By Jennifer Palmer, DVM, CCRT
Cranial cruciate ligament disease is the most common canine orthopedic injury. The gold standard of care is surgery on the stifle, including extracapsular repair, tibial tuberosity advancement (TTA), or tibial plateau leveling osteotomy (TPLO). Now that surgery has been performed, what can we do in-clinic and recommend at home for a safe and successful rehabilitation of these dogs?
During the initial phases of rehabilitation, our primary goal, especially for osteotomy procedures, is healthy bone healing. This requires stringent activity restriction including elimination of running, jumping (even onto/off of furniture), rough play, and stairs. It is equally important that the pet be allowed outside only for bathroom breaks and be kept on a leash. Indoors, confinement to a small space is imperative. This could be a crate or small room where there is no risk of running or jumping. Similarly, nonslip surfaces are critical to avoid slips or falls. These precautions should be continued for approximately eight weeks, or until adequate bone healing is confirmed via post-operative radiographs when appropriate.
Gentle physical rehabilitation including passive range of motion (PROM), laser therapy, and icing can be initiated immediately post-op while the dog is hospitalized. Passive range of motion can be demonstrated to the owner and continued upon discharge. This involves very gently taking all of the joints of the affected limb through a comfortable range of motion and can be performed for ten repetitions, two to three times per day. Often times there are limitations to hip extension, stifle flexion and extension, and tarsal flexion after CCL injury and repair. It is important to continue PROM to help regain these movements, although each joint should only be taken through a range that is comfortable to the pet. The owner can also continue icing the stifle at home for ten to fifteen minutes, two to three times per day. Icing can be continued while the stifle remains inflamed and painful. Passive range of motion can be continued for at least two weeks or until comfortable range of motion at each joint is achieved. Although it is safe to begin these techniques immediately post-op, it is always important to communicate with the surgeon so as not to be making inconsistent recommendations to the client.
Square hind limb placement in seated position
Once the dog is partially weight-bearing on the surgical limb, very low-impact therapeutic exercises can be added. This can include weight perturbations and sit-to-stands. Weight perturbation exercises involve an extremely gentle rocking motion from the healthy limb to the surgical limb while the dog is standing squarely, and/or gentle downward compressions on the dorsal aspect of the pelvis. The goals of this exercise are proprioceptive stimulation and strengthening via encouraging correct placement of the affected paw, slightly increased weight bearing, and isometric contraction of the hind limb musculature. The gentle rocking or downward compression should encourage more weight bearing than the dog will perform without assistance, but it should not be to the extent of causing the dog to sit down or step to the side. Sit-to-stand exercises are essentially “doggie squats.” They are very helpful in building hind limb musculature, as well as helping to remind the dog what a proper, square sitting position feels like as it is common for dogs to sit abnormally during CCL injury and rehabilitation. The keys to this exercise are a.) ensuring the dog sits with both hind limbs squarely under his or her body, as demonstrated by the dog in the accompanying photo, and b.) trying to achieve standing without pulling from the front limbs or walking forward. If the dog is not sitting squarely, this exercise may be uncomfortable and can be tried later on in the recovery process.
Cavaletti pole walking
As recovery progresses, so can the difficulty level of therapeutic exercises. Diagonal limb lifts with the head held up is a great exercise for displacing weight onto the affected limb. For example, if the left stifle has undergone surgery, lifting the right forelimb will gently shift weight onto the left hind limb. Two to three repetitions of ten seconds is a good starting point. Backwards walking is another body weight exercise that yields eccentric contraction of the hind limb musculature while encouraging hind limb joint extension. This exercise does not come naturally to all dogs, but placing a treat at their chest while walking towards them can often trigger the desired movement. Finally, low-level cavaletti pole walking helps with active range of motion, weight bearing, and limb placement. Typically we perform this exercise by placing a bar between two road cones as shown in the accompanying photo. Alternatives to the road cones would be using a ladder, placing a broom handle on or through laundry baskets, or placing a broom handle on or under similarly sized books. The bars or obstacles should start low to the ground, near the level of the tarsus, and gradually get higher as limb comfort and strength improve.
As full weight bearing is approaching or achieved on the surgical limb, more advanced weight-shifting exercises can be added such as opposite hind limb lifting and elevating front paws on a step. Two to three sets of fifteen to thirty-second repetitions of both exercises can be started, and the time can gradually increase based on strength and comfort. Weaves and circles can be performed as well. Weaves involve having the dog walk in a serpentine line to challenge weight bearing with pivoting. To start, the dog could be asked to weave around four objects, turn around, and go back the other direction. This can be completed five times initially. Circling clockwise and counterclockwise can also be introduced. Circling toward the affected limb will be the more difficult direction (i.e. for a dog who underwent surgery on the left stifle, circling counterclockwise, or with the left side on the inside of the circle, will be more difficult than circling clockwise). Five circles in each direction is a good starting point.
It is always critical to tailor each dog’s physical rehabilitation plan to his or her individual needs. If significant worsening of lameness or discomfort develop with a new exercise or advancement, then allowing rest and tapering back of activity is recommended. For an otherwise healthy pet with an uncomplicated recovery, full weight bearing is expected approximately three months post-op at which time a very gradual return to normal activity can be initiated.
- Coates, J.C. (2013). Evaluation and Rehabilitation Options for Orthopedic Disorders of the Pelvic Limb. In M.C. Zink & J.B. Van Dyke (Eds.), Canine Sports Medicine and Rehabilitation (1st, pp. 306-308). Ames, IO: John Wiley & Sons, Inc.
- Foster, S. (2013). Canine Rehabilitation Institute, Therapist Module Lecture: Therapeutic Exercise. Animal Innovation Lab.