, 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 it is not necessary to begin by restricting to a bare minimum of activity. But you should still prevent all running, jumping, and have only short leashed walks. Any activity which causes or increases limping or other symptoms is doing harm to the joint. 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 new 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 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 greatly 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 in the blue-font surgery section below, 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.

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 as therapy is covered further on the 'Frequently Asked Questions' page. Link= FAQ

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.

What is the Purpose of Surgery?

When is Surgery Appropriate?

With the ligament no longer doing its part in holding the stifle together, the joint is unstable. After the injury, the dog's body will try to begin to re-stabilize the injured joint. If the proper conditions are provided, most dogs will slowly build up new tough, fibrous scar-tissue support at the stifle which will re-stabilize the joint. But sometimes the dog cannot manage to start to re-stabilize the joint even when carefully restricted. Then surgical intervention is appropriate.

---- People are often told that "Large dogs require surgery" or "If the vet says there is a complete rupture rather than a partial tear then surgery is necessary." Don't believe it! Such statements are gross oversimplifications of a complex situation. I hear about many very large dogs who recover well without surgery, including those with complete ligament ruptures. These seriously disabled very large dogs who recover well without surgery disprove surgery-advocates' claims that dogs-over-so-many-pounds always require surgery or dogs-diagnosed-with-complete-ligament-tears always require surgery.

---- Since surgery for these injuries is greatly over-recommended by vets, it is not wise for you to make decisions about your dog's treatment based on trusting in a vet's advice. The question to ask yourself should not be: "What does the surgeon say Fido needs?" nor "How big is Fido?" nor "Does the vet say the ligament is completely ruptured?"

---- Many people take their dogs in for exams and are told by vets that their dogs require surgery, but the truth is that No vet can examine a dog and know if the dog needs surgery to re-stabilize the injured joint. The information available to vets from x-rays and exams is not sufficient to indicate whether the dog can re-stabilize the joint without surgical intervention.

Then How Can It Be Determined Whether Surgery Is Necessary?

---- A problem people often face in deciding on their dogs' treatment is that many vets recommend surgery when surgery is not really a better choice than non-surgical recovery. Many vets recommend surgery be done on all dogs they believe may have ligament injuries. Others suggest a very short period of rest for a few weeks and then surgery if the symptoms have not resolved. These are not examples of sound medical advice. Many vets are not well informed on this subject. Other vets are primarily interested in selling high-profit services like surgery.

---- So, when a vet tells you "Surgery is required for your dog", how do you decide whether your dog really needs surgery?

---- The way to determine if a dog's stifle is able to recover without surgery is to restrict the dog's activity as described above in the 'Conservative Management' section. Giving non-surgical recovery a chance is almost always appropriate. Carefully restrict to prevent running, jumping, long walks, and other activities that over-stress the stifle joint. Be consistent with careful restriction and within 8 weeks the early stages of recovery should be apparent. If a dog cannot begin to improve in that time, the dog probably needs surgery unless there has been a misdiagnosis. If your dog does improve, as most do, continue with the restriction, supplements, and slow increases in activity as described above for 'Conservative Management'. Full recovery will take longer than 8 weeks, perhaps much longer. But noticeable, continuing gradual improvement during the first 8 weeks shows that the injured joint is slowly being re-stabilized by the dog's body. An inability to improve indicates surgery is probably appropriate. But remember that what you are looking for is improvement, not complete recovery in the first 8 weeks of restricted activity. If you can look back at week two from week eight and say "Fido is able to use the injured leg more than he could a week or two after the injury. He is still limping, but he is better than he was and slowly continuing to improve." then you have a dog who is re-stabilizing the joint.

Surgery Does Not Prevent Arthritic Changes---

---- Sometimes surgically-inclined vets will tell people that immediate surgery will prevent or minimize future arthritis, and without surgery dogs will be crippled by arthritis. This is not true. It is sales-talk promoting surgery rather than medical fact. The claim that surgery is superior in preventing or minimizing future arthritic risk is based on the false premise that dogs who do not have surgery will not have their activity restricted during their recovery. That they will run around continually re-injuring the joint so that it can never re-stabilize correctly. Obviously this is not the non-surgical recovery being advocated here. Activity must be properly restricted during recovery in order to minimize the risk of future arthritis. This is true for recovery involving surgical procedures as well as for non-surgical recoveries.

--- See this website's page "Arthritis Risk?" LINK= Arthritis Risk? )

---- All dogs who have recovered from serious ligament injuries, whether with or without surgery, are more likely to have arthritis in the future than are dogs who have not had a ligament injury. After recovery, the best way to minimize the risk of future arthritic problems is to avoid any activity which results in limping or other symptoms. After recovery it is usually true that near-normal activity is OK, but any activity which results in a dog having trouble with the leg should be stopped or moderated. Walks may need to be shorter. High-stress activities like jumping to catch a Frisbee should be avoided. Also, you should give your dog the joint-supporting supplements recommended on this website's 'Nutrition & Supplements' page for life, together with top quality food.

LINK= Nutrition and Supplements