Thursday, November 24, 2011

Cruciate Ligament (ACL/CCL) Surgery Post-Op Care: Example Plan

For most dogs, the best treatment for a ruptured cruciate ligament (ACL/CCL) is surgery. When Jasmine had torn hers, I didn't want to hear this.

"Knees love being operated on," said her vet.

Today, knowing what I know now, I have to agree with that.

Making the decision of putting your dog through surgery is never easy. And you still have to decide which of the available techniques to go with.

Regardless of which surgery you choose, however, the post operative care and physical therapy are paramount to the successful outcome. 

Make no mistake, this is where the real work begins. I cannot stress this enough. What you do after the surgery is what makes or breaks the recovery.

That is why I'm very disturbed by the fact that so many people I talk to have not been told this and have not received any instructions in this regard.

I remember seeing this Yellow Lab in the park, who was visibly favoring his rear left leg. When asked, the owner told me that he had a TPLO. He had the surgery a year ago and was still favoring the leg. A year after surgery, there is not such thing as still recovering. It could well be that the surgery didn't go as well as hoped, but I think it is much more likely that the poor recovery was a result of a poor (or non-existing) post-operative rehabilitation.

If you're dog is having a knee surgery, do make sure your surgeon, or vet, gives you detailed post-op rehabilitation and physical therapy plan!

To give you an idea what such a plan should look like, here is the plan we got after Jasmine's knee surgery.

Cruciate Ligament Surgery Post-Operative Care: Introduction
  1. Absolutely NO OFF LEASH exercise for 20weeks. Your dog should be ON A LEASH at all times when outside, even if only in the backyard. The in house activity should be kept to a minimum.
  2. See your veterinarian in 14 days for suture removal.
  3. Follow the physical therapy instructions, given to you by your veterinarian.
  4. See you veterinarian in 4 weeks so he/she can check the healing progress. You can expect your dog to still be lame but weight bearing at this point. If your veterinarian feels that the healing process is advancing as expected, then be sure to continue with the physical therapy
     instructions.
  5. See your veterinarian 8 weeks after surgery for a final re-evaluation of the knee. If your veterinarian feels that the healing process has not been completely achieved, then he/she will call. If all is well then be sure to continue to follow the physical therapy instructions. It may
     take up to 6 months before your dog is as good as he/she will be on that limb.
  6. Cruciate ligaments can tear in any type of animal, because of a misstep. However, in the large breed dogs(Labradors, Golden Retrievers, Rottweilers, Akita’s, Mastiffs) the cruciate ligaments may simply degenerate(deteriorate). 30% of these dogs will have the same problem with the other knee. Therefore monitor your dog especially during the healing process because of the extra weight carrier by the other leg (ask your veterinarian about “towel walking” ). These dogs are also more likely to develop arthritis. The arthritis may or may not cause problems later in life but it is a good idea to keep your dog as lean as possible because obesity will greatly accentuate the arthritic pain.


Cruciate Ligament Surgery Post-Operative Care: Physical Therapy

The first 10 days after surgery:

  1. Apply cold compress to the knee, 3-4 times per day for 15 minutes for the first 3 days. Apply 2-3 times per day for 15 minutes for the next 7 days. This will help decrease inflammation.
  2. Passive Range Of Motion(PROM): This activity involves moving all the joints of the limbs through a comfortable range of motion. This will promote cartilage and joint health, prevent contraction of the muscles and stimulate blood and lymphatic flow. Do be careful as this may cause discomfort in the early stages. You may wish to place a muzzle on your pet to protect yourself and to get the work done efficiently and safely. Your pet should lie on his/her side with the affected limb up. Gently and slowly extend and flex each joint (ankle,knee and hip) 10 times 2-3 times per day. If you are unsure, ask your veterinarian to demonstrate.
  3. Massage the quadriceps and hamstring muscles (large muscle groups at the front and back of the thigh respectively). Best to massage for 2-3 minutes before and after PROM. Massaging will help stimulate blood and lymphatic flow and break down scar tissue within the muscles. Start by applying light pressure and gradually increase it over the coarse of the massage. Try to keep a steady rhythm. Start close to the knee and move up the muscle toward the hip.
  4. Assist your dog over slippery surfaces by placing a towel under the belly and supporting your dog (commonly referred to as towel walking).


Days 10-28


  1. Multiple short,slow, controlled, short leashed (NO FLEXI-LEADS PLEASE!) walks. Start with 5 – 10 minute walks 2-3 times per day. After 7 days, increase the frequency and length of walks gradually so that you are eventually walking for 15-20 minutes 3 times per day by day 28. Monitor your pet’s performance; do not exceed his/her limit.
  2. Continue with the massages and PROM (Before and after the walks).
  3. Use warm compress for 5 minutes before walking and use cool compress after the walk. To save time, apply the compress to the joint while you are massaging the muscles.
  4. See your veterinarian around Day 28. You can assess your dog’s progress by measuring the circumference of the thigh muscles ( it should increase with exercise) or simply compare it to the muscling on the non operated leg. Your veterinarian will assess the knee for swelling, pain,stability and the position of the knee cap.
  5. Use a foam mat or pad 4,5, 6, 8 ft long , thin (¼ to ½ inch) then thicker as legs get stronger to encourage a higher foot fall and increased joint use. Just have them walk back and forth on it.


Weeks 5 to 8

  1. Continue with the slow, controlled ,short leash walks. Gradually increase to 20-30 minutes 3 times per day.
  2. Add functional strengthening exercises. Walk your dog in a figure 8 pattern to the left and the right ( this will help with neuromuscular re-education as well). Start with a large figure 8 , and walk the pattern 4-5 times in one direction before switching to the other direction. As your pet improves and becomes stronger gradually (over 3-4 weeks) tighten the figure 8 (no sharp turns) and switch directions more frequently. Do “sit-to-stand” exercises: Ask your dog to sit and them ask your dog to stand several seconds later (this is not an exercise in speed). Start with 3 to 4 repetitions, 2-3 times per day. Gradually increase (over 3-4 weeks) the frequency (to 10 times 2-3 times per week) and difficulty by asking your dog to sit with the operated leg along the wall and then with his/her hind end in a corner and the operated leg along the wall and then with his/her hind end in a corner and the operated leg against the wall ( by making the space smaller, your are asking your pet for finer control over how he/she maneuvers that limb).
  3. Massages, PROM and warm/cool compresses will still be useful and appreciated at this stage.
  4. See your veterinarian for the 8 week recheck. Your veterinarian will reevaluate the healing progress and make sure that the knee’s stability and range of motion are as they should be.





Over the next two months

  1. Continue to increase the muscling by using the figure 8 technique and sit-to-stand exercise. Do the figure 8 at a slow trot (no sharp turns).
  2. Up hill walks (slowly) will be very helpful as well as walking through deep snow, sand or water. Gradually increase the incline of the slopes and depth of the water/sand/snow.
  3. Ascend and descend stairs slowly ( a flight of 5-10 steps) 2-3 times per day.
  4. Set up a line of cones (use your creativity) and zig-zag through the line at a walk and gradually move up to a slow trot.
  5. Dancing: Hold your dog’s front paws, allowing your dog to stand only on the back limbs. Encourage your dog to take a few small steps in this position.
  6. Incorporate balance activities: have your dog walk over couch cushions (on the floor), walk across a wide board place over a low fulcrum (acts as a teeter-totter when walked over).
  7. Use leg weights. Wrap the weights around both ankles (both limbs even if only one is problematic). Velcro can be purchased from any fabric store and hardware (such as nuts or bolts) can be attached to the velcro. Be imaginative! If using weights, only use 2-3 minutes at a time, and only every second or third day. Do not over do it.
During the second month
Allow short periods of off-leash activity (2-4 times per week). Do not encourage rapid stops or turns (i.e do not throw a ball, frisbee, stick...)


We followed this plan religiously.

No, it's not fun. But it is really important. If your dog is having a knee surgery (or any other surgery for that matter), do make sure that your surgeon/vet gives you a comprehensive, detailed post-op plan. Then, stick to it!

As much as it might seem to be taking forever, at the end of it your dog can return to the life they love, with legs they can rely on.

It's your dog's health,
Jana

Disclaimer: This is an example post-op care plan. Your dog may not be able to follow this schedule. Have your surgeon provide a post-op plan tailored to your dog's case.

Related articles:
How The Oddysey Started: Jasmine's ACL Injury 
Surviving The Post-Op: After Your Dog's ACL Surgery 
Don’t Forget the Physical Therapy
Functional Strengthening Exercises: the What, Why and How
Talk To Me About ACL Injuries
ACL Injuries in Dogs: Non-Surgical Alternatives?
ACL Injuries in Dogs and Stem Cell Regenerative Therapy
Newest Surgery For Ruptured ACL In Dogs
Preventing ACL Injuries In Dogs
ACL Injuries In Dogs: Xena's Story 
ACL Injury Conservative Management: Sandy's Story
My Love Is Sleeping At My Feet: ACL Surgery Complications 
Coco's TPLO Post-Op Diary 
Small Breeds Can Hurt Their ACL Too: Star's Naughty Knee 
One Thing Leads To Another: Why The Second ACL Often Goes Too

37 comments:

  1. Nice Jana :) That is Dr James StClair in those videos by the look of it. He knows a lot about rehab. He also has his supplements, the main post-op one is called Glycanaid HA. It ticks all the boxes for a good post-op / arthritis supplement and I have had a lot of success with it. You can read about Glycanaid here: Glycanaid + Ebook

    ReplyDelete
  2. Dear Dr. Chris, yes, it is. Thank you for the supplement tip! :-)

    ReplyDelete
  3. This is amazing, I had no idea the lengths of care that some vets provide for pets. I just wish I had heard about your site earlier, unfortunately I think my German Shepard mix is too old for any type of surgery. We'll just have to make his remaining years more comfortable. I'll be sure to come back here more often.

    ReplyDelete
  4. Hi, how old is your GSD mix? Has he ruptured his knee ligament? If you're positive that he would not do well with surgery, you can consider a solution with a stifle brace
    .

    Some/any way of stabilizing the knee will allow for better functionality, less joint damage and less pain.

    ReplyDelete
  5. Hi Jana...Julie here (Xena's mom)..would you happen to have a printable version of the Post-Op recovery Example plan? As you know..we weren't told alot with Xena's first leg..and I want to make sure that we do everything right this time...I would love to be able to print out this page....but nothing I do seems to work..any ideas?

    ReplyDelete
  6. Hi Julie,

    email me and I'll send it to you. It is best to have an individual plan but something is better than nothing. The other thing that happens with an individual plan is that it can be adjusted as you go along, depending on the dog's progress.

    ReplyDelete
  7. My 9 lb Maltese (7yr old) is having both legs repaired from cruciate ligament rupture at the same time. I'm worried about handling her, carrying her, etc. with out
    hurting her. Anyone been through both legs done at once?

    ReplyDelete
  8. Yes, there are dogs who had both legs done at the same time. Which surgery is she having? Ideally your vet/surgeon should explain the post-op care to you.

    Generally, what you don't want is too much activity a particularly no violent movements (no jumping on and off furniture, no stairs, stuff like that)

    The thing is, perhaps with exception of first couple of days, you don't want to carry her too much. You want her to use her legs, though carefully. It is important for recovery.

    Lightening the load is a good idea, this is a good product here http://www.bottomsupleash.com/you'll have to look at the available sizes.

    Either way, you want your vet/surgeon to go over the best post-op plan details with you.

    To carry her I imagine you'd want to hold her mainly under her chest with some additional support in the belly area.

    ReplyDelete
  9. I have taken Shylo my Pitbull in this this morning for ACL. I was told that they would be using the Securos technique. I am was so happy to find your blog with all the help with post op surgery and even happier that it is so recent and not info from the archives!! Should I buy ice packs or would ice cubes in a tea towel work as well?

    ReplyDelete
    Replies
    1. Hi Shalou,

      ideally, your vet/surgeon should give you a detailed post-op plan. However, much too often this doesn't happen, that's why I posted this one so people would have some idea what needs to be done.

      Please, keep in mind that this is an outline plan and adjustments might need to be done by your vet/surgeon depending on your dog's progress.

      I can tell you that Jasmine did not like the cold compresses much at all. I find that the "softer" the cold compress was the better she tolerated it. My recommendation would be pliable gel packs type of deal. The softer and more pliable the better.

      Please note that it is best to cover the pack with a layer of gauze for application.

      Delete
  10. So if my vet offered me no post-op care plan... answered each of my questions with a "dont worry about it", "Thats normal", "she'll be fine" and just dismissed my concerns..... then is that vet liable for paying for the second surgery now that my dog's need is worse than it ever was pre-surgery?

    Its been about 8-9 weeks since the surgery and I was told to let her go at her own pace, but not let her loose outside on her own for about 6 weeks, but otherwise, she would be able to get about at her own pace.

    Now her knee is popping and I can feel that the bones are not held in place and moving almost freely. I'm taking her back to the vet tomorrow, but I think that by not giving me instructions (other than the "let her do her thing" type instructions) the vet should be liable for having this fixed.... again.

    ReplyDelete
    Replies
    1. Hi Matt. That certainly does not sound good or reassuring. What surgery was that?

      I can't tell you whether your vet is liable for what happened (legally anyway) and whether they would own up to it. On the other hand, though, I don't know whether I'd trust them getting things right this time.

      But I don't have enough information, really. No post-op plan, though, no instructions ... red flags for me.

      Delete
  11. Good Morning, My lab/boarder collie mix had his cruciate ligament done eight weeks ago, his recovery was doing better than expected said the vet then now 8 weeks out he slipped on the floor getting up and it wasnt that bad of a slip and they think he might have torn it again. Unbelieveable he was doing soo well and now hes favouring that leg again.. but still stretches it and walks on it but not all the time. Im really hoping he didnt tear the ligament again. The vet has been really great and we have been taking extra caution with on the leash and no stairs.. has anyone had the surgery fail that quick?

    ReplyDelete
    Replies
    1. It doesn't take much. One bad slip or jump is all that can take.

      Which surgery did she have? She will need to be examine thoroughly to assess the situation. Different things can go wrong depending on which surgery she had but either of them might need to be fixed.

      Delete
  12. Hi,
    My female chihuahua has just had surgery to her cruciate ligament which was badly ruptured and has had a band to replace it. She also had her patella repositioned. I have found your blog very informative. I was just wondering if I should start the therepy straighaway as she had the surgery 2days ago. She is on a pain relief and a anti inflammation drug also. What would be the best eay to get her started. The vet said not to walk her as yet and just move leg in bicycle movements. She is just very small and I dont want to hurt her too much.
    Thanks Kim

    ReplyDelete
    Replies
    1. Hi Kim, yes, "move leg in bicycle movements" is about right. Did he show you?

      Yes, PROM should start right away. I hope he did show you how it's done and did give you detailed instructions?

      Delete
  13. Our Lab had a full ligament replacement on the 28 November2012. He is 10 years old now. The vet gave us instructions on how to take care of him after the op. he had to be kept still for 2 months. He stayed indoors and only went out to do his business. we went with him all the time.He went for a check up and vet said he was making good progress. he was impressed with him standing on his leg after 7 days after the op when the bandages came off.He recomended we take him to therapy but there is only one place that does it here and she is fully booked. so I am looking for exercises that I can do with him. i read that the first year after the op is very critical that is when the chanches of the other leg going the same way can ocure. Is this true?

    ReplyDelete
    Replies
    1. Glad the surgery went well and he's improving. Above are some of the suggested exercises. Two months might be a bit too long of a rest only. Did you do any range of motion and things?

      Either way, at this stage, I'd discuss with your vet some of the functional and strength exercises as described above, depending on where you're at. The foam is quite handy. Hydrotherapy is always good, swimming is always good if possible. Depending on your weather, if swimming in a pond a pool I'd recommend using a life jacket just to keep things safe.

      Delete
  14. My 11 year old had surgery using the modified flow technique about 3 1/2 weeks ago. He appears to be making progress on his recovery and is using the leg more frequently... But I have noticed that I can feel his knee pop when he uses it and am not sure if that is normal or not. It doesn't pop like it did prior to surgery, but it does still pop some. I'm concerned about the range of motion exercises ... With the pop, should we still be doing these?

    ReplyDelete
    Replies
    1. What is a modified flow technique?

      Popping would concern me, I'd take him back to the surgeon for evaluation. Last thing you want is a knee that is not stable enough or has something going on that shouldn't.

      Delete
  15. I found this incredibly helpful! My 9 year old bichon frise had his surgery about 17 days ago and at his first post-op visit the vet said he needed to be using his leg more. She suggested we tape a plastic bottle cap/cover to the paw of the healthy rear leg (the left rear had the surgery) to make it undesirable to walk only on his good rear leg. Well, I can tell you he is very stubborn and hated the cap - I felt he would hurt himself by tearing at it while I was attempting to do his therapy walks with him. I found the controlled leash walk video extremely helpful and my dog began bearing weight on the bad leg while using that method. My vet never mentioned warm/cold compresses before and after exercises or the bicycle movements recommended here.

    Question: how can I keep him from attempting to jump on/off the furniture? He loves sitting on the couch and looking out the window. I can't isolate him in another room since he gets separation anxiety and has already ruined a door in my home.

    ReplyDelete
    Replies
    1. Wow, bottle cap on the paw? Never heard of that before; sounds quite mean. I don't blame him for hating that.

      Some of the exercises, such as sits towards a wall, figure eights, walking on mild incline etc also encourage use of the leg without freaking out the dog.

      Glad you found the exercises helpful.

      Well, the best way to keep him from jumping on/off furniture, particularly since he's used to being there etc, is to provide an easier access, ideally with a little ramp. That way he can get up and down all he wants and safely. If a ramp wouldn't work because of space issues, then step(s). Ideally not tall but deep enough. Dogs do respond to ramps better, though, and are more likely to use them.

      Delete
  16. My 6 year old Boxer has been lame in his back leg for nearly 5 weeks, took him to vet and they suspected cruciate ligaments, looked it up on internet U Tube demo was def my dogs ailment and he would need operation. Vet has given me painkillers for 2 weeks he is still no better I think they are putting off the inevitable. He is a very active dog I am really worried as to his aftercare as I don't think he is going to get better on painkillers!!!

    ReplyDelete
    Replies
    1. Hi. You're right, drugs don't fix torn cruciate. They can control pain and inflammation but that's all they do. Was your vet able to get the drawer sign? If so, than that does mean it is a damaged ligament.

      There is such a thing as conservative management, but it is not very likely to work for a young active dog, because it means keeping the knee stable by restricting activity. You could consider conservative management with a brace, which does provide external stabilization.

      If the diagnosis is conclusive, your best option is either a brace or surgery. I myself would not wait, because indeed you're just allowing the unstable knee to develop arthritis.

      So first step is confirming the diagnosis, unless that is already conclusive, and the next step is treatment, either with brace or surgery. There are several surgical options out there, you will need to determine which one is best for your dog.

      Delete
  17. My deaf, arthritic 13yr old English springer spaniel bitch is already on carprofen and has (8days) ago torn her ACL. Our vet wanted to do a TTA but I felt it was too invasive for her. I`d light to do conservative management. Is this going to be ok or should I be considering a less invasive surgery e.g tightrope?

    ReplyDelete
    Replies
    1. Well, that depends. Where is the arthritis? What is the overall health? How active is she?

      The upside about the more invasive surgeries, such as the TTA is that the recovery time is shorter. The upside of surgical repair is that it does prevent further arthritis.

      If you feel uncomfortable with a surgery, do consider a stifle brace, such as from www.orthopets.com

      Delete
  18. my german shepherd dog (7 years old ) due to have cruciate ligament surgery in 2 weeks, major problem we live upstairs have purchased a harness to carry her up and down but no way she is going to allow this to happen. desperate to find a solution. can anyone help? thanks

    ReplyDelete
    Replies
    1. Which harness did you get? The Help'EmUp harness? You still have time to get her used to the idea. If you take it slow with plenty of reinforcement, you might get her used to it.

      The important thing is to take it slow and A LOT of reinforcement. First just at the sight of the harness, then interacting with it, then having it put on etc. Similar to this idea: http://www.youtube.com/watch?v=1FABgZTFvHo

      There is another type of harness which supports rear end only, a Bottoms Up leash, is she responds to it better.

      You could train her to it the same way; here you'd reinforce the sight of it, having it touch the body, having it on, having the weight supported and moving while being supported. Again in small steps.

      Other option, depending on your particular situation (the amount of stairs, how steep they are etc) is making a ramp for her. http://dawgbusiness.blogspot.ca/2014/01/physical-therapy-tip-of-month-ramps.html

      Delete
  19. Wow, my Golden Retriever had CL surgery the first week of December 2013 so it's been 3 months and I was never given any physiotherapy post-op plan! I was told to keep movement to a minimum for the first few weeks and to make sure she always went out to relieve herself on-leash. She gradually worked up to short 10 minute walks. She is still holding her leg up at times and won't always put her full weight on it. She also seems lame, which could be arthritis. I would have done some post-op therapy with her at home without question! What would you suggest I do now to make the operated leg more stable?

    ReplyDelete
    Replies
    1. Which surgery did she have? There are things you can do to catch up on the physical rehabilitation but I would recommend finding a physical therapy vet to help you along with that. Or, at least get a second opinion, evaluation and have the new vet help you formulate a plan.

      Delete
  20. Hello, Dr Jane, your article is amazing! I wish all the vets would be so responsible and caring!
    My dog pit/shar pei mix just had a DFO surgery she had 2 3/4 grade patellar luxator with the angle 15%, she is 2 years old. Is there any way you can email me or post her a care plan for this type of surgery

    ReplyDelete
    Replies
    1. Hello Valeriya. I am not a Dr. but I'm glad you found my article helpful. Vets ought to be responsible and caring! If they're not, we ought to look for a new one.

      Your surgeon is the one who should provide you with an individualized, detailed post-op plan. Please demand that they do.

      Your dog should also be evaluated periodically and the plan adjusted based on your dog's individual progress.

      Delete
  21. My St Bernard/Akita mix had bilateral CCL surgery in mid-February. She is 1 and half years old, tore the first CCL at 7 months and then while we were waiting for her to stop growing she tore the second one. It was a nightmare for the first few days and then improved little by little. She was walking on both legs, with us supporting her using a towel, immediately. Did passive ROM until stiches came out. We enrolled her in PT about 2 weeks after surgery and they did hydrotherapy and a few other exercises, which we did at home as well. We stopped bringing her to PT due to cost, but we kept up with the 8 week plan given to us from therapist and vet.

    Just got checked this morning and both legs are doing great. She will be at 10 weeks Monday and I have been looking for a rehab plan for 10 weeks and longer. I really like the example plan you posted and will start to slowly incorporate the 8 to 12 week exercises. She is doing great and glad I did both at same time rather than do one and then have to repeat with other leg a couple months later.

    Anyway, greatly appreciate you posting this sample plan.



    ReplyDelete
    Replies
    1. Great to hear she's recovering well! Glad you worked on her physical therapy, it's so important. And I'm glad this example post-op plan is useful to you :-)

      Delete
  22. Our son's large dog had surgery 1 week ago...She had no bandages or dressing...We have just had the first cartrophen injection and was checked by the vet. She is well rested ( in large crate) and toileted on lead. However I notice a " clicking" sound at the kneecap and the vet physically stretched the joint but could find no click. It is still there when I walk her. She is using the leg well and squats to toilet with no difficulty. Should I be concerned ???

    ReplyDelete
    Replies
    1. Clicking sound in the joint can have various causes from joint laxity, damaged meniscus or simply from sudden release of air bubbles in a joint space (as when people are cracking their knuckles)

      So it might be something or it might be nothing. If she's using the leg well and without problems, I'd think that it might be nothing serious. (My knees clicked when I squatted since I was about 15. Jasmine's knees clicked sometimes) Personally, I'd go by other signs to see whether or not there is significance to the click if your vet isn't concerned, and your dog isn't showing lameness or pain.

      Delete
  23. I have a dog named Buchanan and he ruptured his cranial cruciate ligament last year. I had no idea this was a problem, but apparently it's the most common knee injury for dogs. The rupture was totally repaired by the surgery, and Buck is up and about again. Good luck to your dog in his recovery too!

    Steve Carter | http://wisconsinveterinaryorthopedics.com

    ReplyDelete

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