Post CCL Surgery in Dogs: The First 8 Weeks

It’s normal to see a dog limping after ACL surgery, especially in the first few days after surgery. While recovery times vary from dog to dog, it can take six to eight weeks for your dog to be back to normal after knee surgery.

Cruciate ligament rupture is the most common reason for orthopedic surgery in dogs. 

This post is for you if your dog has been:

• limping on his hind leg for a while.
• suddenly shows signs of pain and won’t put his paw down.
• or you’ve just been told your dog needs a cruciate repair procedure.

You might already be home with your dog after knee surgery, worrying about all the things that might go wrong, unsure whether your dog will cope with cage rest, or what the recovery process should look like.

Maybe your dog had surgery quite a while ago but is still lame.

Owners facing the reality of having to rehabilitate their dogs often feel overwhelmed. Trying to manage their emotions while absorbing a ton of information isn’t easy.

This post will explain the following:

• basic cruciate ligament anatomy
• the disease process
• treatment options
• how to manage your dog’s recovery. 

What is the cranial cruciate ligament?

In dogs, the knee joint (stifle), in the hind leg, two internal ligaments called the cranial and caudal cruciate ligaments help to stabilize the joint. 

In humans these ligaments are commonly referred to as the anterior and posterior cruciate ligaments (ACL and PCL). 

The acronyms ACL and CCL are often used interchangeably. What makes these cruciate ligaments interesting is that they are located on the inside of the joint and are pretty unique in the way they cross each other. 

Most other ligaments attach on the outsides of joints. The purpose of the cruciate ligaments is to prevent the tibia (shin bone) from sliding too far out from under the femur (thigh bone). 

In dogs, the ACL has a much harder job than in humans because dogs’ knees are much more flexed when they’re standing.

in humans, ACL tears tend to occur more often as one-off acute trauma, whereas in dogs it’s much more common for the ACL to gradually go through degenerative changes; first fraying, then partial- followed by complete rupture.

How many dogs are affected by ACL tears?

ACL tears in dogs are the most common cause of hind limb lameness, and the single most common reason for orthopedic surgery in dogs.

The chances of your dog rupturing the other ACL are very high.

30-60% of dogs who sustain a torn ACL in one hind leg go on to rupture the ACL in the other leg within 1-2 years.

Lara Kats, BSc Physiotherapy & MSc Veterinary Physiotherapy 

Dogs who are predisposed to cruciate ligament disease in the first place, share that predisposition in both stifles.

Although some dogs present with a seemingly sudden onset lameness, chances are that the ligament had been slowly wearing down for quite some time, only for a sudden twist, jump or poor landing to cause the actual rupture.

When the first cranial cruciate ligament finally fails, the dog will put more weight on the opposite hind leg, causing excessive strain on the “good” side. 

A physiotherapist can work on your dog’s adaptive movement patterns and help to avoid a second rupture. 

Causes of Cruciate Ligament Disease in dogs

The exact reasons for cruciate ligament disease aren’t certain, but the following play a significant role.

Genetics 

Given that certain breeds (Labradors, Rottweilers, West Highland Terriers, Bichon Frise) are much more prone to CCL injury, it’s widely accepted that genes are a factor.

Obesity

Obesity is a big contributor to not just osteoarthritis, but also to diabetes, heart disease and many others conditions.. Overweight dogs are also far more likely to rupture a cruciate ligament.

Poor fitness

Poor fitness causes a reduction in strength, which worsens knee instability and makes cruciate tears that much more likely. 

How to Prevent ACL Injuries

Unfortunately, you can’t control your dog’s genetic predisposition for ACL (CCL) tears. There are, however, ways that breeders and dog owners can reduce the risk.

Selective breeding

Dogs that have a history of CCL disease should be excluded from breeding.

Weight control

Obesity in dogs has become so common that over 30% of owners simply do not recognize that their dogs are overweight. In fact, in the developed world, obesity affects 20-45% of dogs. 

Obesity is also a huge contributor to the risk of dogs developing cruciate ligament disease. 

If you’re unsure whether your dog is overweight, statistically the chances are very high that he is. Ask your vet for help.

Regular exercise

Daily exercise is important for general health as well as the musculoskeletal system. However, try to avoid the “weekend warrior” scenario in which you try to make up for lack of exercise during the week due to lack of time by suddenly increasing exercise levels beyond what your dog is fit for.  

Joint supplements & fish oil 

Joint supplements such as glucosamine and chondroitin are thought to help delay the progression of arthritis.  Speak to your vet about recommended nutraceuticals and how much to give.

Safety in the home

Avoid letting your dog run around on slippery floors. If your house has laminate, tiles or wooden flooring, use non-slip rugs in high traffic areas.

Treatment options for ACL/CCL Tears in Dogs

Your veterinarian will discuss the treatment options with you. The decision on whether to opt for surgery, conservative measures, or a combination of both will depend on the severity of the tear.

Surgery-Types

There are quite a number of different ways to stabilize the canine knee after a cruciate ligament tear.  The most common are the TPLO procedure, TTA, and the Lateral Suture Technique.

TPLO surgery, or Tibial Plateau Leveling Osteotomy, is an intra capsular (inside the joint) surgery that involves the cutting and rotating of the top of the tibia (shin bone), which is fixed with a bone plate.

TTA surgery, or Tibial Tuberosity Advancement, is a less invasive procedure, but also involves the cutting of bone and metal plate fixation.

The Lateral Suture Technique is an extra capsular repair that involves a nylon suture placed around the outside to the stifle joint.  This type of surgery is better suited for smaller dogs.

Which of these surgeries is best for your dog depends on your dog’s age, size, activity levels as well as the skill of the surgeon.  Speak to your vet about your options.

Conservative management

Conservative management (no surgery) involves a combination of physical rehabilitation, hydrotherapy, pain medications (and weight loss, if the dog is overweight).

Older Dogs

Surgery isn’t an option for some dogs.  Very overweight and older dogs with multiple health issues may not be great surgical candidates. 

Very Small Dogs

For very small dogs, particularly if the CCL rupture is partial, an intensive physiotherapy and hydrotherapy program is worth considering before opting for surgery.

Hydrotherapy (either in a pool or water treadmill) is a great way for your dog to exercise and strengthen muscles without the strain and pain associated with weight bearing exercise. 

Physiotherapy is invaluable to:

• optimize joint and overall body function.
• work on muscle weakness and imbalance
• minimize scar tissue formation.
• provide pain relief.
• delay the progression of osteoarthritis.

A physiotherapist will guide you through an individualized program tailored specifically for your dog, using any combination of exercises, manual techniques, and electrotherapy (such as laser).

Acupuncture is also worth considering to help manage pain, especially if your dog has trouble with certain drugs.

Recovery from Surgery

In most cases, post-surgical full recovery takes between 3 and 6 months, but it’s not uncommon for full recovery to take longer. 

Recovery time after surgery depends on a number of factors, including:

Type of Surgery and Surgeon’s Preferred Protocol

Most veterinary surgeons will provide you with a protocol, telling you very specifically how much exercise is allowed from week to week, a prescription for pain meds, dates for follow-up appointments and wound care advice. If they haven’t done so, ask for a physiotherapy referral as well.

Extent of weakness/ general fitness

Dogs that were very unfit, with significant muscle wastage and additional health problems are likely to take a little longer to recover.

Temperament & training

The main reason for complications following surgery are exercising too much and too soon.

A laid back dog who can deal with restricted exercise and has been well trained will cope much better than a high energy dog that has no impulse control. 

Recovery after surgery is one of those times that pet owners find out the hard way that not training their dogs in basic life skills (like lead control, being ok on their own and having an “Off” switch) doesn’t actually help their dogs when life happens and things get complicated. 

Recovery is more difficult when your dog pulls on the lead (risk of strain, re-injury), or can’t settle in the crate. 

If you have a dog that struggles with these things, it’s not too late and even more important to work on this now, to ensure an optimal healing process. 

Depending on individual surgeon’s protocols:

Weeks 1-2

Your dog should have strict rest for the first two weeks. This usually involves cage rest with supported short walks for bathroom breaks.

Tip: Get a Doggie Lawn to protect your pup’s healing leg

By using a doggie lawn, your dog won’t have to navigate stairs or risk infection from the great outdoors. Your dog will have a shorter, much more pleasant walk to go potty with one of these amazing inventions.

In addition to helping your dog recover faster, Doggie Lawns are also useful for:

• housetraining puppies or older dogs
• High-rise/apartment dwelling dogs
• Extreme weather conditions: blizzards, rain, snow, hurricanes and heat
• Puppies going through vaccination shots
• Arthritic or incontinent dogs
• Owners with busy schedules
• Owners who have difficulty getting outside
• Traveling with dogs: boats, RV’s, airplanes and hotels

Wound care

Keep the wound clean and dry and make sure your dog doesn’t lick it.  You will probably need to have him in an Elizabethan collar until the stitches are removed (usually 10-14 days).  

In the first 24-48 hours, using an ice pack may help if your dog tolerates it.

These first couple of weeks are probably the hardest part for most dog owners, but most dogs adapt to the cage rest routine surprisingly well. 

Multiple Crates

If space allows, get two or more crates so you can move your dog around the house with you without having to move a crate around.

If your dog doesn’t settle in the crate and is at risk of injuring himself, then you may have to get a little creative.

The point of a crate is to restrict movement.  If your dog is highly anxious and  throwing himself around in the crate, but settles perfectly well in a pen, or small room, then use that. 

Perhaps consider investing in a video monitor.

Gradual Weight Bearing

By the second or third day you want to see your dog starting to put some weight on the leg.  Make sure the toilet walks are very short, but use them to encourage weight bearing.

Watch for signs of infection

A bit of clear oozing or very small amounts of bleeding are normal. If the wound is very swollen and painful, smells bad, or is oozing anything other than a little bit of clear fluid, contact your vet.

Maintain pain meds

Even if your dog seems perfectly fine, make sure to keep him on any prescribed pain medication.

Sling

A sling or harness is recommended if your dog is large or heavy and has to use stairs to go potty outside.

Weeks 2-4

By now your dog should be weight bearing fairly consistently, and your vet’s protocol is likely having you go for slightly longer walks. 

The stitches will have been removed and hopefully your dog has settled into a restful routine.  

Weeks 6-8

Most veterinary surgeons will recommend that hydrotherapy can start now.  Physiotherapy can start earlier, but most surgeons tend to refer around this time.

Once your dog is cleared to move around the house freely, consider using steps next to sofas and your bed.  You may also want to use a ramp for your car.

Surgical Complications to Watch For

No two cruciate repair recoveries are the same.  Sometimes complications do happen:

Infection

Sometimes the wound, or the joint become infected.  It’s important to be watchful of this.  The sooner antibiotics are started the better.

Meniscal tears

Inside the stifle joint, on the top of the tibia, there are two cushion-like bits of cartilage.

These are usually damaged to an extent following cruciate rupture.  Your surgeon will have tried to leave as much of them intact as possible.  Sometimes further tearing occurs after surgery. 

This can be extremely painful.  If this is the case, it may be necessary to perform arthroscopic surgery to remove the torn bit.  Usually this is a very simple procedure.

Refusal to bear weight or persistent lameness

Some dogs really struggle to weight-bear fully after surgery.  This is particularly common in smaller dogs, as it’s so easy for them to get around on just three legs. 

If your vet has ruled out meniscal tears, infection and any other post-surgical complications, it’s really important not to allow non-weight bearing to continue for any length of time.

Consider consulting a physiotherapist to help you.  

At Home Management

Here are some things to try with your dog during the recovery period.

• -walking very slowly
• -ask your dog to lift a front paw (even just off the floor) in standing on a non-slip surface
• -speak to your vet about pain medication options
• -restrict how much your dog walks on 3 legs, and focus on continually and consistently getting a shorter quality walk rather than a long walk. Little and often is better.

The Risk of Osteoarthritis

It’s important to understand that as soon as a joint has had any degree of internal trauma, osteoarthritis is pretty much inevitable, regardless of what treatment or type of surgery is used to stabilize the joint.

All dogs with cruciate ligament disease, even before the ligament tears, already have osteoarthritis.  However, there is a lot you can do to minimize how bad osteoarthritis gets and how fast it progresses.

Summary

Most dogs do really well after cruciate ligament surgery. 

Do everything you can to ensure you follow your vet’s post-surgery protocol, particularly regarding restriction of exercise. 

Once your dog gets the all-clear, be mindful that exercise needs to be regular and consistent.  Any increases in speed and duration of walks must be implemented very gradually. 

As time goes by, your dog will be more likely to show signs of osteoarthritis (stiffness, especially after resting and occasional flare-ups).  Pain medication will help with this, but you may be able to delay the need for this with physiotherapy and hydrotherapy.

Sources:

www.purina.eu

www.scientificamerican.com

www.fitzpatrickreferrals.co.uk

www.vetfolio.com

The Canine Meniscus: Injury and Treatment

Lara Kats, BSc Physiotherapy & MSc Veterinary Physiotherapy