Post-Op CCL observations from the front line

There’s something I’ve noticed with post-op cruciate dogs.  Regardless of the surgery type, if there has been a hiccup in their recovery (prolonged swelling, inadequate pain management, concurrent or late-stage meniscal tear, infection near the plate, broken screw, or so on), those dogs tend to have perpetual issues.

What kind of issues?  What I’ve noted time and again is that in cases of non-linear healing, those dogs will often have a perpetual, permanent, limp or off-loading of the surgical limb.  Often times, these dogs aren’t painful months or even years after the surgery.  Even in cases where the dog has full stifle ROM, no adjunct areas of pain or dysfunction (SIJ, lumbar spine, iliopsoas, Sartorius, tarsal or hip joints…) and appropriate muscle tone, he/she can still be seen to off load the surgical leg.

Why?

Well, I have always believed that two major factors in cases such as this are the psychologic and habitual elements.  Prolonged pain can changes the central nervous system, and cause an overrepresentation of that limb (and/or problems in that limb/joint/region) in the homunculus of the brain.  In turn, any issue in that limb is ‘exaggerated’ when reported to the brain.  Limb functioning is altered compared to the other side.  For a short entertaining clip about pain and the brain check out this YouTube Video:  https://www.youtube.com/watch?v=1ylbrkstYtU

And if this is happening in our canine patients, I think it’s hard to normalize.  It’s hard to normalize in people (with whom we can work on the psychology of pain management).  So, to address it in dogs, we likely have to use physical stimulus to change the psychology.  (But hold onto that thought…)

 Other factors that I think are at play (especially in sporting dogs and show dogs) is that we may not be getting them ‘sport-ready’ and are not taking these dogs far enough along in their rehab journey and not prescribing higher levels of exercise to get them to higher levels of function.  Why the sporting dogs and show dogs in particular?  Well, this subset of dogs also comes with owners that notice the nitpicky alterations in gait or weight bearing, turns of the leg, positioning of the foot, bend of stifle, level of the topline and so on.

So, if we look at the component of return-to-sport rehab, we need to learn to prescribe higher levels of exercise (bursts, change of direction, strong muscle contractions, acceleration, deceleration, etc.)  We need to get comfortable in doing so.  Test the exercises in clinic and then prescribe.  Additionally, we don’t have any testing measures to help guide us in canine rehab!  Looking for a research project?  There’s one!  Want a good read on this subject in human PT?  Check out: https://mikereinold.com/return-to-play-testing-after-acl-reconstruction/  

 Why this topic now?  Well, I saw the dog I discussed in a previous Four Leg blog post:https://www.fourleg.com/Blog/414/A-little-story-about-a-suture-reaction-and-a-novel-suggestion-for-treatment

Short recap:  The dog had an extracapsular repair and had a suture reaction that lasted for 9-weeks post-op and only resolved when the owner gave her Benadryl.  Fast forward nearly a year… and she will still occasionally toe touch in standing and offload the leg.  (No pain, full ROM, no meniscal tear, no ‘other’ issues… just habitual at this point – in my opinion.)

 

What are my thoughts? What’s my take home?

  • 1.Manage pain and swelling aggressively early on in the post-operative period.
  • 2.Ensure your rehab incorporates advanced strengthening (i.e. d/c the UWT and do ‘bootcamp’ at about the 6 – 8-week mark.)
  • 3.Retrain sport-specific tasks.
  • 4.Rehab for longer or bring the dog back in for rehab at a later stage. 
  • 5.We need research into canine fitness tests.
  • 6.We need to think outside the box to break habitual limb use dysfunctions.

What am I going to do with my patient mentioned above?  I think she needs to do more sporting activities, maybe different ones.  Maybe pulling (to engage the rear end).  Maybe carting (to learn to use her body differently).  Maybe Schutzhund (to build power and explosion).  I’m looking to think outside the box on this one!  

Reference: Laurie Edge-Hughes, BScPT, MAnimSt(Animal Physio), CAFCI, CCRT; Owner, Four Leg Rehab Inc.

https://fourleg.com/Blog/446/Post-Op-CCL-observations-from-the-front-line

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