Treating Canine Ligament Injury Without Surgery
Diagnosis & Treatment of Canine Ligament Injury
Introduction | Diagnosis & Treatment | Surgical_Recommendation? | FAQ | The_Conventional_ Surgeries | TPLO / TTA | Arthritis_Risk? | Clicking?Popping? | Meniscus_Info | Nutrition_and_Supplements | Success_Stories | Human_Parallels? | "But_the_vet_said..." | Contact_Me

The nature of canine ligament injury and its diagnosis and treatment are the subjects of this page.  The focus here is on non-surgical treatment, since I believe that is the best first-choice option in most cases. How to decide if surgery is necessary is considered.  The different types of surgery are discussed in detail on other pages of this website. 

The joints involved in these ligament injuries are similar to the knees in people. In dogs and other quadrupeds these joints are called the 'Stifle'. Injuries to the ligaments of the stifle are common in dogs. These injuries can be sudden or develop slowly.  There may be months of intermittent mild lameness caused by gradual breakdown of the ligament. Or there may be a sudden complete rupture of the ligament brought on by some stressful activity which leaves the dog holding the leg up, unable to put weight on it at all.  

Before the ligaments are damaged the stifles(knees) have several things, including the ligaments, holding them together in such a way that the bones of the leg can move against each other properly while stability is maintained. After ligament injury the stifles are less securely held together. The ability of the stifles to resist improper movement is lessened. Not eliminated, but lessened.
 
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 an injury of a muscle or tendon 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 -- Sometimes vets are overly rough in examining the leg. I hear regularly 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 extreme manipulation 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. It is not all vets who are excessively rough when examining dogs' legs but I hear about this regularly enough that I always suggest to people that they never let their dogs be examined without being present themselves 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 injured 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. This is like smashing a watch to see inside trying to find out why it is running slow.
        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.
-- An unconscious dog will be even more at risk of being further injured by an overly rough manipulation.
-- If the vet is a good one who 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 is determined that there are no broken bones I would choose careful restriction of activity as the appropriate treatment 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.
        
Restoring Stability Is The Goal-- A dog with torn ligaments needs the injured stifle to be stable again so that the leg can be used normally and further joint damage prevented. Restoring stability is the goal of conventional surgery and non-surgical conservative treatment. TPLO and TTA are different in that they change the geometry of the stifle rather than restore stability.
 
If you are considering TPLO or TTA, please read the 'TPLO / TTA' page here at this website.
 
'Conservative Management' of Ligament Rupture
Non-surgical 'Conservatively Managed' recovery from ligament injury is based simply on restricting the dog's activities so as to avoid re-injury from excessive stresses to the joint while new tissue support develops as part of the natural healing process.
        '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 new tissue which will act as support for the stifle joint.  This is a natural healing process. Before the injury, the ligaments kept the bones in place at the joint while allowing proper movement.  After the injury, with the ligaments not performing this function any longer, the newly forming tissue will do this in a different way. The new supporting tissue has a tough fibrous nature. It forms in a way that holds 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 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 suture strands used to stabilize the stifle become a permanent replacement for the torn ligaments. This is not true. (Please see the page 'The Conventional Ligament Surgeries' for more detail on this)
 
Restriction, Restriction, Restriction!-- The new supporting-tissue takes months to build-up sufficient strength so that the joint is as secure as it can be from re-injury. During this recovery period, while the new supporting tissue is incomplete, it is vulnerable to being damaged by excessive stresses. And there is also risk of further damage to other joint components during this period of lessened stability. (Please see the 'Meniscus Info' page). A dog must be prevented from running, jumping, long walks, or any other activity which might cause damage to the recovering stifle joint or impede recovery.
        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.
        It's important to be very serious about restricting activity. 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.
---- 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?"
 
Getting Started-- The early days of recovery are the period when the joint is most easily re-injured. In general, when dogs are seriously disabled by a ligament injury it is important to restrict their activity to a bare minimum at first. As the new supporting tissue builds up at the joint and the joint becomes more stable, you will see that the dog starts to use the leg a little bit, then a little more, over the course of weeks.  Be patient. It may take nearly the full 8 weeks before you see improvement in some cases.  Once you see improvement you can begin to very slowly & cautiously increase activity. Increase walk times and swimming, 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 successfully return to normal activities. 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 highest possible degree of function has been reached.
        Any increased symptoms would say "Too much activity. Too much too soon for that recovering stifle." Decreasing activity would then be appropriate. Then, when the symptoms have been reduced to their earlier state, introduce increased activity more slowly. It is important that the increases in activity be small. Increasing 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 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.
        Many dogs with ligament injuries recover very well simply by having their activity restricted to prevent excessive stresses. They do not require surgery to recover. Nor is their recovery or future joint condition improved by surgery.
 
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 next section, 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 would be appropriate. I would certainly try a brace before considering surgery. (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.
 
 As recovery proceeds, people may see that their dog is no longer limping and decide that the dog must be nearly 100% recovered and increase activity too rapidly or even end all restriction abruptly. But that stifle(knee) is still far from completely recovered even when the limp is gone and there are no symptoms at all. Increasing activity too quickly can result in a serious re-injury and a return to the beginning of recovery.
 
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.
 
There are answers to frequently asked questions about braces and other aspects of injury & recovery on the FAQ page here at this website.
 
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 tissue support which will re-stabilize the joint. But sometimes the dog cannot re-stabilize the joint even when carefully restricted. Then surgical intervention is appropriate. The question for each individual injured dog is "Does this dog require surgical intervention to re-stabilize the injured joint?" 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. There is a great deal of variation in these injuries and in the individual dogs' capacity for recovery. Each dog's injury is unique. The information available to a vet from an exam is not sufficient to indicate whether the dog can re-stabilize the joint without surgical intervention if carefully restricted.
 
People are often told that "Large dogs require surgery" or "If the vet believes there is a complete rupture rather than a partial tear then surgery is necessary." Statements like that are gross oversimplifications of a complex situation. I hear about many very large dogs who recover well without surgery, and also about seriously disabled dogs who recover well without surgery. My Tigger was diagnosed as having totally ruptured ligaments in both stifles. He was seriously disabled by the injury and over 100 pounds, but recovered very well without surgery. I regularly hear of many other similar examples which disprove surgery-advocates' claims that dogs-over-so-many-pounds always require surgery or dogs-diagnosed-with-complete-tears always require surgery.  It is not wise to make judgements about individual dogs' treatment based on generalities and assumptions. When you're deciding on treatment for your dog's ligament injury, the question you ask yourself should not be: "How big is this dog?" nor "Does the vet say the ligament is completely ruptured?"
 
Then How Do You Determine 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 recovery without surgery. Many vets want surgery done on all dogs they believe have ligament injuries. So when a vet tells you "Surgery is required for your dog", how do you know if 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. Giving non-surgical recovery a chance is almost always appropriate. Carefully restrict from 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 much longer than 8 weeks, but noticeable, continuing gradual improvement during the 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.
 
(Please see the page 'The Conventional Ligament Surgeries' and the page 'TPLO/TTA' for more on surgery.)
 
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 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?")
---- 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 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.  

Click here to go to this website's page "Looking Deeper Into A Recommendation For Surgery"

Restriction After Surgery
---- It is common for surgeons to make unrealistic claims about how long it will be before a dog can safely return to normal activities after surgery. While many factors enter into how long recovery will take, it is generally true that surgery is not really a faster way to recovery. While a dog may be able to use the leg in a limited way sooner after surgery, this is not full recovery. The length and type of restriction for the fullest possible recovery after surgery will be much the same as with non-surgical Conservative Treatment. A too-rapid increase in activity after surgery can be disasterous. It is easy to do too much too soon, but almost impossible to be too cautious.
 
******************************************
 Question: "Max, Your website seems to be strongly against surgery.  Do you think surgery is ever the right choice for a dog with ligament injury?"
---- Some dogs do better with surgery. But which dogs are these? The question "Which is the best way to treat the injury?" in any particular case can be answered much better after a period of careful activity restriction. Nevertheless, it has become commonplace for many vets to recommend immediate surgery for almost all dogs who have ligament injuries. Proceeding immediately to surgery is often based in the business aspects of veterinary treatment.  (To put it bluntly-- There is money to be made with surgery.) Additionally, these same vets often misrepresent the risks involved in surgery and make unrealistic claims about the results that can be expected from surgery.
--- It is also true that there are many cases in which ligament injury diagnosis is mistaken.  Not every limp is caused by a ligament injury, but some vets seem to never see a limping dog without saying "TPLO is needed".
--- Many dogs recover very well from ligament injury without surgery, and of course misdiagnosed dogs should not be subjected to surgery.
---- It is not surgery itself that I am against. It is surgery that is not in the dogs' best interests. It is clear that simply accepting a vet's recommendation for immediate surgery is not wise.  The recommendation for a diagnostic period of 8 weeks of careful restriction is meant to give you a better idea of whether your dog is going to be able to re-stabilize the injured joint without surgical intervention. When surgery is appropriate, it is a helpful aid to recovery.

Question: "Max, my vet says the 'Conservative Management' non-surgical method you recommend won't work.  He says only surgery will work."
---- There are several things which cause many vets to have inaccurate ideas about non-surgical treatment. For the reasons brought up on the 'Surgical Recommendation?' page here at this website, this is a persistent error.
---- At many university vet schools, vet students are taught canine ligament injury treatment by surgeons and are given little or no training concerning non-surgical treatment.  As a result, many vets who were trained in these institutions have no knowledge of the possibilities of non-surgical treatment.  And even many vets who recognize the usefulness of CM do not have a clear idea of what the 'restriction' in non-surgical treatment should consist of, nor that activity should be slowly and incrementally increased rather than suddenly resumed when symptoms resolve. They may advise simply "Rest the dog for a few weeks." without detailed instructions. I often hear from people who believed, based on their vets' advice, that some insufficient restriction (like leaving the dog free to run in a large yard) was all that was needed. Or that once the dog's limp improved it was fine to immediately resume normal activity.
---- When restriction is not done properly, the dog's chances of improvement are much less.  If normal activity is resumed abruptly when there is improvement, there is likely to be a re-injury of the joint. When clients report results like that, this reinforces in vets' minds the idea that non-surgical treatment doesn't work well. With these misunderstandings about what constitutes proper non-surgical treatment so widespread, it is no surprise that it is seen by many vets as a less attractive choice than surgery.
---- Consider this analogy:
If a commonly-used casting procedure for broken legs was to put the leg in a cast, then remove the cast after 2 weeks and resume normal use of the leg, what would happen?  Bones would fail to heal or re-break.  The failure rate for casting would be very high.  Would this mean that putting casts on broken legs is an ineffective method of treating broken bones? Or would it mean that this two-weeks-in-cast method of applying the treatment was flawed? In a parallel way, non-surgical recovery for dogs' ligament injuries is often mis-applied then called ineffective.
---- When properly done, non-surgical treatment is very often effective and provides a low-risk method of obtaining the best possible result.

To succeed with non-surgical recovery it is necessary to properly restrict the dog to avoid reinjury.
Here are some ways to fail:
     1) "My dog wants soooo much to run and play! He's been held back from doing what he loves to do for weeks & I just can't deny him what he wants so badly without giving in now & then.  Just a few minutes of romping one or two days a week shouldn't hurt."
---- But it does hurt!  Regardless of whether a dog has surgery or not, running & jumping and other activity which puts excessive stress on the joint must be prevented.  Not just reduced.   
     2) "All this restriction & extra trouble.  Month after month of it. It's more trouble than I want.  The surgeon says recovery is quick after TPLO.  It's expensive so it must be good, right?  We'll try the surgery." 
---- Recovery is not quicker after surgery.  TPLO surgery has horrific risks.  The dangers of TPLO are often lied about.  Being expensive doesn't mean TPLO is superior.  It's not.  There is no quick and easy way to recover from ligament ruptures.  Recovery requires careful restriction and patience.        
     3) "Fido got better very quickly with restricted activity.  Three weeks of restriction and then he was able to run & jump just like before.  But then he hurt himself again in the same way after a few days off restriction.   So he went back on restriction.   He got better again & we let him off restriction again after another few weeks, but a few days later he hurt himself again.  This 'conservative treatment' restriction idea isn't working."
---- The dog will stop limping and seem to be back to normal long before the joint is really fully recovered.  Re-injury of the incompletely recovered joint will continue to be possible for many months.  It's important to increase activity very slowly over months, always watching carefully for signs of over-doing the dog's exercise.  Re-injury happens after surgery too.
      4) "Fido will lose muscle mass if he doesn't get exercise.  I feel like he needs to stay active to keep that leg muscle strong.  I make up for him not being able to run by doing lots of long leash walks but he is limping more at the end of the day and doesn't seem to be getting better."
---- This is a mistaken approach often heard from people who are very active and athletic themselves.  Don't worry about the muscle during the early months of recovery.  Too much activity will cause re-injury.  The re-injury will be obvious if it comes from a sudden excessive stress like jumping.  But you can also cause minor repetitive injuries day after day by too much low-stress walking.  That muscle will build back up just fine after the joint is recovered.  Give the joint the first priority.  The joint needs slow short walks which very gradually increase over many weeks.  Once the dog senses that the stifle is stable again, he will use it more and re-build the muscle. These ligament ruptures are not the kind of injury you can deal with by forcing activity.  That joint needs minimal stressing to recover.