Saturday, July 17, 2010

ACL Injury Conservative Management: Tucker's Story

My Conservative Management Experience, and Success the Second Time Around
by Mandie Shaner
Dog Knee Injury CCL
Tucker is my (almost) 6 year old American Bulldog. I should have known from our first meeting at the shelter when he jumped a waist high gate to greet us that it was going to be a wild ride, but he never ceases to amaze me with his antics. Tucker is one of those dogs that can just look at you and make you giggle uncontrollably. He's part dog, part cow and 100% lummox. Some of what makes him so goofy, is also what makes him so prone to cranial cruciate ligament (abbreviated CCL) injury. He is extremely top heavy with a giant head and chest, but somehow his tiny back legs did not manage to follow suit, and over the years he has experienced damage to both of his knees. Some breeds of dog are also more prone to cruciate ligament injury due to the conformation of their legs, and Tucker is also at a disadvantage in this regard. His back legs somewhat turn in, making them a lot less stable than other dogs with similar weight.

In October 2007, Tucker was diagnosed with a full CCL tear, and our veterinarian recommended a TPLO right away. Without knowing anything about the surgery or what it entailed, we decided to not decide at that moment and do some research on our own. Through our research we found an alternative to surgery called Conservative Management. Conservative Management for dogs is a somewhat loosely defined term basically meaning rest, anti-inflammatory medications and supporting the natural healing process of the leg over a period of 4-8 weeks. The idea behind CM as a CCL treatment technique is that by reducing the load on the knee for one to two months you can give the joint a chance to build up muscle and scar tissue to compensate for the loss of the injured knee ligament.

We really felt we owed it to Tucker to at least try to heal him using a more natural approach, and we gave CM a "go" for a few months. The CM practices we tried the first time around were restricting him to leash walking only for bathroom breaks, confining him to a small, carpeted area of the house while we were gone, using Rimadyl to help with inflammation, and trying a dog knee brace. Despite all of our best attempts and hard work, we were unable to see the results we wanted, and after a few months of CM we opted to go with a Traditional Repair surgery (which we were again advised against by our veterinarian who strongly preferred the TPLO), from which Tucker has healed completely.

In late 2009, Tucker once again became intermittently lame in his rear leg, but this time it was the non-surgical leg. He had been limping on and off on his surgical leg for about a year following the traditional (which is an extracapsular repair using the leader line technique) repair, but had seemed to finally be getting around ok until this new lameness began. At first it started that he would only limp in the morning, but it gradually progressed to toe touching every other day. We decided to take him to the veterinarian to have the drawer sign test performed and get a definitive diagnosis.

As expected, Tucker tested positive for the drawer sign, although the veterinarian said that he did not think it was a full tear as of yet due to the fact that Tucker was not toe touching on a regular basis. Despite not believing it was a full tear, he recommended a TPLO or TTA be done within the next month. I explained to the veterinarian that I wanted to try Conservative Management, and he wished me luck, informing me that generally only dogs under 30 pounds have success without surgery.

After leaving the office that day we began a strict Conservative Management regimen. Remembering all of the trials, tribulations and difficulties we encountered during Tucker's Traditional Repair surgery, I really wanted to make sure we could make CM work this time and avoid the trauma of surgery.

Luckily, my husband and I both work from home doing freelance WordPress web development, and one of us would be able to stay with Tucker at all times to make sure he was staying calm, quiet and resting. This second time around I did things a bit differently. I still kept him confined to controlled, leash walking when he needed to use the bathroom, but I also made it a point to walk a half a block or so each time we went out. My logic here was that it was important to keep the joint somewhat strong and moving while his body was working build up scar tissue and muscle around the torn ligament. I was careful to make sure that he did not get overly excited, jump and/or run, because I was sure that any strenuous activity or quick motion would tear the ligament for sure and set us back.

Along with the short leash walks, he was confined to a small, carpeted space in the home at all times. This was slightly different from the first attempt in that this ensured he would not be able to get up quickly and run to the door if he heard something, or be able to slide on the non-carpeted areas of the house. I felt absolutely terrible forcing him to stay in such a confined area, but I knew I was doing what was best for him.

Of great importance for any dog with CCL issues is proper weight management. During the time leading up to his second CCL injury, Tucker had been getting one too many handouts while visiting our relatives in Pennsylvania, and had subsequently gained a significant amount of weight. As part of his Conservative Management plan I decided to cut back on his food intake, and switched him to a higher quality, protein rich food. Over the first month of CM he lost about 5 pounds, and got down a total of 12 pounds during the entire CM period. We have worked hard since then to keep the weight off, and it seems to be an important part of maintaining his joint health.

The inflammatory process can be very damaging to the body in both humans and dogs. Managing inflammation is an integral part of any successful round of Conservative Management. This time I really wanted to go as natural a route as possible, but seeing how much pain Tucker was in at the beginning of the CM period, I decided we should at least start him on a round of Rimadyl to make him more comfortable. The only downside to the Rimadyl is that it tends to make him feel so much better that he forgets he is hurting! To keep this in check I adjusted the dosage to ensure he was not in any pain, but made sure he was aware of it enough to take it easy on himself. Concerned about the effects of long term use of NSAIDs on the liver, I wanted to transition to a more natural approach to inflammation control as soon as possible.

After about the first month of the Rimadyl I found information on using Yucca Root to help ease inflammation, and thought I would give it a try. I transitioned from one to the other over the period of about two weeks, knowing in my head that I would keep him on the Rimadyl if I noticed a decline in the way he was feeling. After completing the transition to Yucca he seemed to be doing just fine, and we've been keeping up with the Yucca Root extract ever since. His dosage is 9-10 drops of yucca extract in his food with a bit of water to dilute it.

In addition to the Yucca, we began giving 1000 mg of Omega-3 Fish Oils twice per day during Conservative Management. The idea behind the Omega 3 fatty acids is that it helps to lubricate the joints and reduce inflammation. We've had nothing but positive results from using this supplement, and it is another one we continue to use. We also had always been doing the Glucosamine/Chondrointin supplements, and continue to use these as well. Cosequin seems to be the most palatable variety, as well as a vet favorite, but we've tried many brands with similar amounts of success.

After about 8 weeks of CM, significant improvement in Tucker's knee health was seen, and he was no longer limping or toe touching as he once had been. This was a long 8 weeks of strict CM, but in the long run it was worth avoiding the cost, risk and recovery process associated with any of the surgical procedures. We are aware that CM is not defined as a “fix” for an injured cranial cruciate ligament (CCL), but with the use of supplements and an alternative, holistic anti inflammatory medication like Yucca, we have seen great results. Over time his leg will build up the scar tissue necessary to stabilize the joint, and hopefully do so without any major arthritic consequences.

Overview of My CM Protocol:
  1. Weight Management - We cut down on treats and snacks while transitioning to a higher quality food which we fed less.
  2. Inflammation - We started with Rimadyl and Omega 3 Fish Oil (1000 mg capsules, twice per day). After 1 month of the Rimadyl I transitioned to Yucca Intensive, and give 9-10 drops diluted in food.
  3. Joint Support - Glucosamine and Chondrointin supplements are good to support joint health in any dog.
  4. Rest - Make sure your dog stays in a confined area without distraction. Carpets are preferable, avoid steps, jumping, running or rough play during this time. Toys such as frozen kongs filled with peanut butter or bully sticks are a good way to help them alleviate boredom.
  5. Controlled Exercise - Take a few, short, leash walks per day under controlled conditions to ensure your dog maintains muscle, and to also encourage the growth of scar tissue around the injured ligament.
  6. Pay Attention to Your Dog - Your best friend will tell you how they're doing. Go at their pace, and avoid doing too much, too soon!

Mandie Shaner is the founder of Dog Knee Injury, an owner resource dedicated to helping people facing CCL injuries in their pets. She also is active in Pit Bull advocacy/animal rescue through Save A Bull, and co-owns a WordPress web development company: Design SEO Hosting.


  1. Mandie, this is so promising. The day after Christmas 2011 (about 2 weeks ago), my 12 year old, just under 40lb beagle, Clyde, tore his second cruciate. He was still limping on his surgery leg (from 13 months prior), which is now his good leg.

    He has a full tear in the second leg, but we were hesitant about the surgery for our old fella, who still hasn't completely recovered from the last surgery. The vet agreed that CM was a reasonable strategy, given Clyde's circumstances (age).

    We are also lucky to be able to have someone with him most of the time, and we're doing much of what you describe here. But, we're still worried, given that he now has to rely so heavily on his surgery leg.

    He seems to be doing well 2 weeks in, but I wondered if you could provide me some guidance on two things:

    1) Did you find any use in the knee brace you tried the first time around? Would you recommend adding that to a CM strategy?

    2) Post 8 weeks, what did you do and what success have you had? I've found some scientific articles suggesting various strategies for long term CM, but don't really grasp all the jargon. Are there particular steps you took after the 8 week period that you'd recommend?

    Finally, given that you're now so far out from the 8 week period, how's Tucker doing?

    Thanks for your story!

  2. Hi RKT, this is Jana, I'll see if I can get Mandie to reply. You can also try contacting her through her blog (the links are in the bio at the bottom of the post)

    Poor Clyde; we had the same thing with Jasmine, her second knee went three months post surgery on the first one. We did do the second surgery immediately though, she did fine with that, her legs are good as new now. It was very heartbreaking though. We figured, however, better than then at some point later when it could happen when she'd might need the leg most.

    He shouldn't have been limping on his post-surgery leg 13 months after though?! There is no such thing as still recovering from a knee surgery that long after the fact?! Something isn't right there. Either something went wrong in the process or physical therapy is needed to get the soft tissues working right or there is arthritis in that knee. Is he "still" limping on that leg or did it go away and then returned?

    1) I believe that a brace is a great thing to add when going with CM. Here is why: CM is basically about keeping the knee stable via controlled exercise and control of movement; then the knee can develop fibrous tissue which at the end is what stabilizes the joint (it's the same idea with the surgery; except the TPLO, TTA, TTO, which in addition to that are meant to add further stability by changing the anatomy of the knee). The point is to prevent the joint parts from moving around, so the fibrous tissue can grow nice a tight.

    The brace will do pretty much the same thing the surgeries do, except externally: will keep the join parts put so the fibrous tissue can develop nice and tight to hold the joint together in place of the ligament.

    By preventing the joint parts from sliding around it also helps lessen pain, inflammation and arthritis. Think of it as surgery without the surgery sort of thing. So it would make good sense to me to use it.


  3. My dog Henry had a complete tear last year, so my wife and I took him to the vet and she told us it would cost $2800 to fix it. We didn’t listen to her and we are glad we didn’t. After doing a lot of research, we decided to purchase Woundwear's A-Trac Dynamic Brace for $300. Purchasing this brace was the best alternative to surgery I found. It saved me thousands of dollars and greatly improved the quality of Henry's life.

    Once we got the brace, Henry did not mind it at all and I have been very happy with the results. He was able to walk without a limp immediately, and the brace kept the knee very stable. Henry is now 100% healed thanks to Dr. Spatt and his brace! I highly suggest this brace to anyone looking for a surgery alternative option for their dog's leg injury.

    -Elizabeth B.

    1. Hi Elizabeth, thank you for sharing! I'm glad the brace worked for you!

    2. Elizabeth,
      My dog was just diagnosed with a soft tissue injury which sounds like a partial tear to his ACL. I have to take him back to the vet in three weeks for xrays and he is on pain medication.
      In the meantime, I am having a difficult time keeping his activity level low but know that he needs to rest for the injury to heal. I was online researching knee braces and came across the one you are referring to. How long did your dog have to wear it for before it healed? Thanks for the review.

    3. Hi Elizabeth, we were considering a brace option but at the end we went with a surgery. This was the brace I'd go with if we were to choose that option.

      It is my understanding that the brace would need to be worn for about 6 months. When I talked to the founder of OrthoPets, though, he was recommending that even after that it would be a good idea for Jasmine to wear the brace for long hikes or times when we'd expect some strenuous exercise.

      How old is your dog and what is his overall health?

  4. We, too, had success with WoundWear's A-Trac brace. One of the reasons we went with it was because our dog, Henry, was 13 years old and we feared the surgery would be too stressful for him. For those of you who had questions, I think the folks at WoundWear would tell you each dog/case varies as far as how long your dog will have to wear the brace, but our dog has been wearing it for about 3 months now. He not totally recovered yet, but his progress has been really good. And Jana, as far as wearing the brace during strenuous dog activity--that seems like a good idea to me! I don't think there's anything wrong with that. People wear their supportive braces when they exercise/play sports etc all the time. It's a good, responsible security measure and something we'll likely be doing even when Henry is back to 100%.

    1. Hi Audrey, glad it's working well for Henry. A brace is a good non-surgical solution when surgery isn't a good option.

  5. Hi Jana,

    Found your blog searching for conservative care. My American Bulldog has injured her ACL for the second time in a few months, and we are really skeptical about the expensive surgery option the vet has recommended. These dogs are so full of personality, spunk, and silliness, aren't they? Thank you so much for the reassurance.

    1. How do you mean the second time? The other leg or knee treated with conservative management got worse?

      To be honest, with the knees, surgery is about the best thing you can do. There are several different types to choose from, some more expensive, some less, each of them having its pro's and con's. The choice of surgery also depends on the dog. Things such as tibial plateau angle, activity level and how well you might be able to keep you dog under control post-op would influence choice of the type of surgery.

      If you don't want to go with surgery at all, I'd recommend using a stifle brace.

      How old is the dog?

  6. I'm so glad I found your post. My 8 year old mixed breed had a TPLO about a year and a half ago. Recently, he's started showing signs of limping (occasional) on his non-surgical leg. I don't want to put him through another surgery, so reading about the Conservative Care is exactly what I'm looking for, and at the exact right time!
    I have a few questions, if you wouldn't mind answering....
    Where do you get your Yucca Root and fish oil? (I also would like to transition away from Rimadyl, he's been on it since before the surgery)
    And the knee brace? I did a google search and found a few different styles. My dog is 55-60 lbs.
    Thank you for your help!

    1. Hi Rose.

      The brace which I consider the best is

      There are other similar products popping up lately, they don't seem to be cheaper as far as I can tell so I'd go with the gold original.

      Before you do anything, though, do make sure you have a solid diagnosis. Plus you'll likely need your vet's help with making the mold.

      Fish oil we use pharmaceutic grade, as heavy metal contamination is something one has to worry about these days. We were using Aller G-3 gels. Urban Wolf also has pharmaceutic grade fish oil supplements and there are likely more. You might want to check out your local pet health food store.

      Krill oil is also very good.

      Yucca root I don't know where to get, you'll have to look around.

  7. Jana,
    My five year old flat-coated retriever was just diagnosed with a partial ACL tear in his right knee. It is further complicated by the fact that he has severe hip dysplasia in his left hip (apparently he's had that since he was a puppy). He is not limping at this time and he is on restricted walks, Cosamin, and pain killers when necessary. The only thing he can't do is climb stairs. While I recognize surgery is a viable option, I'm concerned with the rehab given that his left hip is a mess with considerable muscle wasting. I've had both a partially and fully torn ACL and went conservative rehab with the first and surgery/rehab for the second, and I'm completely back to normal; however, I don't know that it works the same way for a dog. I haven't had a surgical consult yet, but I'm wondering if a possibility of 3 surgeries (right ACL, left hip, left ACL-which tends to go within a year for at least 50% of dogs) isn't demanding a ton of rest for an active flat-coated retriever. He's already appearing depressed about not being able to play with all the dogs in the neighborhood like he normally does and we're only 3 weeks into the injury.

    1. Hi Paula, sorry about your baby. That's a lot for him to deal with.

      The thing is, that every of the problems is a contributing factor to the other problems getting worse.

      The best think, indeed, will be to discuss the situation with an orthopedic surgeon. Yes, there would be post-op rehab but it may or may not be an ideal solution. With the problems fixed, he could get back to his life, while otherwise he might have to remain restricted and his pain might be getting progressively worse.

      With Jasmine, initially, we didn't want to do a surgery for the same reasons you mention, but eventually we decided that it was a best course of action in order for her to "get her life back".

      That said, should we have decided on the conservative management, we would have employed the stifle brace.