First Aid and Medical Treatment for Your Dog's Damaged Cruciate Ligament
First Aid for Your Dog's Knee Injury
If your dog is limping, you need to check the entire leg and try to determine what is wrong. Do not jump to any conclusions just because your dog has injured his cranial cruciate ligament in the past.
- Start with the foot. Hold it in your hands and watch your dog's reaction. Is it painful? Look at the pad and see if there are any cuts, swellings, or loss of skin. When a dog licks on the pad because of pain or itching, she can take the skin right off.
- If you do not notice any cuts or swellings, check between each toe. Is there a bit of gravel, a thorn, or an injury that you cannot see when looking at the pads?
- Check the nails for cracks or swelling around the base. Sometimes, you will not see anything but your dog will react when you wiggle the nail.
- If the foot is okay, start moving up the leg. You should flex the hock and watch her reaction.
- Massage the rest of her leg gently and look for the swelling from a broken bone or another injury.
- If you still haven’t found anything, move on to the knee. A dog with a luxating patella may have been lame in the past so you might already know how to deal with it. If it does not go back into place easily, try to extend the dogs leg and gently massage the kneecap back into place.
- A damaged cranial cruciate ligament (in people it is called the anterior cruciate ligament, or ACL) is the most common cause of hind leg lameness in the dog, so if your dog is larger, a damaged cruciate ligament is more likely. (If you have a Rottie, a Lab, a Golden, or a German Shepherd, be especially suspicious.) The only way you can identify it is by the “cranial drawer” sign. Hold onto the femur, and if your dog is relaxed, she will allow you to slide her lower leg forward so that her knee is moved from front to back more than normal. If things are really bad, you might even hear a “pop." This can be painful, so not all dogs will want you to mess with their leg.
- The most important part of first aid care for a cranial cruciate ligament injury is keeping your dog calm. Do not let her jump up and down and make things even worse.
If your dog is not already on a leash, put her on one. (If she is not on a leash she might go running off chasing something before you even have a chance to stop her. Even if she stops as soon as you tell her the damage can already be done.)
- If your dog is small or medium sized, carry her back to your house or car.
- If your dog is too large to carry, walk her very slowly.
When you get home, encourage her to lie down. If your dog jumps up and bounces up and down every time the doorbell rings, confine her to a crate or use a leash to keep her tied down to one spot.
- Anti-inflammatory drugs: When you take your dog in for an exam your vet might put her on one of the new generation non-steroidal anti-inflammatory drugs. Don’t wait around until then—you should give her something right away to decrease the swelling associated with the injury. Aspirin is the safest drug that you have at home. Give her 8-20 mg/kg and then give her another dose in about 24 hours. Give a small dose, see how she responds, and if she is still having problems you can give a larger dose the following day. (Since aspirin will upset the stomach sometimes, I always give a dose with a meal. If your dog is not eating because of the injury then give her something tasty like lunchmeat.)
- Gentle massage and an icepack: If you are not at home and do not have an ice pack available then take some ice cubes and wrap them in a hand towel. This cold treatment is meant to reduce swelling immediately after the injury and may or may not help, depending on the extent of the damage. When you apply it to the knee leave it on at least 15 minutes while GENTLY massaging the tissue above and below the knee. Applying an ice pack wrapped in cloth to the affected knee will allow you to observe any swelling, and may have a calming effect on your dog. (Some dogs are very upset after an injury and whine and move around excessively since they cannot understand why they are in pain. Sitting down on the ground with them for a few minutes while you apply the ice pack and massage might make a big difference.) Some practitioners recommend an ice pack post-surgery. At this time there have been no studies that show that this helps.
- Check the hips: Even if you are sure that the cruciate ligament is affected and bothering your dog you should complete the exam of his leg and check out his hips. Many people will assume it is an ACL injury even when something else is going on. A dog that has hip dysplasia and secondary arthritis can also come up lame suddenly.
When You Should Take Your Dog to a Veterinarian
If your dog is still limping after you have given him first aid and taken him home to rest, you need to take him to your vet for an exam. I cannot tell you an exact number of days to wait for recovery or watch him for changes, but I do want to emphasize that you can do a lot for your dog at home and that this is not an emergency.
The vet will perform a physical exam where he flexes the knee and checks for pain, feels the muscles on both sides to check for any difference, listens for any clicking, and feels for any crepitus (a “scratchy” feeling) that indicates things are not the way they should be inside the joint. Dogs with a damaged knee sit oddly and he will watch the dog to see if he is holding his leg out when he sits down. He will probably then perform some tests. The first, the cranial drawer test, is when he will hold the femur in one hand and try to move the knee forward by pushing the tibia back and forth.
You can decline any or all of these tests, but if you are considering surgery, you should go through with them.
Some vets will recommend x-rays to try and see the cranial cruciate ligament. X-rays might show swelling but cannot be used to visualize the cruciate. In some cases, your vet might even recommend the ligament be checked with a laparoscope. While your dog is under anesthesia a small incision is made above the knee and a tiny camera is pushed into the joint to look at the damage. If the tests are inconclusive but he still suspects a cruciate injury he may recommend a cranial drawer test be done while your dog is under heavy sedation.
Your vet may or may not recommend surgery at this time. The tibial plateau leveling osteotomy (TPLO) has been around several years and is the surgery that is most likely to be recommended. A 2013 study done by the American College of Veterinary Surgeons indicated that the success was better than with the TightRope (TR) or tibial tuberosity advancement (TTA). There are other alternatives but not all are available in all areas, and not all have the same chances of succeeding.
If your vet does not recommend immediate surgery, he might tell you to rest the dog and treat him medically with NSAIDS like Metacam (meloxicam, which may have fewer side effects than the aspirin you have been giving your dog after the injury). Some reports in journals like that of the AVMA (Journal of the American Veterinary Medical Association) state that medical treatment will not work and surgery is the only way to go.
If your vet recommends immediate surgery to prevent the development of arthritis, you need to wait. All dogs will develop some degree of arthritis after a knee injury, and rushing into surgery will do nothing to prevent it. No one can guarantee otherwise. Do not rush into anything.
This is the most common test to determine whether or not your dog has damaged or torn his cruciate ligament. The test may or may not need to be done under sedation.
Will Surgery Be Necessary?
If surgery did not stress out so many dogs, was successful 100% of the time, and did not cost so much, it might be worth it.
- Unfortunately surgery to fix a damaged cruciate ligament is expensive. If you ask what to do in an internet forum some self-righteous person will tell you that you are a terrible person for not having the money and you should rehome your dog. If you do decide to have the surgery, you do need to be aware that the cost to perform surgery on your dog's ripped ACL is anywhere from $2000 or more, depending on where you are. Even dog owners that care about their pets and have a special savings account for medical expenses might have trouble coming up with that much. If the expense is not a problem for you, there are other reasons to hesitate.
- It is also unfortunate that cruciate surgery is often not effective. The success rate you are told will depend on who you are talking to so it is hard to give you exact numbers. A vet that does the surgery is more likely to tell you that over 90% of dogs will have almost full recovery. Someone who managed their dog medically will tell you that even AVMA surgical studies show that non-surgical methods work at least 2/3 or the time.
- The actual stress of the surgical procedure has to be taken into account. A dog can live with a torn or injured cruciate ligament though and old dogs and any dog with a medical problem are at increased risk during anesthesia. Not going through with surgery can be an easy decision if your dog is 15 and suffering from kidney failure. If your dog is middle aged, however, even a battery of lab tests do not guarantee that there is not a problem just below the surface.
So how do you do the right thing? You will not know if your dog needs surgery until you give him at least 8-10 weeks to recover medically. If you have one of those dogs (maybe about 1/3 or those that injure their cruciate) and:
- Your dog is not improving AT ALL with medical treatment
- Your dog is not a senior and has no obvious or underlying secondary medical problems
- Your dog is large and too active to stay still for further non-surgical recovery
- You can afford it and have a successful surgeon in your area
Then surgery may be a good idea.
When Is Surgery a Bad Idea?
- If your dog is old and has health problems that make him likely to have problems while under anesthesia for a long orthopedic procedure.
- If your dog is younger but suffering from a health problem that will make surgery especially dangerous.
- If your dog is obese then he is going to have a poor recovery prognosis. You will have to get his weight under control.
- You are being told to have the surgery quickly so that your dog does not develop arthritis.
- You are being told there is no alternative but euthanasia.
In a recent study, 24% of the dogs had serious complications and 20% of the dogs required a second surgery on the same knee. One of the dogs in the study had such significant complications that the leg had to be amputated. This is not a common occurrence, but it does happen. Your dog´s surgeon should tell you about this before he proceeds.
Medical and Nonsurgical Options
- Rest: This is the most important part of healing both for alternative therapy and after a surgery. In human medicine, this may be the only treatment recommended. In veterinary medicine, we know that your dog needs strict rest to recover so he must be confined to a small room or cage; if he is allowed to walk around the house he needs to be kept on a leash so that he does not run to the door when the bell rings or run up and down the stairs.
If your dog rests too much, however, his muscles will weaken and he will have a hard time getting around even with an improved cruciate. Look into providing some exercise with hydrotherapy and provide passive motion every day through massage therapy.
- Dietary changes: Most of the dogs that are injured are overweight or morbidly obese. Their diet needs to be changed immediately whether or not a medical nonsurgical or surgical therapy is chosen. Part of his poor body condition may be due to the cheap grain filled diet he has been eating. The best dietary improvement, then, is a raw prey-type diet composed of substances high in glucosamine, like chicken legs. It is not as easy as just opening up the bag of dog food your dog may be used to but the potential advantages are important. There are several other health benefits you should learn about.
If you have investigated a raw diet and are not able to go through with it I recommend you look into a diet that you can cook at home. In the reference section you will find details of a book by Dr. Pitcairn, a holistic veterinarian, and in that book he gives details of the best diet for your dog at this time.
- Anti-inflammatories: The medication that you give your dog will depend on whether or not he is under the care of your veterinarian. Some NSAIDs are available only by prescription, and you should follow the doseage recommended by your vet. If you are treating him at home I recommend aspirin. You can give him anywhere between 8-20 mg/kg, but it should always be with food since it can upset his stomach.
If your vet recommends that your dog be given an intra-articular steroid injection I do not think it is a good idea. An injection into the knee might lead to an infection or destruction of the cartilage, and in human medicine is never used in an instable joint for this reason.
- Acupuncture: Acupuncture might help your dog since the proper techniques can increase the blood flow to the joint and improve the ligaments ability to strengthen itself. However, I think that the stress of taking a dog out of the house and hauling him to a holistic vet for acupuncture treatments is excessive. If your dog has a torn cruciate ligament you should order an acupressure treatment chart and learn how to improve blood flow to the knee so that you can treat him while he is still resting at home.
- Massage therapy: This alternative therapy method has been proven to be effective in humans with acl injuries, but with dogs I think it should be done by the owner and may or may not be as effective.
- Hydrotherapy: The best form of hydrotherapy available is the underwater treadmill. Dogs are allowed to walk and meet their exercise needs during recovery but the water supports the body. There is almost no stress to the joint since the water is holding the dog up.
Since many of the dogs that damage their cruciate ligaments are also overweight, they need that exercise more than ever.
If your vet will not allow you to use the hydrotherapy facilities without surgery, the other alternative is to take your dog swimming in a lake or river. Unfortunately injured dogs can get overly excited when you finally take them out so you have to use a leash and stay with him at all times. (If it is too cold for you to get in the water with your dog it is too cold for him to go swimming too.) Dogs must wear a life jacket since they might be weaker than usual, and since the bottom of a river or lake can be muddy you have to make sure he does not slip and do more damage to his knee.
- Omega 3 fatty acids, antioxidants, and herbs: A cruciate injury will affect a dog life no matter what you do so it is a good idea to try these alternative therapies.
- Omega 3 fatty acids will help lubricate the knee joint, protect against further damage to the cartilage, and may reduce inflammation. There are some reports of diarrhea and weight gain with fish oil, so it has to be started gradually and built up so that the dog can tolerate it with no problems. Since dogs with cruciate injuries often need to lose weight the calories given in fish oil have to be figured in and his food decreased to make up for the calories.
- Antioxidants can reduce the continued damage to your dog's knee from free radicals. Vitamins C and E are great for this, so if you give your dog snacks, be sure it is berries, apples, and carrot slices. Vitamin C is also needed for collagen synthesis so it may have another benefit in a cruciate injury.
- Several herbal therapies are available. If you decide to try something, do so for at least a few months, as results may take time. I have read several reports on the benefits of using yucca, a plant that has both anti-oxidant and natural steroid properties, and turmeric, a spice that has anti-oxidant and also has anti-inflammatory properties that can help your dog. If you use these products for several weeks try taking your dog off aspirin and see if he seems to still be in pain.
- Pre-packaged herbal products: If you spend a few minutes searching for non-surgical alternatives to anterior cruciate surgery you will find many sites that are selling you products. The product Agile Joints for Dogs contains turmeric, an antioxicant, sasparilla, devils claw, alfalfa, and some other herbs. Several of the herb mixtures may be valuable but when you are purchasing a mixture it is not the same as using a pure herb.
- Knee brace: In human medicine, euthanasia is not an option so if surgery is declined an ACL injury is treated with rest and compression. Compression should be a cornerstone of your dog's treatment too. He will develop arthritis in his leg secondary to a cruciate injury because the femur is moving around on top of the tibia. A brace does not stop that, but then again neither does surgery.
What a brace can do is keep the knee from sliding forward or from side to side. If the ACL brace is fitted correctly it can limit the development of arthritis and give your dog time to heal.
Since many surgeons consider this a palliative only, there are few studies on the knee brace´s effectiveness. According to one recent AVMA study 98% of dog owners who went through with the TPLO surgery were happy with the results and only 86% of the knee brace owners reported the same satisfaction. Of course the people who went through with the surgery spent thousands of dollars more, so when you spend so much it is human nature to say you are satisfied with the results.
I have been pleased with this brace because the harness keeps it from sliding down and it provides good lateral support for a damaged cruciate ligament. You do have to measure your dog's leg to order the right size and order the harness separately.
How Do I Wrap My Dog's Knee Without a Brace?
While you are waiting for your brace to arrive you need to keep your dog quiet and follow the medical recommendations in this article. In the house, however, if your dog is quiet but you are worried about further injuries since he is not confined, you can use a human elbow bandage similar to shown in this video.
An elbow bandage will not work if your dog is very small or giant. For most dogs, however, it is a good method to hold you over.
How Long Will It Take for My Dog to Recover?
If you choose alternative medical treatments and allow your dog to recover without surgery it is going to take him at least 2-3 months to recover. Even then, there is a good chance that he can re-injure the affected knee or injure the other cruciate ligament so you have to further restrict his activity.
If you choose to go through with one of the surgeries then recovery time after surgery will depend on what method you choose, which surgeon performs the work, the day of the week, and who you ask. Some vets will tell you that dogs start walking in a month. This does not mean that they have normal activity levels, however, so the recovery time after surgery should be as long as the recovery time after medical treatment. A good estimate would be 2-3 months. The studies done of dogs that are not lame after surgery were not done until the dog was one year post surgery.
What Should I Do?
I am not a surgeon. I am a veterinarian and concerned dog owner. Since I have seen numerous failed surgeries and the dogs suffering because of the efforts, I believe that if your dog has a cruciate injury you should treat him conservatively before opting for surgery.
Surgery is not even an option for most people where I live and the dogs do fine after medical therapy. I will not tell you that surgery is always wrong though. I just would never put my own dogs through a procedure that caused pain without producing any cure.
Types of dogs injured: https://pets.webmd.com/dogs/acl-injuries-in-dogs#1
Surgical procedures: Tobias, K, Johnson, editors. Veterinary Surgery, Small Animal. Volume I, Section IV. Elsevier, 2012
Is surgery necessary? : Hart JL, May KD, Kieves NR, et al. Comparison of owner satisfaction between stifle joint orthoses and tibial plateau leveling osteotomy for the management of cranial cruciate ligament disease in dogs. J Am Vet Med Assoc 2016;249(4):391-398.
Surgery success rates: https://www.ncbi.nlm.nih.gov/pubmed/23432511
Christopher SA, Beetem J, Cook JL. Comparison of long-term outcomes associated with three surgical techniques for treatment of cranial cruciate ligament disease in dogs. Vet Surg. 2013 Apr;42(3):329-34. doi: 10.1111/j.1532-950X.2013.12001.x. Epub 2013 Feb 21.
Surgical complications: https://www.ncbi.nlm.nih.gov/pubmed/27379597
Dunlap AE, Kim SE, Lewis DD, Christopher SA, Pozzi A. Outcomes and complications following surgical correction of grade IV medial patellar luxation in dogs: 24 cases (2008-2014). J Am Vet Med Assoc. 2016 Jul 15;249(2):208-13. doi: 10.2460/javma.249.2.208.
Surgery will not prevent arthritis: Hurley CR, Hammer DL, and Shott S. Progression of radiographic evidence of osteoarthritis following tibial plateau leveling osteotomy in dogs with cranial cruciate ligament rupture: 295 cases (2001-2005). J Am Vet Med Assoc. 2007;230:1674-1675.
Alternative medicine: http://www.dogsnaturallymagazine.com/treating-a-torn-cruciate-acl-holistically/
Nutrition: Richard Pitcairn DVM, Natural Health for Dogs and Cats, 3rd Edition, Rodale, 2005
Knee braces: Wucherer, KL. Conzemius, MG. Evans, R. Wilke, VL. Short-term and long-term outcomes for overweight dogs with cranial cruciate ligament rupture treated surgically or nonsurgically. Journal of the American Veterinary Medical Association 2013;242(10):1364-72.