Features February 2010 Issue

Alternatives to Canine Surgeries

“Conservative management” is an often overlooked – but frequently effective – option for ligament injuries.

Dogs go lame for all kinds. Arthritis, Lyme disease, paw injuries, muscle sprains, bee stings, interdigital dermatitis, and dislocated kneecaps can make any dog limp. But when an active dog suddenly can’t put weight on a hind leg, the most common diagnosis – for more than a million American dogs every year – is a torn cruciate ligament. In 2003, according to the Journal of the American Veterinary Medical Association, the cost of treating those injuries exceeded $1.32 billion, and the price tag keeps rising.

Kimber, Debbie Kazsimer’s Shiloh Shepherd, recovered fully from a torn cruciate ligament with the help of a brace, physical therapy, swimming, massage, supplements – and without surgery.

The most common prescription for canine knee injuries is surgery. Unfortunately, operations don’t always work and some patients, because of age or other conditions, are not good candidates. In recent years a nonsurgical approach called “conservative management” has helped thousands of dogs recover from ligament injuries, and it is growing in popularity. At the same time, conservative management is not a cure-all. It doesn’t always prevent the need for surgery, it is not necessarily less expensive, and it can require as much time and effort as post-surgical rehabilitation. At its best, conservative management improves the outcome of whatever treatment is needed for full recovery.

“Conservative management consists of any nonsurgical treatment of injuries,” says Faith Rubenstein, who founded an online forum devoted to the subject in 2004, “including physical therapy, chiropractic adjustments, acupuncture, massage, nutrition, the use of a leg brace, nonsteroidal anti-inflammatory drugs, medicinal herbs, prolotherapy, weight loss for overweight dogs, and other noninvasive treatments.”

Rubenstein, who now lives in Austin, Texas, first encountered ligament injuries when her 100-pound Briard, Dakota, then six years old, experienced a partial tear of his cranial (anterior) cruciate ligament. “When our veterinarian recommended that we see an orthopedic surgeon,” she says, “I went looking for answers.” An academic researcher who is now a private investigator, Rubenstein discovered the term “conservative management” in a veterinary textbook.

The orthopedic surgeon diagnosed a partial tear in both of Dakota’s knees and recommended immediate TPLO (tibial plateau leveling osteotomy) surgery. In this procedure, the tibia is cut, then rotated and held in place with a metal plate and screws so that after the broken bone heals, weight-bearing exercise stabilizes the knee joint.

“I had misgivings about this method,” she says, “especially because surgeons at the School of Veterinary Medicine at the University of Pennsylvania don’t use it. I spoke with Gail Smith, the head of the University’s department of clinical research, and with Amy Kapatkin, a board-certified orthopedic surgeon who was then at Penn. What Dr. Kapatkin said made perfect sense to me. She asked, ‘Why break a bone to fix a ligament?’ My whole interest in conservative management was triggered by my fear of the TPLO.”

The University referred Rubenstein to an orthopedic surgeon who used other methods. He found Dakota to have so few symptoms that he agreed to write a prescription for physical therapy in hopes that it might make surgery of any kind unnecessary.

“Physical therapy and exercise made all the difference,” she says. “Dakota never needed surgery, and neither did his littermate, Aubrey, who tore his cruciate ligament a few months later. Many veterinarians believe that the only effective treatment for these injuries is surgery – either TPLO or another surgery – but that simply isn’t true. Conservative management can help most patients, including those who eventually have surgery, and then recover and lead active, happy lives.”

Understanding ligaments

The stifle (knee) connects the femur (thigh bone) and tibia (leg bone) with a patella (kneecap) in front and fabella (a small bean-shaped bone) behind. Cartilage (the medial meniscus and lateral meniscus) cushions the bones, and ligaments hold everything in position.

Two key ligaments, the anterior (front) and posterior (back) cruciate ligaments, cross inside the knee joint. In animals, these ligaments are called cranial and caudal, respectively. The anterior or cranial cruciate ligament prevents the tibia from slipping out of position.

Veterinarians see most ligament patients immediately after their injuries, when symptoms are acute, or weeks or months later, after symptoms become chronic. If not immediately treated, most ligament injuries appear to improve but the knee remains swollen and abnormal wear between bones and meniscal cartilage creates degenerative changes that result in osteophytes (bone spurs), chronic pain, loss of motion, and arthritis. In some patients, osteophytes appear within one to three weeks of a ligament injury. Swelling on the inside of the knee, called a “medial buttress,” indicates the development of arthritis in patients with old injuries.

The main diagnostic tools for ligament injuries are X-rays, which can rule out bone cancer as a cause of leg pain, and a procedure called the “drawer test,” in which the veterinarian holds the femur with one hand and manipulates the tibia with the other. If the tibia can be moved forward, resembling a drawer being opened, the cruciate ligament has been torn or ruptured.

The drawer test is not necessarily conclusive because the tense muscles of a frightened or apprehensive dog can stabilize the knee temporarily. To produce more accurate results in such cases, patients may be sedated before being tested.

In the tibial compression test, which is another way to check for ligament damage, the femur is held steady with one hand while the other flexes the dog’s ankle. A ruptured ligament allows the tibia to move abnormally forward.

“A complete cranial cruciate ligament tear is always a surgical case,” says Stacey Hershman, DVM, of Hastings-on-Hudson, New York, “since otherwise the knee cannot function as a hinge joint.” Advocates of conservative management recommend that whenever the tear is partial, nonsurgical techniques be given an eight-week try. If symptoms improve during that time, they say, the odds favor nonsurgical recovery. If symptoms don’t improve, conservative management techniques can be used as pre- and post-operative conditioning and therapy.

Next: After an injury

Comments (18)

@ CynthiaandLuna: Would you mind posting a status soon about the brace? I know you said you would, but just wanted to let you know that interest is there. My dog's 9, 107 lbs, and he has the same issue.

Posted by: strea | August 15, 2014 9:04 PM    Report this comment

If you are looking for a brace you need to check out the A-Trac Dynamic Brace by Dr Joel Spatt at woundwear.com Not only is it a great product at a fantasic price, but the people there genuinely care about what they are doing. I made a mistake on a measurement and they caught it and stopped the order to confirm it for me - saving me time and money on return & exchange fees, but most important, it got the right brace to my dog ASAP and I can not thank them enough for that act of kindness!! I will be back every couple weeks to let everyone know how the brace is working. My dog is an 85 lb terrier/greyhound mix and currently she is not putting weight on her left hind leg due to an acl injury. She is 8 yrs old and I am hoping the brace will help us avoid surgery. Woundwear.com has posted videos on YouTube and it looks like they have gotten some incredible results so I'm excited to share our experience with you all!

Posted by: CynthiaandLuna | August 10, 2014 1:56 PM    Report this comment

Dogdancer. Could you please tell me where in Florida that you purchased your dog's leg brace? Thank you.

Posted by: pkunnath | July 30, 2014 12:30 PM    Report this comment

Wanted to share our experience. Our 10 year old active 68 pound Aussie/sheepdog mix recently tore his CCL. It was a traumatic injury, that happened when he came down in a hole while playing fetch. We were really torn on what to do and got opinions from three vets. 2/3 recommended TPLO, one said there were pros and cons to each. We waited 2 months (with extreme activity limits) to see if our dog would heal up on his own, but at 2 months there was almost no improvement, he could only toe touch with the bad leg. At that point we decided to go with the old fashioned ex cap surgery. We did this for several reasons. First, the TPLO procedure just seemed extremely invasive. Second, our dog is incredibly active and we just didn't think we could keep him crate bound for a full month. With the ex cap he could begin all activity (gradually) even stares. Surgery showed a complete CCL tear as well as a torn meniscus. The first 3 days were terrible after surgery, but since then he has had a wonderful recovery. At 3 months he is about 80 percent weight bearing, almost has normal muscle back, and can run at a full tear (scaring me to death in the process, my recovery may be longer than his). Anyway, I would just recommend you talk to several vets and feel really comfortable with the one you choose. And take your time, we almost rushed in to TPLO and I'm glad we didn't.

Posted by: Treeclimber | June 19, 2014 2:39 AM    Report this comment

I can understand the apprehension in having TPLO surgery, but we had a great outcome after this procedure. Perhaps my dog was one of the lucky ones. He has done amazingly well 2.5 yrs after his first TPLO surgery. But, he blew out his other knee a couple months ago, another fully torn ligament and torn meniscus, after a rowdy bike ride. No doubt he needed another surgery but I struggled with TPLO based on the horror stories I've read. But then I realized that I have to base it on my own experience and his previous good outcome (and the fact that, generally, people don't post positive outcomes on the internet, just bad ones). Charlie had his second TPLO surgery on the other leg today. Now my dog's hind legs are worth a small car =). If it keeps him active and happy, then it's money well spent. He is a 95 pound bull mastiff/pit mix and is the best doggy doodle in the whole world. I am praying he recovers as well as he did last time. It does seem like an unnatural thing to do to a dog's legs. I hope I made the right decision which was largely based on my experience and my vet who I completely trust. (He does not perform these surgeries but refers out to other board certified surgeons.) Just my experience...they aren't all bad.

Posted by: iheartkarma | May 29, 2014 6:54 PM    Report this comment

Want to thank you for this article. After my 2yr old lab suffered a tear I struggled with with moving to surgery too quickly after finding out how invasive it was. After seeing your article started researching. The second vet agreed that we could take it slow, but we needed to keep this crazy girl on a short leash (literally) and keep her super skinny. We put her on weight management food, gave her 1100mg of glucosamine condroitin MSM a day, after a couple months did regular swimming in a local pond, and limited her play. It took a year, but happy to report there is no clicking or looseness in her knee, and no surgery in her near future! Vet says this is very unusual case, but congratulated us on the progress we made.

Posted by: KD | February 27, 2014 7:00 PM    Report this comment

Thank you! My giant breed dog has a torn ligament and the vet was very fast (too fast!) in recommending the TPLO surgery on both knees and he is only a year old and suspected that there might be other alternatives to surgery for him. Your article prompted me to find a holistic vet in Asheville to give us a second opinion and recommendations on alternative therapies before we make a decision and this article gave us a nice base of information to work from so far. Fingers crossed!

Posted by: Jo Hannah | February 18, 2014 10:29 AM    Report this comment

Thanks for writing this article. My big older dog tore her ACL CCL Cruciate Ligament tendon. The vet said the gold standard was tplo surgery. Absolutely no risks. And to have money available to do the other knee too. Said we would need about $4,000 for the TPLO and $1,000 for pre and post surgery checkups and NSAIDs and pain meds. Then save another $5,000 because the other knee joint will tear in a few months anyway. And read that to save another $5,000 to pay for the complications that will happen in 1 in 3 dogs that get CCL surgery. I was told to have $15,000 set aside for tplo surgery. Then I read so many forums about those who had the surgery and the nightmare that followed from infections, bad surgeries, resurgeris, dying from the NSAIDS like rimidyl and previcox, bone cancer at the implant site, corrosion of the implant, etc. Too scary to risk surgery on my dog. I am very thankful for those that posted their experience with TPLO, TTA, tightrope, fishing line surgeries, etc. I read many many articles on pros and cons of CCL surgery. Apparently ccl tplo surgery is a fad and high profits for tplo surgeons. One thinks if they buy the most expensive surgery that their vet recommends plus the vet may get a referral fee or gift of some 10% of the $4,000, they are doing the best thing for their dog. Nothing can be further from the truth. After much research, I started looking into dog knee braces. I tried several dog knee braces that had severe slippage issues and the velcro was impossible getting all tangled in the long hair. But kept searching. I finally found a local posh dog knee brace in Florida. It was much improved dog knee brace with buckles on the outside of the leg, so easy to attach, no velcro on the upper leg, but straps and easy click buckles instead. It was easy to put on quickly. And it stayed in position. My big dog with a full tear has been wearing the posh dog knee brace for several months during the day, and out on dog walks. She can walk comfortably for longer and longer dog walks, and I can see the knee is healing. It is a slow process but she is happy now and is fine with wearing the posh dog knee brace with conservative management I am happy after many months of trying to find a safe solution for our dog. Thanks again for all those who shared their nightmare experience with CCL surgeries. Because of you, you saved my dog from going through a nightmare of pain. With research of articles and reading forums of experiences, we made the right decision to avoid surgery. I am very happy knowing I did make the right decision for my dog and did the safer alternative with the more affordable posh dog knee brace. I hope my experience will help others make the right decision for their dog and hopefully avoid ccl type surgeries, and the nightmare that may come with ccl type surgeries.

Posted by: dogdancer | September 26, 2013 9:59 AM    Report this comment

Although the author evaluated the results of surgery vs no surgery I did not see any mention of the use of prolotherapy for treating dogs with torn cruciates. I would like pet owners to know that prolotherapy is a viable third alternative to surgery or no surgery and in my hands it has been extremely effective. I have been performing proliferative therapy (prolotherapy) on both small and large breeds of dogs with torn cruciates for 10 years and would estimate it to be at least 80% effective in significantly reducing lameness and enhancing the quality of the pets life. Cold laser therapy can be used with prolotherapy to hasten the formation of fibrosis and the relief of pain. For those who have never heard of prolotherapy it involves injecting a specially prepared solution around and into the affected joint. Repeated injections are given every three weeks for approximately 5 visits. The injections are given under either sedation or light anesthetic. What prolotherapy does is stimulate fibrosis and the thickening of the joint capsule and other supporting ligaments around the damaged joint. Over a period of time the newly formed fibrosis contracts and tightens the joint. The procedures is very safe in experienced hands. Prolotherapy was orginally developed for use on humans and was first introduced in the mid 1950′s. For more information on prolotherapy visit either of my websites: myholisticpetvet.com or doc4pets.com .

To find out about prolotherapy for humans visit "caringmedical.com".

Posted by: woodside27452 | November 19, 2012 9:07 AM    Report this comment

Do you know anyone in Australia that works with the braces for dogs torn ACL, as we are going thru homeopathic injections, and thought the brace would also be very supportive.

Posted by: debc | September 30, 2012 11:07 PM    Report this comment

Hi, those of you who used the wound wear brace, can you give an indication of how much it cost?

Posted by: stephanie r | September 3, 2012 4:02 PM    Report this comment

Hi, those of you who used the wound wear brace, can you give an indication of how much it cost?

Posted by: stephanie r | September 3, 2012 4:02 PM    Report this comment

Thanks for the great article! I was doing some research and found that even with surgery a successful recovery is not guaranteed (only 85% success rate). My 13 year old husky mix had a full cruciate tear a little while back, and my vet said the surgery would be around $4000. Thankfully I found a surgery alternative brace at Woundwear while doing some research online. I felt comfortable contacting Woundwear to learn more about the product, and they were very helpful and easy to work with. I went to my vet to get the brace sized correctly, and now my dog is able to put weight on her leg while wearing the Woundwear A-Trac brace. I highly suggest the brace to others interested in a brace! Again great article!

Kelly B.

Posted by: KellyBrown | July 31, 2012 2:37 PM    Report this comment

Great article, thank you! My lab had a tplo surgery 2 years ago for a partial tear and I've regretted that decision terribly. She has never recovered and has had pain and limping ever since. Now I'm reading about how ineffective the surgery is and it's really upsetting because I went to one of the best hospitals and surgeons in the country (head of surgery at Angell Memorial in Boston) and they said this was the **only** choice. The implication was that nothing whatsoever could be done except surgery and no one ever said anything about the risks and possibility of failure.

At any rate, looking forward, does anyone have any thoughts about the therapies described above applied to a failed tplo situation?

Thank you!

Posted by: Unknown | July 28, 2012 8:17 AM    Report this comment

Great Article! My dog Zep had a full cruciate tear, it was not fun at all! Our vet recommended surgery, but we were not ready for the plunge. I did research and found articles such as this one and did not even know a brace could be used! After much research we went with the atrac dynamic brace by Woundwear. Dr. Spatt was very helpfull and had me get the right measurements etc. Zep is doing great! I suggest people looking into braces! Once again, great article!

Ed K.

Posted by: EdKawalsky | July 10, 2012 1:10 PM    Report this comment

When my Golden, Sammie partially tore his CL, his vet immediately put him on an anti-inflammatory and told me he needed total rest! Miraculously, he cooperated and was on the mend relatively quickly. I spoke to his acupuncture vet and we started treatments which also helped immensely. She recommended swimming therapy too, so after 4 or 6 weeks (I forget which), he started swimming. He LOVES swimming and fortunately made a full recovery within months. He still swims once a week for fun! Naturally, he has arthritis now which bothers him once in awhile. He is going to have stem cell therapy this summer to help alleviate the pain from arthritis before it slows him down.

I was fortunate to have the guidance of a great conservative vet AND a great holistic vet. Surgery was the last option, but neither of them ever recommended it throughout Sammie's recovery.

Posted by: Cindy G | May 30, 2012 9:33 AM    Report this comment

In Quebec, you can find orthotic-prosthetic devices and other rehabilitation products (harnesses, ramps, wheelchairs, etc) for animals at www.orthodesign.ca (they do business also with Canada, USA and Europe)

Posted by: OrthoDesign.ca | April 13, 2012 3:46 PM    Report this comment

thank you so much for this article! Yesterday I took my Great Pyrenees to the specialist who told me that she absolutely had to have an operation on BOTH knees for ruptured ligaments in the knees that would cost us a total of 6600$. I decided to look for alternative ways and found your article and I am so grateful. I've taken notes and hopefully won't have problems finding these products here in Quebec,Canada, but then there's alwyas internet! Thank you again for giving me hope.

Posted by: andree | April 12, 2012 10:37 AM    Report this comment

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