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Ligament and Tendon Problems
Follow-up on earlier question on ACL repair
Cruciate ligament injuries
Cruciate ligament ruptures in both back legs
ACL surgery in large dog - arthritis risks
Cruciate ligament damage plus arthritis
Knee injury - extreme pain
Cranial cruciate ligament injuries
Torn cruciate ligament in Sheltie
Anterior cruciate ligament repair
Ruptured ligament
Cranial Cruciate ligament (CCL) surgery
Bicepital Tendon Bursitis
Partial rupture of cruciate ligament
Cranial cruciate ligaments and fleas
Cruciate Ligament
Severed tendon injuryalso see Lameness
also see OCD
also see Orthopedic
Followup on an earlier question on ACL repairQuestion: We are trying to decide whether or not to do an ACL repair on our 5 yr
old 70 lb Newf-Chow mix. He apparently did some sort of injury to his left
rear ACL last spring. At that time he was consistently limping and the
diagnosis (after xrays and an exam under anesthesia by a Tufts orthopod) was 99%
ACL injury. I have read about TPLO and been to the TPLO sites.The situation now is that he does not limp as long as we do not
exercise him. But a half hour of chasing a ball or a nice long walk at a
moderate pace and he is limping again for the next couple of days and then he
goes back to a more normal gait.So he clearly isn't normal. 5 seems young to condemn a dog to a
genteel lifestyle. And I don't know if we increase the risk of arthritis by
not doing anything. But on the other hand it's very easy to keep him from
limping (just don't take him on those nice long walks). And it seems
like pretty major surgery. So I'm not sure the benefit is worth the risk.Any thoughts welcome. And THANK YOU for your wonderful site!!
THANKS,--Mai-Lan
Answer: Mai-Lan
It is often hard for me to decide with certainty when it is best to
attempt to repair a cranial (anterior) cruciate ligament injury and when not
to. I feel pretty confident that dogs under 35 pounds really do about as well
without repair of the knee as with it. I feel pretty confident that dogs
over 90 to 100 lbs. do better with repair than without it. It is the
dogs between 35 lbs and 90 lbs that are hard for me to decide about.I really think that I would probably only consider the tibial plateau
leveling osteotomy (TPLO) procedure at this time in a situation like
yours. This repair procedure seems to work better in situations in which there
are already degenerative changes in the joint, which is very likely with the
duration of the injury (since last spring) at this time. Many veterinary
orthopedic surgeons disagree with this advice, though. They feel that
stabilization of the stifle is almost always better, using any of the
currently popular techniques. I base my opinion on observation of the
patients in our practice and a small number of studies that have
followed dogs after cruciate ligament repair long term. The only problem with
the TPLO surgery is that there are no long term studies that I have been
able to find, so I am basing my opinion on shorter term studies and on the
dogs who have had TPLO surgery in our practice. So far, they seem to be doing
much better than I can remember dogs doing with any of the previous
repair procedures but all of them have been operated on within the last two
years, so I don't have long term results to report, either. We do not do any
cruciate ligament repairs. We send all our patients who need this to
surgical specialists in our area. I think if I did the surgeries I might
believe in them a little more -- it is just human nature.With that preamble in mind, I think that I would probably be comfortable
advising a client of mine to consider TPLO surgery for a dog in your
dog's age range and size, even after a delay in going for surgery. I have
heard that this surgery is a little harder to do on really straight legged
dogs, which chows often are, so you might want to ask the orthopedic
specialist about this if you do go for a consultation visit prior to making a
decision. On the other hand, it wouldn't upset me too much if a client
of ours opted not to have surgery because I would think that over time
their dog would do almost as well as the dog that had surgery.I would probably recommend trying glucosamine and chondroitin
supplementation, because studies in people seem to support a role for
these compounds in stifle injury repair. I would recommend using aspirin or
other pain relief medication on the days my patient was likely to become sore
or was sore and would recommend moderate exercise on a regular basis.I hope that this helps some. I know it is a little frustrating that I
have such a wishy-washy opinion about this particular surgery but it is
unfortunately a real reflection of how I feel about it.Mike Richards, DVM
12/1/2001
Question: DearDr. Richards
I have a 55lb boxer mix, just now 3 yrs, who loves to run, hop, jump
and have fun. 1 year ago he hurt his left rear leg. To me it seemed to be
due to an injury (I remember the day). However, he was diagnosed 2 weeks
later with a torn ACL. After ~3 months of on and off rest (2-4 weeks at a time) he
still became lame after any off-leash exercise. Every time he seemed heeled but then
he would be in a great deal of pain for 2-6 days followed by recovery again. I
finally decided on surgical stabilization (extra-capsular I think) even though
they never got a significant "draw" on the knee. The surgeon did find
a tear and removed 1/4 of the meniscal cartilage said to be damaged.
The recovery was very slow and painful. He remained lame on this leg in
that he never would bear his full weight on it nor would he sit on it or
use it when going down stairs. Well now he does bear weight on it because he
must. Several weeks ago the other (right) leg went lame! Again it
seemed due to trauma. He is not using the leg at all yet.My questins for you are:
1) How can this be degenerative when it seems to be due to trauma and
he is so young?
2) Since you seem to be an advocate of medical treatment over surgical
tell me how such a degenerative rupture can heel thyself? Does time
just allow compensation? Why aren't other ligaments in the area
degenerative?
Does trauma make it worse? Why did he become lame every time he ran
even with so much rest in between?
3) What does meniscal cartilage damage entail? Is this also
degenerative or just due to the weakening of the leg? Is there any way to know if
this has occured in the second leg before commiting to surgery?
4) Why do you think TPLO is a stronger repair? Would you wait till
this technique is more established before going for it? I doubt I can
afford it nor have I found a surgeon locally who performs it.
5) Without surgical repair, how long would you suggest for a better
recovery - completely???? Even if it seems all better how long should
I wait till he can be given some freedom? Or do I have to break his
spirit (no off leash fun) in order to prevent him from experiencing such pain
again?Thank you so much for any advise you can give me.
Stacy
Answer: Stacy-
1) Not all cruciate ligament injuries in dogs are due to degeneration
of the ligaments, that is just the most common cause in dogs. Traumatic
injuries can occur in dogs just like in humans and are probably more
common in very active, athletic dogs. This may be a more likely scenario given
your dog's age, although it is a bummer to have traumatic injuries to
both legs.2) The ligament does not heal with surgical repair and it doesn't
repair itself when surgery is not performed, either. Surgery has one of two
goals, to stabilize the joint (most intra-capsular and extra-capsular repair
techniques) or to change the angle of the tibial plateau to correct the
tendency for the drawer movement to occur (tibial plateau leveling
osteotom procedure). If surgery is not performed the joint capsule and tissues
surrounding the knee will eventually scar enough to provide stability
to the joint. I do not know with certainty whether it is better to try to
stabilize the knee or just to wait. In searching for studies on this I
have not found any studies that followed dogs their whole lives, or even for
several years, to see if surgery makes a difference long term. I know
that many of my clients opt not to have surgery and that I can not detect
much difference between patients who have cruciate ligament surgery and
those that don't over time but that is must one vet's subjective opinion.
We have had several dogs have TPLO surgeries now and they do seem to do
better than non-operated dogs, to me.The cranial cruciate ligament is the most susceptible ligament to
injury but all the ligaments in the knee can be injured. We see collateral
ligament injuries on an occasional basis.When the cartilage is injured along with the ligament there is a
tendency for there to be more pain than when the cartilage is not injured. If it
is necessary to remove a large portion of the cartilage the likelihood of
long term pain increases, as well. Even when the stifle is surgically
repaired most dogs still have arthritis formation and this is more painful for
some dogs than for other dogs. Finally, there is a chance that another joint
has weakness, especially the hips, or that there is also neurologic pain,
such as might occur with lumbosacral instability or disc disease that might
be present along with the cruciate ligament injury. Over time the signs of
lameness may change enough to make it possible to diagnose one of these
problems or it they may be found in further diagnostic efforts in a dog
who doesn't recover well from the cruciate ligament injury.3) Meniscal cartilage damage occurs because the cartilage is not firmly
fixed to the bones and sort of floats between the bones (to a certain
degree). So when the cruciate ligament is damaged and there is more
movement between the bones the cartilage can be pinched or torn in the
excess movement. When the cartilage is injured the subsequent arthritis
in the joint is usually worse. It is possible to see cartilage damage with
MRI scans in most cases and arthroscopy is also possible, although this is
still a surgical procedure. Regular X-rays don't show cartilage damage
at all and dye infusion wasn't too reliable in enhancing the X-rays enough
to see the damage when that was the only other option. One of the best
reasons to have surgery is the ability of the surgeon to look for cartilage
damage prior to doing the surgical repair.4) A small number of our patients (I think three, but that is just from
memory) have had TPLO surgery. Subjectively, they seemed to have a much
quicker return to function and they seem to have better long term
function, so far, as well. I am susceptible to the placebo effect and have
thought that a couple of other cruciate ligament repair techniques were really
going to be better before finally resolving that I didn't see a lot of
difference over the long term, so I can't say this won't happen with
the TPLO procedures. I also don't know whether really long term
consequences will occur because I think that about two years ago was the first time
one of our patients had this procedure so there hasn't been much long term
time to evaluate the procedure. However, the opinion among the surgeons who
I know is that this procedure is working better, requires less after care
( probably a big factor in its success rate) and is particularly good for
big or very active dogs.5) For my clients who opt not to have surgery I recommend not engaging
in things like Frisbee (tm) chasing for a couple of months, but do not try
to restrict exercise other than that, except for the reduction the dog
imposes on itself. I think that continuing moderate exercise is helpful but
have not seen any studies to back up that opinion, either.It is important that you understand that my opinion that dogs who do
not have surgical repair of cruciate ligaments do about as well as those
that have surgery, with the possible exception of TPLO surgery, is NOT the
majority opinion among veterinarians. It is just one of my quirks and I
could easily be wrong.If this information raises more questions, please feel free to ask
them.Mike Richards, DVM
9/28/2001
Cruciate ligament ruptures in both back legs
Question: My 8 yr old mixed breed female dog was diagnosed 2 weeks ago with a torn
cruciate ligament in her right back leg. Bed rest for 4 weeks was prescribed with
Rimadyl. Last night I came home to find her not walking on her back legs at all;
basically dragging herself around. I went back to my vet who said that she now
definitely need surger for the right leg as the left one was also starting to shows
signs of a tear. I am scheduling her for 5 days from now. She had a consult with
an Ortho. surgeon who is the one that said surgery. He said the the success
rate is 80-90% for these things. Is this correct? If not, at this point, do I have any
other alternatives? Shes been on 50mg of Rimadyl along with
glucosamine/MSM and Vitamin C. She currently weights 55 lbs and should be
around 40 so she's on a diet.
I just very worried about her as the total lameness came suddenly and we've
ruled out any neuro problems.Thank you Kathy
Answer: Kathy-
It is not unusual for dogs who have a cruciate ligament rupture in one leg to develop one in the
other leg. It is a little unusual to have two severe ruptures at the same time but when it does
occur, the signs are similar to what you describe. It is not unusual for veterinarians and pet
owners to think that partial paralysis is present or that the severe lameness is due to spinal disc
disease. It is good that your vet recognized this problem.Surgical stabilization of the stifle (knee joint) is advocated by most veterinary surgeons when
cruciate ligament rupture has occurred. Despite this, I can not find any studies that compare
surgical repair to conservative treatment over the lifetime of dogs to show that surgery is actually
beneficial when compared to long term comparison with medical treatment alone.Three years ago we had a large German shepherd in our practice who ruptured both cruciate
ligaments at the same time. Her owners were not able to afford surgery and so they just cared
for her by supporting her rear with a sling so she could go outside with them and helping her up
later when she needed help. After several weeks she could get around on her own and she
shows no significant sign of lameness on yearly physical examination since that time, although I
believe that I can palpate arthritis in the stifles and expect that eventually that is going to cause
problems.So this is the best way I can sum this up; surgery is almost always advocated by surgeons. It is
likely that it does help reduce the amount of arthritis that occurs but in a long term study of
cruciate ligament surgery in dogs in Australia, about 50% still had detectable arthritis in
surgically repaired joints and about 10% of dogs were persistently lame despite attempts to
surgically stabilize the joint. A new surgical technique is currently being used for cruciate
ligament repair. It is called a tibial plateau leveling osteotomy (TPLO) and it can be done in both
large and small dogs. It may be a good choice for the situation in which there is a bilateral
cruciate rupture since it seems to be a strong repair procedure. On the other hand, if surgery
isn't an option there is a very good chance that in a few weeks, to a few months, you will find
that your dog is doing OK, anyway. Especially if you can manage the weight loss --- it helps a
great deal.Good luck with this.
Mike Richards, DVM
8/3/2001
ACL surgery in large dog - arthritis risks
Question: Dr Mike, THANKS
He's still lame although better and has been examined under anesthesia by an
orthopod. They still think "99% this is an ACL tear." I am hoping that the
osteosarcoma question is less likely, as that X-ray was clear and it's now
getting better rather than worse with time. Dog favors the leg when first
getting up and while standing still, sits holding it straight out rather
than tucked under him and gets up and down carefully but otherwise looks
pretty normal and can take his weight on it to pee. We are pursuing
"watchful waiting" until the fall because it's mild and it would be very
difficult for us to do the necessary severe exercise restriction post
surgery during the summer. Orthopod feels we are OK re not developing
arthritis for this time. Arthroscopic surgery has not been presented as an
option so we are talking open knee surgery.Our questions at this point
- Other than the usual risks of surgery ie (anesthesia, infection) what are
the risks of knee surgery itself vs leaving it alone (given that it's mild)
with regard to long-term prognosis ie arthritis? What is done for an ACL -
do they suture it?- Should we be more aggressive with regard to investigating arthroscopic
rather than open surgery? (the person who saw him is an orthopod at Tufts so
this isn't exactly a backwater)- Should we be more aggressive with ruling out injury to the other joints
you suggest before agreeing to have his knee opened given that the orthopod
seems pretty convinced that's where the problem is?- Isn't 5 y/o in a 70 lb dog a bit young to have degenerative problems?
AARGH - this was supposed to be my exercise dog and we were doing GREAT
until this happened!THANK YOU AGAIN
Answer: Mai-Lan-
There is not a clear answer to the question about the risks of arthritis
with surgery and without it. To the best of my ability to tell, no one has
actually studied dogs that do not have surgery, long term, to determine the
percentage of dogs that develop arthritis or that develop permanent
disability. However, based on observing the patients in our practice over
the last 22 years, I think that the differences between dogs who have had
surgery and those that haven't have been relatively small differences in
arthritis formation and in future use of the leg. I think that at least 50%
of dogs who have surgery still have significant arthritis and that about
70% of dogs that don't have surgery have significant arthritis later. I
can't recall a dog in our practice who had surgery, or who did not have
surgery, that refused to use the leg later. I know that some patients in
both categories developed very significant arthritis later in life, leading
to great difficulty getting around, but I do not have a good feel for how
much surgery improved the odds of avoiding this outcome -- or even if it
did. I wish that I could find some sort of really long term follow-up for
dogs with and without cruciate ligament repair but if this data exists I am
currently unaware of it.The ligament is rarely sutured. In almost all cases the remnants of the
ligament are removed and then some sort of stabilization procedure
performed which attempts to reproduce the effect of the ligament on the
joint. In the past these have generally fallen into two groups of
procedures, ones that attempted to duplicate the path of the ligament in
the knee joint (intra-articular repairs) and ones that stabilized it
externally, usually by using wire or large suture passed through holes
drilled in the bone to provide stability. More recently, a new procedure,
the tibial plateau leveling osteoplasty (TPLO) surgery has been developed.
This procedure attempts to provide stability by changing the angle the
angle of the tibial plateau (the top of the lower leg bone) to provide
stability. This procedure seems to work better than the older procedures,
especially for big dogs. It also has less follow-up care. It is a more
complex procedure due to the need to remodel bone. At the present time I
think that if my large breed dog needed cruciate ligament surgery this
would be the option that I would chose. This is not a surgery that can be
done arthroscopically.Even though I think that it is always a good idea to rule out injuries to
other joints, from a practical standpoint the odds that an injury causing
decreased weight bearing without obvious fracture or luxation in a rear leg
is a cruciate ligament injury is very high. If the surgeon finds evidence
of laxity in the joint and didn't find anything obvious in any other joints
that is sufficient for most veterinarians to focus on the stifle injury
without worrying about the other joints.We see cruciate ligament injuries that seem to be due to degeneration of
the ligament rather than a sudden traumatic event in dogs as young as two
to three years of age but it is much more common as dogs get to the six to
eight year old range. So five years is a little young but not out of the
possible range for this sort of injury at all.It does not bother me when clients opt not to seek surgery for cranial
cruciate ligament injuries, even in large dogs. My feelings on this might
change if the TPLO surgery proves to be as good as it seems like it might
be right now. Over time, it will become clear if this surgery really
provides a major life-long benefit. The intra-articular and extra-capsular
surgeries do not provide enough advantage, in my opinion, to make me feel
like not doing them is a serious mistake. Lots of veterinarians disagree
with me so it is important that you understand that this is just my opinion.I do not know if the TPLO surgery is an available option but it is becoming
a more widely available procedure and it might be worth asking your
orthopedic surgeon, or your regular veterinarian, about this.Mike Richards, DVM
7/24/2001
Cruciate ligament damage plus arthritis
Question: Hi, Dr. Richards,
My 14 yr. old English Springer Spaniel was diagnosed yesterday (via an
X-ray) with a ruptured cruciate ligament in her right rear leg after limping
around for the last 2 weeks. The X-ray also showed significant arthritis in
the knee. She seems very uncomfortable. She cries a lot and is not eating
very well. My vet advised me that surgery is the only way to fix it, and
that due to the arthritis already present in the knee, he did not think it
would help much.Since the dog is already being treated for liver disease (CAH), he had me
increase the her dosage of prednisone from 10 mg. every other day to 10 mg.
every day, which hasn't helped much. He is reluctant to use NSAIDs due to
the liver disease, even though she may be in remission (her liver values
have been normal for the last couple of years, although the SAP is elevated,
possibly due to the prednisone).Given this scenario, would you consider surgery? Trying NSAIDs? Money is
no object; I just want the dog to be as comfortable as possible for whatever
time she has left.Carol
Answer: Carol-
I wouldn't be pushing for surgery to repair the cruciate ligament in this
situation, either, except if the pain persists. In that case, I would worry
that the meniscal cartilage may be damaged in addition to the ruptured
cruciate ligament. Damage to the cartilage probably occurs in about a
fourth of cruciate ligament ruptures. Exploring the stifle and removing the
damaged areas of the cartilage can alleviate pain and it is worth
considering exploratory surgery for this reason if pain persists. After the
stifle is examined it is relatively easy to go ahead and stabilize the knee
to some degree at the same time.If surgery is done it is best to try to cut back on the dosage of
prednisone at least during the recovery period, to allow healing to occur
without the interference of the corticosteroids. That may not be possible
since she has the chronic active hepatitis problem, though. So that has to
be factored into the decision making, too.If the pain hasn't resolved or if pain relief is necessary
post-operatively, it is possible to use narcotic pain relievers in dogs.
Hydrocodone, codeine and morphine can all be used in dogs, when necessary.Hopefully, the pain has mostly resolved and you are just dealing with the
residual arthritic pain. In that case, the prednisone should help. We are
willing to use carprofen (Rimadyl Rx), when it seems necessary, even with
some pre-existing liver disease, but I can understand the reluctance to do
this, since it causes liver problems in some patients. I rate the risk of
using carprofen in patients with known liver disease as less than or equal
to the use of prednisone on a daily basis, though. Of course, that's just
an opinion and your vet is absolutely entitled to have a different one!Mike Richards, DVM
6/5/2001
Question: Hi
Sorry to hear that you have been ill; hope by now you're feeling much better.I am a relatively new subscriber but I have been enjoying your material very
much. I wrote to you a while ago about my lab/shephard mix who had developed
a cough; well now he's developed another problem, I can not reach my vet
until next week and I'm so worried about him I don't know what to do. He
woke up last Sunday morning screaming in pain, when he walked his right hind
leg just dragged behind him. At first my vet thought it might be a spinal
injury but after x-rays and an examination he said my dog had torn the
ligaments around his knee. He prescribed metacam and cosequin and told me to
give him lots of rest. What sounded simple has turned into a nightmare. I
began the medication on Tues.. On thursday my dog started barking
excessively. On Friday he barked all morning and now on Saturday he has
literally barked and howeled all day. He is exhausted, he has been wondering
around on his sore leg all day and by now he is so tired and in such pain he
can hardly walk. My dog is a very nervous animal who does not do well with
anything new. Its quite normal for him to become a little disoriendted at
times and wonder around the house whinning for a short time. But we've never
seen anything like this. W're tried everything we can think of. I'm afraid
he's going to die of exhaustion if I can't make him rest but he won't even
put his head down. He's on so many medications I was wondering if this
behavior could possible be some sort of drug reaction.Medication taken:
insulin
phenobarbital ( he takes seizures)
imodium ( he has IBD)
salazopyrine
cosequin
metacamIf its not from the medication do you have any idea of what could be going
on. Any info would be really appreciated.
Answer: R-
There should not be this much pain associated with a cranial cruciate
ligament rupture which is the most common ligamental knee injury, but there
might be this much pain with injury to more than one ligament in the knee
or with disruption of the collateral ligaments, although this sort of
injury normally is associated with known trauma, like being hit by a car.I really think that you should have him re-examined by your veterinarian.
If that is not possible for more than a day or so, I would strongly suggest
seeing another vet or looking for an emergency veterinary clinic if that is
a service available in your area.It may be necessary to re-take X-rays or to consider referral for more
sophisticated testing such as a CT or MRI scan of the back if more signs of
back problems have developed since the last exam. Many times, our initial
diagnosis is based on mild or moderate clinical signs that get a lot worse
-- and when they are worse, it is easier to tell what is going on
sometimes. If that is the case, it may be possible to reach some
conclusions without more sophisticated testing. In any case, you need to
have a re-examination, as a minimum.With the medications you mentioned, there are possible interactions. These
probably aren't the current problem, though.Sulfasalazine (I think this is the US name for the medication salazopyrine
) causes lots of other medications to have stronger effects because it
competes for protein binding sites that carry the medication. When the
binding sites are occupied by sulfasalazine, there is more of the active
ingredient of the other medication in the blood stream. There are no
specific recommendations to avoid any of the other medications on your
list, though.Meloxicam (Metacam Rx), is a non-steroidal anti-inflammatory medication.
This group of medications can cause gastric irritation, although I have not
heard of this degree of pain associated with that problem. Usually they
just cause dogs to stop eating and perhaps vomit. They can cause ulcers,
but even this is usually not painful enough to produce the type of
vocalization you are describing. I do not know of an interaction with the
other medications but meloxicam is not approved in the United States, so I
can't check a package insert to see if these types of reactions have been
reported.Insulin dosage is affected by some of the other medications and if the
sugar levels have changed as a result of new meds, that might be causing
some of the problem. If salazopyrine is sulfasalazine, then it can cause
insulin to be less active, as can phenobarbital and possibly the
non-steroidal anti-inflammatory medications such as meloxicam (although I
do not if it does this specifically, it is just in the right class). So
perhaps the combination of all these effects has produced a problem with
the maintenance of normal glucose levels --- but this is just another
reason to get a re-exam by your vet so it doesn't change the advice.I really think that the problem is that the knee injury is more severe than
your vet thought or that another problem is present at the same time.
Cartilage damage can occur when the ligaments rupture and it can be very
painful. So that is worth considering. On the other hand, cruciate ligament
injuries in pets come on gradually and it is possible for these to worsen
quickly if the dog is walking abnormally due to another problem or even to
occur coincidentally with another problem.We are currently working with a patient who came in with a crouched walk
and severe pain. We through bilateral rupture of the cruciate ligaments was
very likely but it turned out this dog's knees seemed to be OK. Regular
X-rays of his back failed to show a problem so we referred him to a
neurologist who did an MRI exam and found that there was a significant
problem with pressure on his spinal cord from inflammation around one disc
space. It just didn't show up on normal X-rays. This is the sort of problem
that can make diagnosis of pain difficult, so it may take several tries to
find the source. Hang in there until you know what is wrong or the pain
subsides.Good luck with this.
Mike Richards, DVM
12/4/2000
Cranial cruciate ligament injuries
Question: I must ask about my dog who's had surgery on his knee. Again, please
write just when you can. I can't imagine the amount of emails you must
get, and I, of course, get lots of info from my own vet, and just
appreciate your second opinion.
I have a shepherd/husky -- 5 years old, active, active dog. He's torn
both ligaments in his back knees. He had an operation a year ago on the
left knee that never healed properly, and his right knee was just operated
on 3 months ago. The right knee has healed beautifully. The left knee
was operated on again, and the surgeon reported, "there was an area on the
weight bearing surface of the lateral condyle where the cartilage is
sclerotic and unattached to the subchondral bone." She said, she curetted
this cartilage away. She also told me that often she sees cartilage
problem in the left condyle in young dogs, but not in a 5 year old, and
she couldn't explain why there would be this problem.
I have my dog on a pet insurance plan, and so he was operated on by a
specialist. What does this all mean? I have a hard time understanding
all of this. From what my vet tells me, there may be permanent damage to
the left knee, and he told me to see how the next 2 months go. What is
the long term prognosis for him? I think with all of these operations,
I've maybe prolonged his life a bit -- i.e., a pain-free kind of life
longer than without the surgery, but I assume he'll have painful knees as
he gets older? Should I be more careful about throwing a ball for him etc?
Again, this is just another opinion I'm asking for, and I know it's
difficult when you haven't seen the dog, but any information you can offer
is so helpful to me. I feel much better when I know everything I possibly
can on my dog's health. Thanks again for your time!
LoriAnswer: Lori-
I can not find much information relating specifically to the area of
sclerotic cartilage that is described, but I can give you some information
regarding the general prognosis for dogs that have cranial cruciate
ligament injuries, which I am surmising is the case with your
shepherd/husky mix.There have been several long term follow-up studies done on dogs with
cruciate ligament injuries. Most dogs with this problem will have arthritis
after surgical repair of the cruciate ligament but most of the time this
will not be so severe that it interferes with a fairly normal lifestyle.
These dogs won't be Frisbee (tm) catching champions, but they can get
around well enough that almost all owners are content with the progress in
follow-up studies. Late onset (older dogs) cruciate ligament injuries and
cartilage damage are the two prognostic indicators most likely to produce
an unsatisfactory outcome, though. In our experience, even dogs with
cartilage damage are usually able to be mobile well into old age with the
use of medications such as glucosamine/chondroitin combinations,
non-steroidal anti-inflammatories (aspirin, carprofen (Rimadyl Rx),
etodolac (Etogesic Rx)), by keeping weight under control and through
moderate exercise on a regular basis.Weight control is very important in pets that have arthritis or for which
it is reasonable to expect that they will develop it, such as a dog that
has had stifle surgery. Keeping a dog thin (at or just below ideal weight)
can make a huge difference in the dog's ability to get around. If weight is
a problem, start working on weight control now, for the best long term results.The exercise maxim "use it or lose it" is true when it comes to arthritic
joints. Regular moderate exercise, avoiding high stress on the stifle
through activities such as jumping or sudden stops and turns, is
beneficial. It is much better to encourage fifteen minutes of exercise
every day than two hours of exercise one day a week, for instance. Swimming
is probably the best exercise for dogs with damaged stifles but a swift
walk or slow run is probably fine, too.There is evidence that early use of glucosamine and chondroitin in people
with cruciate ligament injuries is helpful in lessening the long term
complications. There is no reason to believe those benefits wouldn't occur
in dogs. If it is necessary to use non-steroidal anti-inflammatory
medications to facilitate exercise (make it possible?) then I would
advocate starting them early on, too. In general we start with aspirin and
use the other medications as time goes on and they seem more necessary but
your vet may have different advice for this situation based on his or her
assessment of how your dog is doing.Good luck with this. It would be better if there had not been cartilage
damage but there is still a good chance for mobility well into old age,
despite the presence of this problem, if you can control the other
contributing factors to loss of mobility, such as weight gain and loss of
strength from too little exercise.Mike Richards, DVM
12/4/2000
Torn cruciate ligament in Sheltie
Question: Dr. Richards,
I have an 11 year old Sheltie with an approximately 4 year history of arthritis. He has recently been diagnosed
with a torn cruciate ligament of the right hind leg. He was examined by his vet who recommended rest and
Rimadyl to see if the leg would improve. It has improved somewhat, however, he is still limping quite a bit. He
was further examined by an orthopedic vet who recommended surgery.To further complicate the matter my Sheltie has recently been diagnosed with Cushing's syndrome. He is
currently taking Anipryl and Cosequin DS and has shown a reduction in his liver enzymes. And is actually
doing quite well at this time except for a decrease in his activity level.My question is, in your opinion, do you feel the benefits of surgery would be worth the side effects and
recovery time for him. We were told by the orthopedic specialist that the leg could improve on its own without
surgery, however, arthritis might be a later concern. This is already a problem for Casey, which has been
helped tremendously by Rimidyl. My main concern is his being sedated for the surgery with anesthesia and his
seeming long recovery time.He is a beloved member of our family and we want only the best for him. His quality of life is very important to
us. The Cushing's diagnosis is a definite consideration as to his life expectancy.Thank you for your time and consideration.
Thank you, Sandra
Answer: Sandra-
I think that the June issue of the VetInfo Digest, which is in the subscriber area, had information on
cruciate ligament injuries.Most dogs under 35 lbs. in weight will do just as well with surgery as without it, based on at least
two studies of cruciate ligament injuries. Most shelties are under this weight. Obese dogs may
benefit more from surgery than dogs who are closer to their ideal weight, though.Hyperadrenocorticism interferes some with wound healing and would make aftercare of a surgery
more difficult. It is important to understand the post surgical care prior to deciding to do surgery for
cruciate ligament injuries, as it is difficult for some people to manage. If good aftercare is not possible
it may be best not to do surgery.Every veterinary orthopedic surgeon that I know recommends cruciate ligament surgery for any
cruciate ligament injury. I think they are sincere in their belief that it provides a quicker recovery and
less long term degeneration in the joint. Some general practitioners feel this strongly about surgery, as
well. I think that many general practitioners are more ambivalent, though. Many dogs who develop
cruciate ligament injuries already have significant arthritis, making the outcome of a surgery less
important. In addition, most dogs do well enough that their owners are content with the progress
within two to three months. We see lots of dogs whose owners can not afford surgery or will not
consider it as an option. Almost all of these dogs eventually become comfortable enough, although
arthritis is sometimes a problem later.In the end, you still have to do what you think is best. I would really carefully consider whether
surgery is necessary if your sheltie is less than 35 lbs. in weight and not obese, especially given the
other problems present. If your vet does not feel strongly that surgery is necessary, or feels strongly
that it is, that should be factored into your decision making, too.Hope this helps some.
Mike Richards, DVM
8/4/2000
Anterior cruciate ligament (cranial cruciate ligament, ACL, CCL) repair
Question: Dear Dr. Mike
Our Aussie Sheppard mix who will be five in September had her ACL
replaced in Mid January. She has always been very active. My wife took her
out riding with her horse 2 or 3 times per week and I am a hiker so she
usually went a couple of times per week with me in the mountains of Northern
New Mexico for 4-5 hours. We do spend six months in Florida where she had the
surgery. After the surgery we followed the instructions religiously and she
made an excellent recovery up to a week or so ago when she injured her bad
leg again (left rear) I have been careful to watch her closely on all walks
and it seems that she only gets in trouble at full cantor or gallop. When
walking or trotting she is fine. After she hurt the leg we confined her
pretty much for 3 days and have now started exercising her each day with
short walks 10-15 minutes twice per day. Prior to this occurrence we were up
to 30-45 minutes. Also try to take her for short swims a couple of times per
week.
My question is could she have just strained the tendon by over stretching or
what? Also what should our therapy program be to regain her strength. It is
now over a week and she is vastly improved limping only occasionally and
usually if I remind her to walk walk she uses the leg. I want to get her back
in shape to hike but in no way wish to rush it. Any advise would be
appreciatedThanks Steve
Answer: Steve-
In most instances of anterior cruciate ligament (cranial cruciate ligament,
ACL, CCL) repair, the ligament is not repaired. Instead, some sort of
stabilization of the joint is accomplished using natural tissue from the
stifle, large suture material, surgical wire or realignment of the bony
structures (tibial plateau or fibular head) so that the joint is stable
until the joint tissues become strong enough to compensate for the loss of
the ligament. Often, this "repair" will break down after several months to
several years and this may result in temporary lameness for a few days to a
few weeks while the joint responds to the new laxity. It is not possible to
be sure this is what happened, but it is a possibility. Other possibilities
include a sprain or strain unrelated to the cruciate ligament or meniscus
(cartilage) damage that sometimes occurs in stifle joints secondary to
cruciate ligament problems. There is also a reasonable chance that this the
increase in exercise time was a little too quick and she has muscular,
joint or tendon soreness in another area.As long as you continue to see progress towards more normal motion of the
limb, this is probably not a major setback. It is usually best to rest an
injury like this for a few days. Usually it does not take more than 5 to 10
days of rest. Then start back to about 50% of the exercise level you were
at when the injury re-occurred. Then add about 10% per week to the exercise
level until you are up to the level you need to be at. It is hard to go
this slow and sometimes it isn't necessary, but I find from personal
experience that my knees do a lot better if I stick as closely as I can
stand to this sort of recovery period.Hope this helps.
Mike Richards, DVM
6/12/2000
Question: Dear Doctor Richards,
My four year old beagle, Hershey, was diagnosed with hip dysplasia
about three years ago. Immediately following the diagnosis, I took him to
Cornell Vet School; they said he that although he was limping, he was
"compensating nicely" for his dysplasia and "was not a candidate for hip
replacement". They advised me to put him on a diet (he weighed 45 pounds)
and to give him rimadyl.
He was limping pretty badly at that time despite the pills, so I took
him to a new vet who was licensed to do acupuncture. That vet told me the
real cause of Hershey's limp wasn't his hip dysplasia at all, but a torn
cruciate on the opposite knee, probably injured because of his weight and
the irregular gate he had developed due to his hip. About three months into
the acupuncture, he ruptured the ligament entirely and had surgery.
He seemed to recover completely from the surgery. Currently, he
does not limp and is quite active, despite the hip dysplasia. My question is: what
else can I do for him to help him have the longest and best quality of
life?
Most specifically, would some type of canine chiropractics help? He is
currently on Cosequin, vitamin E, C and selenium, gets regular, moderate
exercise and has lost over ten pounds . I never resumed the acupuncture
after his recovery as he showed no outward signs of pain or limping; I
also took him off rimadyl for the same reason; yet, I often wonder if he's in
pain, and I can't tell. My vet thinks I am over-reacting and says to just
keep on doing what I'm doing.
In short, I love this little guy, and want to give him the best
care for his condition and the best possible future. Everytime I see an old dog with
arthritis, I get so nervous, wondering what old age will bring Hershey with
his joint problems. Is early or severe arthritis inevitable with this his
condition, or can I be doing something else now to prevent it? Is it likely
that he will tear the other cruciate as he is very bowlegged? I'd hate to
have him go through that experience again. Any advice you could offer would
be greatly appreciated.
Thank you,
LaurieAnswer: Laurie-
Cranial cruciate ligament rupture is a common problem in dogs. Most of the
time it occurs as a long term degeneration of the ligament, similar to the
history that you describe. Approximately 40% of dogs with cranial cruciate
ligament rupture in one leg will experience a rupture of the cranial
cruciate ligament in the other leg, usually within a couple of years of the
first one. Since this is a degenerative disease, it is hard to prevent the
rupture of the ligament in the other leg.At the present time, a limited amount of research supports using
chondroitin and/or glucosamine to help prevent degeneration of the opposite
joint. I am not sure whether this will be supported over time by other
research but it seems to be a safe combination of medications, so
continuing the Cosequin (tm) is a good idea, since it contains these
ingredients.Weight control helps a great deal with almost all orthopedic problems so it
is very good that you have been able to get Hershey to lose
weight. Moderate exercise is also a very good idea.I don't think that anyone promotes acupuncture as a preventative for
further joint disease, so I don't think that stopping once pain is no
longer evident is wrong.I am not aware of any studies supporting or refuting chiropractic care for
this type of injury.I think that your vet is probably right. You are doing very good things to
help Hershey to have a better chance of not rupturing the other cruciate
ligament. You seem to be very in tune with Hershey, which makes me think
that you will be able to tell when he is in pain, since subtle things like
eating less, not wanting to be touched, hiding from you, decreasing
exercise voluntarily and poor sleep would all probably be noticed. So not
using pain relief medications chronically is probably OK. Since you are
doing all the right things at this time, you are doing what you can to
prevent future problems. This is a common enough problem that if any new
information comes out, I will try to get it into the VetInfo Digest quickly.Keep in touch with your vet and have Hershey checked out when you are
worried. That really is probably enough for now.Mike Richards, DVM
5/30/2000
Cranial cruciate ligament (CCL)surgery
Question: Dear Dr. Mike,
Thank you for your response to my request for a
subscription as I have an immediate concern about a
torn cruciate ligament in my lab mix four year old
dog, Sadie. She weighs 70 lbs. The history is as
follows. In Oct.,99 she began favoring her right rear
leg and would hold it up about half the time she was
up and around. My vet tried anti-inflammotory
medication, I believe Rimadyl, on two occasions with
no noticeable results. In mid Nov. 99, she had x-rays
with a diagnosis of a torn ACL. He performed surgery
that same day, and she came home the next day. I
followed all post op instructions, but the improvement
was very slow. She returned twice for staple removal
and to have a fluid pocket drained. After several more
post op checks from then until the present, he said
everything felt solid and it would take time. However
he did want to recheck the x-rays. She was put back on
medications for pain and inflammation. This past week,
after the x-yas he thought the sutures had come loose
and wants to do more surgery to put in a stronger type
af suture he described as a fish line type. I am not
totally sure but I believe the original surgery
involved an artificial ligament. I am very reluctant
to have her undergo more surgery without more
information or a second opinion. She walks about two
or three blocks weather permitting on a leash daily,
has some stretching of the leg exercises, but still
holds it up more than I would think she should after
three months. My vet has said repeatedly that this is
a long rehab and will not be 100%. I would appreciate
any advice, sources of information, that you could
provide me with. Sincerely, SueAnswer: Sue-
I have very ambivalent feelings about cranial cruciate ligament
(CCL)surgery, based on a couple of problems that I perceive with it. These
have been tempered somewhat by the introduction of a newer surgical
procedure for repair of these injuries that seems to work better than the
older ones in large dogs, which I will describe later.Cranial cruciate ligament repair works better in the hands of some surgeons
than in others. Part of the difference is probably in selection of cases
and in the method of repair chosen. There are probably fifty different
surgical procedures for CCL repair. This almost always means that none of
them work well --- or there would only be one repair method. My guess is
the 10 to 20% of the patients we see with cranial cruciate ligament
injuries have surgical repairs. These dogs appear to regain use of the leg
more quickly than dogs that do not have repairs, most of the time. At least
two of our patients have actually taken much longer than average after
surgical repair to recover, but surgeries always pose some risk, so this is
probably to be expected. Over the long term, though, I see very little
difference between patients whose CCLs are repaired and those that are
not. Patients still develop degenerative joint disease over time and there
is about an equal need to use medications to control pain and inflammation
in patients who have had CCL repairs and those that have not, if you look
only at the long term picture. Due to this, I have been reluctant to push
hard for surgical repair of CCL injuries. There are some other advantages
of surgery, such as the ability to repair cartilage defects and other
injuries to the joint that might occur in conjunction with the CCL rupture.
Disadvantages of surgery primarily involve cost and the necessity for
aftercare that can be difficult for some pet owners.The other side of this coin is that I don't recall ever meeting a
veterinary orthopedic surgeon who wasn't convinced that CCL repair made a
big difference, at least when they did the surgery. I don't say that to be
sarcastic. I think that these vets are sincere in this evaluation. So I
have always felt that my personal experience may vary somewhat from the
norm in veterinary medicine.Recently, a new procedure has been developed for repair of these injuries
called a tibial plateau leveling osteotomy. It seems to work better for big
dogs and it requires less difficult aftercare, making it even more likely
to succeed. Dogs must still be restricted from exercise for several months,
though. I can not be sure that the long term effect of this surgery will be
any better but right at this point I would consider it for a dog of my own
that had a CCL injury, based on the reports of success, so far. This
procedure requires special equipment and training and it is probably going
to be necessary for your vet to refer you to an orthopedic surgeon if you
would like to consider having it done.I can't evaluate your dog's condition, obviously. In my practice, I tend to
advise either going to an orthopedic surgeon to have CCL repair done or to
skip the procedure and hope for the best. That advice is based partly on my
reluctance to do surgeries that I feel I won't ever do enough of to get
really comfortable with, though. CCL surgery fits in that category given my
practice area. Most of the time dogs adjust reasonably well, over several
months (three to four) and will use the leg fairly comfortably after that,
even without surgery. As I said at the beginning of this note, I am very
ambivalent on this subject. I really do think I would consider TPLO surgery
for one of my dogs, at this time, though. If someone is doing this
procedure in your area it might be worth checking into.Mike Richards, DVM
2/14/2000
Q: I have determined that the problem is in the dog's shoulder area. The top portion of her leg, approximately @ the shoulder joint is very sensitive. There also seems to be knotted or swollen portion. Are we still talking arthritis? My vet basically gave me the same advice as you did, although I have considered seeing an orthopedic specialist if nothing changes by Monday. Would that be pemature? Thanks for your previous reply.
A: It is possible that your dog may have bicepital tendon bursitis. That would cause lameness and pain in the shoulder region. This tendon is normally pretty painful when directly palpated if that is the problem. Your vet will know how to locate this tendon and see if it may be the problem. It is also possible that there is an arthritic problem in the shoulder joint or referred pain from somewhere else. If you are concerned and wish to seek a second opinion, I see no reason not to do that, especially since you are going to a specialist. It would make sense to call your vet and discuss where you think the pain is and consider a recheck with your usual vet since you feel you can localize the pain. That helps a lot in narrowing down the diagnostic workup necessary to confirm what is going on. It is often a lot easier to make a diagnosis on a second visit when the problem has had time to develop a little
Mike Richards, DVM
Partial rupture of the cruciate ligament - Dalmatian
Q: Dear Dr. Mike- I wanted to give you an update about "Storm". We took her to the U. of Illinois and had her seen by a neurologist who then sent her to an orthopedic surgeon. A new set of x-rays were taken of the left knee and all came to the same conclusion-partial rupture of the cruciate ligament. We took her last Wednesday, she had surgery Thursday and we got to pick her up today at 10 AM. She is not bearing
weight on that leg very much to not at all. She is in quite a bit of pain as I suspected she would. There is some arthritis in the joint from the irritation. The synovial fluid in the joint was a bit thickened and the doctor ordered a C/S plus the synovial membrane was thick and he sent that for histology. The area was debrided and I hope that this helps her. I got a call every day with an update about how she was doing. I am very glad
to have her back home. She was very much missed. I am very glad we took her there to be evaluated. It definitely was missed by the specialist in December. How did this happen? Is it because she is so active? She runs alot!! I wanted to let you know how things went. Thank you for all of your help and concern. It was greatly appreciated. Take good care.
Debbie
A: Debbie-
I am glad to hear that this was a problem that there is a good chance of success for the surgical repair. Unlike people, most cruciate ligament ruptures in dogs are thought to arise from degenerative joint disease, although I am not aware of a known cause for that to start. The ligament weakens gradually over time and then eventually develops tears. In a partial tear there may not be enough joint laxity to allow for the typical diagnostic signs but the dog may still be very aware of a problem. Even in complete tears it sometimes takes more than one visit to really confirm that there is excessive laxity in the joint (a drawer movement). An exam under anesthesia is often necessary to confirm this problem and many vets are reluctant to anesthetize a patient at the first sign of problems.
I hope all goes well from here on out.
Mike Richards, DVM
Cranial cruciate ligaments and fleas
Q: Dear Dr.Mike; I rescued an abandoned male Staffordshire Terrier mix (Pit and Boxer mix, we think)about 8 years ago. He has been quite healthy until recently, developing lameness in his right rear leg with no apparent signs of infection or tramua. His hip joints appear normal, although he seems have lost some weight as well as his overall muscle tone. Normally , at his last Vet visit Buck's weght was 90 lbs and solid as a rock. I would guess that he has lost 10lb. I have looked through your pages which have given me great information, but far reaching for an uneducated guess to my pets ailment. which onset of the lameness occured after having fleas. Currently I am making an appointment for him to see the Vet, although your opnion on-line would be appreciated to help with my concern. Thank you.
A: Although it is impossible to tell you what might be wrong without an examination, the most common cause of persistent lameness in one rear leg in middle aged and geriatric dogs in my practice is degeneration of the cranial cruciate ligaments. This is more common in overweight dogs and the weight loss would be helpful if it isn't from a dire illness. Curiously, there is a connection between flea infestation and the incidence of cruciate ligament injury, in my opinion -- just based on the histories clients give me. I really wonder if the persistent scratching while standing on just one leg contributes to this problem. It could just be my imagination, though. We have not kept careful statistics on this.
Mike Richards, DVM
Q: Hello Dr. Mike, My mother is in her 70's and the doctor told her that her dog is going to have to have surgery for "CRUCIJTE", she doesn't understand what it is and could you explain it to me so I can explain it to her. I feel the doctor didn't explain it so she would understand. Thank you,
A: Rita or Roy- I think you are referring to surgery for a cruciate ligament injury in the stifle (knee) joint. The cruciate ligaments are a pair of ligaments that help to stabilize the knee as it moves. They cross the joint from in a sort of "X" pattern, leading to the name "cruciate". Usually the anterior (cranial) ligament ruptures -- the names just mean the ligament located more towards to front of the joint. In dogs this is most often a degenerative disease in which the ligament gradually weakens and finally breaks. This gives the impression of a suddenly occurring injury. Often, the ligament in the other leg is weakening at the same time and will rupture at some time in the future. With the ligament damaged, the joint is unstable and degeneration of the entire joint (arthritis) develops. Surgery helps to stabilize the joint and stop this process.
The major difficulty facing your mother is aftercare. Depending on the surgery done (there are a lot of ways to stabilize the joint), it may be necessary to confine the dog to a cage or small confined area for several weeks and it is necessary to avoid stairs and to walk the dog on a leash only. For an older person the aftercare can be very difficult. I realize that this may come to late to help much in this regard but if surgery has not been done, please contact your mother's vet and make sure that proper arrangements are made for post-operative care. It may be necessary to find someone who can help your mother care for her dog or to consider boarding it for the first few weeks after surgery.
Mike Richards, DVM
Q: Dear Dr. Mike, My Lab sustained a bad cut on his foot (what I would call his wrist area) that severed two tendon almost completely and cut an Artery completely through. This happened 11 weeks ago and he immediately had surgery where they completely repaired the tendon injury. We kept him quiet for eight weeks and he was given a clean bill of health and was considered fully recovered. However he continues to favor the good leg and in the last week has regressed to where he doesn't want to walk at times and holds the leg up at his side at times. I have gotten conflicting stories from the vets in my office, one says he is just sore and will experience good and bad weeks but is no longer in danger, the other says that he can re-injure the tendon even at this point and is still very much in danger. Who am I to believe. As a footnote, my dog will let me poke and prod at the area without pain and no discomfort what so ever. I had hoped to have some piece of mind at this point but find myself constantly concerned and protective of what he does. Thank you very much for reading my question. ... Brad
A: B- It is not uncommon for it to take several weeks for dogs to heal after injuries to tendons or joints. It is important to check for swellings, heat in the injured area or other signs of infection, since this is the most worrisome complication. Injuries in this region usually will heal satisfactorily even without surgery, probably due to the fact that dogs don't do a lot of complex things with their feet, like write or operate heavy equipment. There isn't any reason that I can think of not to use a pain reliever to make your dog more comfortable until this heals completely.
Mike Richards, DVM
The following sites may be extremely helpful to you when considering what to do about
cruciate ligament injuries.The originator of this surgery wrote the first site listed below --- but never updated it (he died, so it won't ever be updated, probably).
http://www.slocumenterprises.com/anterior_cruciate_ligament.htm
http://www.petsurgery.com/tibialplateaulevelingosteotomy.htm
http://www.medvet-cves.com/Articles/TPLO.htm
Last edited 07/13/05