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Post Operative Rehabilitation for Cranial Cruciate Ligament Rupture(CCLR)

By: Victoria L. Kearns LVT, CCRP Physical Rehabilitator

Rupture of the cranial cruciate ligament is one of the most commonly encountered orthopedic problems in dogs. Early post-op rehabilitation has many benefits. These benefits help to promote early weight-bearing, decrease discomfort, slows then reverses muscle mass atrophy, increases range of motion(ROM), and helps to slow the progression of osteoarthritis. This article will be describing the typical progression of an exercise program that is performed on all cranial cruciate ruptures.

Patients are normally transferred for physical rehabilitation three days post operatively. Before performing any exercises it is imperative that the rehabilitator read through the patient’s record for the past medical/surgical history and perform an evaluation. This evaluation allows the rehabilitator to see the capabilities and needs of the patient and based on those needs, a rehab exercise program is devised.

 

The evaluation begins by assessing the patient’s gait. How much pressure is the dog putting on the affected limb? Is it non-weight bearing (NWB), toe touching, partial weight bearing (PWB) or fully weight bearing. Most patients are toe touching to partial weight bearing by 48 hours post-operatively. Next, both hind legs are palpated to determine if there is any muscle mass atrophy, particularly the quadriceps, bicep femoris, semimembranosus and semitendinosus muscles.  Measuring the thigh circumference on both hind legs helps to confirm the muscle mass atrophy that was palpated. The patient is then laid in lateral recumbency and the incision is checked.  Any bruising, swelling or irritation would be noted. If the incision is bound down or open anywhere, it would also be noted. The stifle itself is then palpated. One hand is placed on the cranial part of the stifle while the other hand is placed on the caudal metatarsals just below the hock. The affected stifle is then very slowly and gently flexed and extended checking for crepitus, discomfort, instability or tightness. The last step in the evaluation is the measurement of the joint angles with a goniometer, called goniometry and is measured in degrees. The joint angles to be measured are the hip, stifle and hock. It is important to measure both hind legs to compare the differences. Normal flexion on average is 50 degrees for the hip, 40 degrees for the stifle and 30 degrees for the hock. Normal extension for all the angles of the hind limbs is between 160 degrees – 170 degrees. When the evaluation is completed the treatment may begin.

 

Week 1, 1st week of rehabilitation

The goal of the first week is to reduce inflammation of the affected area and to prevent muscle mass contracture. Short 3-5 minute leash walks with a sling is a must before starting any exercises. This allows the patient to perform necessary eliminations and allows the rehabilitator to assess hind limb gait, noting the amount of weight bearing, non-weight bearing or if there is any head bobbing-indicating pain. Following completion of the walk, the dog is then laid on its side and the quadriceps bicep femoris, semimembranosus and semitendinosus muscles are gently massaged is to help loosen and relax the muscle groups before passive range of motion is performed. Passive range of motion (PROM) helps to move the synovial fluid around the joints and will help prevent muscle contracture. Proper hand placement is essential for PROM. One hand is placed cranially to medially at the distal part of the femur above the patella and the other hand is placed caudally on the metatarsals just below the hock. While keeping the limb level, all the joints are slowly flexed and extended as if the dog is on a bicycle. After the exercises have been completed, transcutaneous electrical nerve stimulation (TENS) is used. This machine uses electrical current to stimulate cutaneous and peripheral nerves via electrodes on the skin surface. This helps reduce or alleviate pain sensations by “numbing” the nerves with a lasting effect of six hours. Ice packs are used simultaneously with TENS for the first week. This reduces inflammation in and around the surgical site.

 

Week 2, 2 weeks post-op

 

The goal of the second week of rehab is to continue to prevent muscle mass contracture and to promote consistent weight bearing of the affected limb. The patient is sling walked first and the gait is assessed.  The patient is then laid down and a moist heat pack is placed on the affected stifle prior to the start of the exercises. Moist heat penetrates into the muscles, loosening and relaxing them for exercise. Following the completion of heating, the stifle is gently flexed and extended to the patient’s tolerance. The thigh muscles are then massaged to further loosen and relax the limb. The first weight bearing exercise that is performed is called standing plus weight shifting. This exercise is performed by placing the patient in a standing position with its hind feet as squared as possible under the hips and then gently swaying the rump side to side, without moving the feet. Proprioceptive input is another technique that not only helps to promote weight bearing and gives the stifle a mild stretch but, sends signals to the brain telling it that it is OK to use the limb. To perform this exercise, the rehabilitator’s hand is placed around the hock of the affected limb where the foot will then be pulsated on the ground (the bottom of the foot should not leave the ground). Incline standing may also be incorporated for the second week of rehab. The patient’s front legs are placed on a step while the hind legs remain on the ground. The hind end is then gently rocked side to side. This exercise promotes weight bearing and can increase muscle mass.

 

Weeks 3 to 7

The goals for weeks 3-7 are continued muscle building and return to normal function/activities. The walk time is now increased outside and no longer requires a sling. During the walk the patient is walked up and down curbs to help promote an increase in weight bearing. This exercise is called curb walk-overs. By this time the patient should only exhibit a mild lameness in the affected limb. All exercises from week 2 that were previously mentioned are increased, including heating, and a few new ones are now incorporated. Slow, controlled leash walking up steps is now introduced. Dancing is also a new exercise being performed. The front legs are picked up and held and then the patient slowly walks forward and backwards. This will help with extension of the hind legs and weight bearing. Circles are a simple exercise that will allow the patient to become more comfortable using the limb. The dog is literally walked in circles with the affected limb on the inside of the circle. This forces the dog to put an increased amount of pressure on the limb thus, further helping to increase weight bearing. Another exercise that is now performed is sit to stands. The patient is asked to sit and when a squared sit is accomplished, the patient is then asked to rise. A treat is normally used to entice the patient into the proper sitting position. Underwater treadmill walking is a great, unique modality that is used to increase muscle mass and promote full weight bearing. The patient is placed in the tank with a leash and lifejacket for safety and then the tank is slowly filled until water has reached a desired height. The treadmill belt is then started and walking will begin.  Most dogs, even if they do not like the water will start walking with time and encouragement. The water is heated to 98 degrees to ensure patient comfort. This also relaxes the body while increasing circulation. Patients’ physical progress determines the speed of the treadmill and the height of the water. The use of swimmies placed above the hock of the affected limb is also sometimes used to increase muscle.

 

There are many factors that influence a patient’s progress. Success of the surgery, weight, age and client compliance are just a few that could have a huge impact on an animal’s recovery. Proper client education and communication is key.  Every patient that is discharged from rehabilitation goes home with a home exercise program so that the owners may continue the patient’s progress at home and have a better understanding of what to do and what not to do.

 

Specific rehabilitation protocols vary from patient to patient and are customized to meet individual needs and capabilities. All exercises should be performed by a certified and trained rehabilitator.

 

                             

                          

 
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