Should my Dog Still be Limping After ACL (CCL) Surgery?
This is a common question, and the most common answers I give are as follows, based on what I find in my practice:
If your pet is limping your pet has about a 98% chance of being pain.
The most recent version of this topic may be found in my book for Kindle on Amazon. I have edited the topic to be concise and easier to read than what is contained here, however I have left some of the following info on this page for now because this topic receives thousands of hits on this site. Evidently it’s a big problem around the world! The link to my book using Amazon.com is:
and the book is not expensive
Your dog is not limping solely “because he/she had surgery”; the dog is limping because he/she is painful after surgery. This situation is also not really an issue of having to retrain the dog to use the leg…again, they are very most likely not using the leg because it is painful, and there are usually very good helps available for your pet, both pharmaceutical and non-pharmaceutical. This point is one I spend a lot of time going over with people, even on many occasions when their veterinarian hasn’t been quite convinced that there is pain. The vet not recognizing that the pet is in pain could be due to many reasons. Pretty much all I do daily is determine the level of pain in my clients based on multiple factors, including the animals response to daily activity and exercise programs I have outlined. I then determine whether more veterinary intervention is needed and also the next best course of functional rehab.
After working with athletes and other animals for over 30 years, as well as dealing with quite a bit of pain personally, I am well-versed in dealing with determining pain and working to eradicate it. Dogs usually aren’t quite acting themselves in the clinic when they see the vet, and most veterinarians I know, with whom I’ve had lengthy conversations, will admit to having been trained to look at the quality of the surgery and not necessarily add pain in as a factor. Often your pets regular veterinarian will give up any post-surgical medication intervention to the surgeon, and when the meds that the surgeon scripted run out, the limping begins. I find that vets with whom I work often are finding the benefit of dosing adequate medications so that the pet will use their leg in my rehab programs, and the pets do, every time we get the combo of pain relief correct (and when there’s nothing additional going on, as I cover below). Veterinary medicine, on the whole, wasn’t teaching that animals felt pain, in so many words, until the late 1980′s. Another point is that in human medicine, we don’t have pain management down to an exact science, by far, and that is for people who are able to speak or convey in language and signs we are accustomed to understanding better.
1) The pain could be due to the dog being too active.
2) The pain could be due to the dog not having enough pain meds that they are actually taking.
3) The pain could be due to the knee having an infection.
Those are the three most common situations I encounter after the surgery site has been checked by the veterinarian and has been deemed stable to the best of their knowledge. Follow your vet’s discharge instructions regarding restricting and controlling the activity of your pet, and I also have beneficial instructions regarding this on my homework pages on this site. Depending on the type of surgery performed, many things can go wrong with the items used to stabilize the knee, but that situation is not the most frequent culprit I find in my practice and experience. I cite infection as another culprit, and that can come from outside, i.e. licking the incision site, or that can come from suture or implants, etc…on some occasions. You will often be able to narrow down the issue to infection if moderate to high amounts of at least two analgesics are used and the dog is still limping until you try antibiotics. If your pet stops limping 1-3 days after the introduction of antibiotics, then it is likely that you have some form of infection. The “usual” pain medications don’t “usually” get rid of infection pain.
The fourth issue that I occasionally find is a torn meniscus. In older dogs that I’ve worked with for non-surgical help after a torn cruciate ligament, it has been beneficial in my area to combine Tramadol, Gabapentin, and an anti-inflammatory to get them through the additional pain of torn meniscus and on to better weight-bearing and therefore better muscle improvement. Other drugs may be used more prevalently in other countries. These drugs are great to help with the scientifically-proven exercise choice of gravity-based, weight-bearing drills, which is the most productive way to build bone, bone strength, and supportive tissue strength, including muscles. The increased thigh muscle will help support the joint and in most of my cases has served to stabilize the joint very well. This work will often also help your pet get past the acute phase of torn meniscus. I have had many of these meniscal tear cases work out with sufficient pain relief over time, however, if you have access to surgery procedure to have the meniscus scoped out (two small slit incisions will be made), then that can be a moderate remedy, too. I say moderate remedy because scoping is less invasive than opening the whole knee for full cruciate repair surgery, if you are wanting to avoid surgery. I have had cases that resolved and were strong after the non-surgical work for torn ligament and that have gone on to have the meniscus scoped out without fully opening the knee as would be done in the ligament repair surgery.
Elsewhere on this site, under “Research”, I have posted data from human sports medicine research citing that both torn meniscus and torn ACL can do very well without surgical intervention. These good outcomes involve exercise and physical therapy. Surgery for a torn or ruptured ACL/CCL and/or torn meniscus is optional and making the decision for this surgery is not a “life or death” decision. Those papers are here if you would like to know more about the studies for non-surgical remedy :):
If limping and pain are your pets issues, stop them from doing too much activity & read my recommendations on my homework page, which may be found here:
If your dog does not have an anti-inflammatory and an additional analgesic, like Tramadol and/or Gabapentin, for the first few weeks after surgery, then I recommend you ask your vet to consider supplying those. Use rest, restriction, and even ice during the time your pet does not have other pain relievers. Fish oil, fish containing Omega 3′s (or other animal dietary sources), joint supplements (Like Xymogen DJD, Glycoflex III, Cosequin DS) are beneficial, as are natural anti-inflammatories, like turmeric/curcumin, ginger, rosemary, etc…I like a product called Xyflamend by New Chapter for this. (No, I don’t receive any compensation for mentioning any of these online or in verbal discussion ;))
If your dog is on moderate-to-high amounts of those analgesics and is being restricted as recommended yet remains lame after a couple of days of renewed restriction and medications, then it is highly possible that your dog has an infection. An infection can be present and will cause pain, even if there is no known swelling or seepage. Anti-inflammatories and the other pain relievers will not relieve infection pain. In my area the vets will often prescribe Cephalexin for a two week course, and the limping usually ceases within the first 24 hrs. of taking the antibiotics.
Infections can occur for many reasons, and an infection is not necessarily someone’s “fault”. I see many patients that are licking at their incision, even if ever so slightly or infrequently (according to owners), and I am telling you that even a small amount of licking can cause a raging infection. Most often, though, I see infections that aren’t seeping or causing additional signs of there being an issue. We are confirmed in our suspicions when the antibiotics have great effect and the limping/lameness/pain is relieved. My own dog incurred infection in a very clean surgery hospital, however she had a weak immune system, and also due to other circumstances was open much longer on the table as she would otherwise have been. Lots of things can cause infection.
I do recommend remaining on additional pain relievers in order to begin my exercise protocol, primarily because your pet has been dealing with a lot of pain and has not been using the leg very well, if at all. Even when the infection is dealt with, your pet will likely need additional pain relief to help them use their leg as best possible while following the restrictions and the recommended exercises.
Those are the basics.
Limping does NOT mean that the dog (or other animal) needs to be taken to a water treadmill to induce usage of the affected leg. Limping means that there is a problem that needs be rooted out and dealt with. See my suggestions at the beginning of this post for the most likely culprits I have taken over the rehab of many dogs that were forced to walk in the water treadmill, didn’t have sufficient pain control, and often have had infection, which was easily rooted out after process of elimination. Some of these dogs, however, have ended up having additional injury that was also discovered after appropriate pain meds were given yet expected relief was not achieved. Some of them incurred injury by being forced to work in the water treadmill, with the practitioner suspecting they were ‘just not using the leg’ as if it were psychological. In my experience, if we deal with the root problem, which is pain, and we find the source of the pain, which can be as simple as “I just had surgery”, then the walking will happen, leg use will occur. Animals aren’t sitting around plotting disuse of their leg and overthinking the issue. They also aren’t holding out so you will give them more drugs. It’s rarely, if ever, “just psychological” with limb disuse. It wasn’t psychological when they were first injured, before surgery…
I use massage with the small Homedics unit featured in my massage video: http://rehabilitationandconditioningforanimals.wordpress.com/2011/11/27/simple-massage-video-uploaded-to-youtube/
I sometimes use ice, and sometimes laser therapy on the knees with infections or lots of effusion (joint swelling). I also recommend that my clients do not work the animals until the pain is relieved substantially. “Relieved substantially” means that they are only slightly favoring the leg. My exercise programs are designed to work in conjunction with adequate pharmaceutical pain relievers, where those are needed.
I have utilized many non-pharmaceutical methods of pain relief, however after surgery it seems that pharmaceutical pain relief (pills) gives the most benefit. Those pain relievers may be reduced over time as the muscles are built, the joint heals, and appropriate, slow, progressive, reintroduction to activity is accomplished. Please know that most post-surgical and some post-injury-non-surgical pets need to be on pain meds for 4-8 weeks, with 8-12 weeks usually being more productive. During this time, it is important to gauge their activity levels and utilize appropriate return-to-function exercise programs, only increasing activity slowly while gaining good pain control and only reducing pain control meds as more activity is able to be achieved without added discomfort (lameness, etc…). Use my homework for the exercise plan.
This means, stop going from total restriction to “return to normal activity”. Humans cannot go from a two-month layoff back to winning one of the top five marathons in the world, even if they are world-class…progressive reintroduction has to occur, regardless of what level you, as an athlete, or your pet were at prior to injury/surgery.
Oh, and, yes, there is always the possibility that your animal has destroyed the surgery in some manner. But the top three reasons for lameness & limping that I already cited are really the most prevalent causes. I have had a few clients who have simply not restricted the animal (dog, cat, horse, llama…) and have allowed far too much activity and have blown up the surgery. A typical example is a dog that is allowed to run up and down stairs and bounce all over the place. They usually blow out knee surgeries and have to have re-dos. Only speaking of knee surgeries here, four more biggies come to mind, and none of these have had to do with the owner allowing too much activity, although in two of them the surgeon tried to blame the owner and/or rehab, but infection was the ultimate culprit. Often I am not called onto a case until extra damage is done, so I am accustomed to rooting out these things, and hopefully this little bit of info is helpful to you.
Just speaking of knees, and just off the top of my head, one of those additional blowup cases was a tiny dog that had both cruciate ligaments and both patellas (kneecaps) operated on all at once. The practice of doing all that surgery at once is more common than you might think. The owner was very compliant, doing things the “right” way, and she had me come each weekday for a month to do the exercise and therapy work at least once daily, so she would “know” it was done correctly. I suspected infection right away in one knee because of the abnormal amount of swelling just a day or so after surgery. I reported to the surgeon excessive joint swelling (effusion) and other signs that accompanied this situation and that increased my belief that we had an infection compromising the repair. I could feel the pin in the problem knee working its way out. This would be a common side effect of infection. The short story is that the pin was removed many weeks later, and there was infection that would have most likely happened within several hours of surgery, given when I noticed the swelling.
Another case is mentioned elsewhere on this blog, that of the Great Pyranees that had knee surgery and ended up blowing out his opposing hip during recovery at a veterinary surgery center. By the time I saw him, I determined he definitely did not have adequate pain meds on board, for either the knee alone and much less for the addition of the FHO hip surgery as well. It is my guess that he was far, far too painful during recovery after the knee surgery and could not support himself well on the operated, atrophied leg. He had a series of very great complications, and the biggest battle, after we saved his life from gastro & infection-related near-death, was getting adequate pain relief for this very heavy and slightly lazy dog. Eventually so much time went by that his dysfunction (physical and psychological, in this case) complicated his recovery.
A third incident involved a dog that had a bone-modifying knee stabilization surgery (CBLO) and was damaged while in recovery at the specialty hospital where he had surgery, best we are able to determine from pre-and-post surgery xrays. The client was familiar with my work, and she called me to evaluate her dog when he was still exceedingly lame a little over a week out of surgery. He had been to work in a water treadmill already at a facility. When I first saw him, he was lame beyond what I would expect, based on my experience and based on the lack of swelling of any sort, however he also did not have enough pain control on board, based on established protocol and based on his lameness. He was set to go for another water treadmill session within the next week, and I drove home to the owner that she really, really needed to alleviate his pain and have the surgeon take another look at him. He was only being given an nsaid (non-steroidal anti-inflammatory)(Rimadyl, Vetprofen, Metacam, etc…). I pushed her to get Tramadol from either her regular vet or the surgeon. Weekend coming up, regular vet deferred to the surgeon, surgeon not responsive, associate vet finally gave script over the weekend. Yay! The pet went to his second, pre-scheduled, water treadmill session, and I saw him the following day. I told the owner to make an appointment with the surgeon and not do any more activity until they got an x-ray. The dog was far too lame for having the nsaid plus the new moderate doses of Tramadol on board. He had been on antibiotics for the surgery, if I recall correctly, so we didn’t think it was infection, plus, there wasn’t a large amount of effusion (knee joint swelling). It turned out that she got the x-ray and his fibula was broken and the screws and plates were pulled out from where the bone was cut. Eventually we were able to go back and compare post-op rx-rays and find that it seems the fibula was broken in recovery just after the surgery or ? We don’t know. What mattered was moving on and doing the best for the pup. It has been a little over a year and he is doing great! He had some re-dos and a long period of multiple pain reliever drugs being juggled. He was not on any meds at about a year out from the incidents. He did, however, need to take the pain relief drugs for many months. The point to these short stories is to give some brief recounting of post-surgical abnormal knee incidents so you may be informed and move forward with your pet. I am not going into full case studies here.
The fourth incident that comes to mind actually involves two small dogs with the same issue: both had suture repair of torn CCL/ACL and one was encouraged to run up and down the flight of stairs in the home soon after surgery because the owner thought it would help strengthen the dog. The pet had adequate pain meds, so the owner thought he was healed and encouraged this running. He blew out the surgery. The owner did receive instruction from the vet telling him of restrictions, etc…but restriction is not what happened, and often people are confused even if they receive adequate instructions. The restrictions are very important. The other case was also a small dog, and the owners felt sorry for her and allowed bouncing and running all over the house. She blew out two surgeries in one knee and about a year later had the same surgery on the other knee, this time with many restrictions heeded.
The first incident I told several paragraphs ago could happen to any pet, however in the many cases I’ve treated, even it is unique. The second and third are ones I see in large dogs once in a while because of complications in recovery. I’m convinced they should be recovered in the hospitals like a horse would be, in a supported sling, instead of on the floor! So, cover your bases regarding the first three reasons your dog may be limping/lame and pursue vet care based on this information.
In my area, we also have many vets that practice acupuncture and a few that do chiropractic work, so I often direct my patients to their services for the additional pain relief benefits. I know, based on how many I know of in this area that have had complications, as well as from feedback I receive from around the world, that very many of you out there have dealt with complications. Realize, though, that most issues I see before *major* complications set in are resolved by following the three guidelines at the beginning of this blog.
My own dog, Grace, had OCD (osteochondritis dissecans) in her knee(s), and before I knew more, before I got into this vocation and began putting together what I already knew from sports medicine and exercise physiology, I chose a TPLO surgery for her when she tore her first knee ligament, in the genetically malformed knee. She had about a half softball calcification at the medial aspect of the operated stifle, and a previous surgery performed to hopefully stimulate correct bone growth was unsuccessful. The TPLO cut was a non-union, meaning the bone did not grow back together after surgery. It wouldn’t have grown back, presumably, given that the bone was damaged inherently as it was, but I guess it was thought at the time to be worth a try, or that being able to move the position of the head of the tibia and have the plate in place to stabilize it was a positive step, given the other issues. I wouldn’t do it for that same dog and that same set of circumstances again today, but I know a lot more than I did those many years ago. That genetically bad knee turned out to be her better one over time, as the other knee eventually became destroyed. She tore the second CCL in about a years time, and I chose a TPLO for that knee as well. She seemed to have a compromised immune system, so we had a habit of starting her on Cephalexin some days prior to any surgery. Due to some circumstances, she ended up with a resistant pseudomonas infection seemingly immediately after surgery, complete with need for drains for the green slime over several weeks while I administered powerful, injectable antibiotics for weeks. It was clear within about two years that the infection had really eaten up her knee. She had two more scopes (arthroscopic surgeries) to clean out debris. She eventually became bone-on-bone in both knees, the infection knee being the worst, and she eventually tore all three ligaments (diagnosed via signs, x-rays, palpation, and common sense, collaborated by vets) in the worst, infection knee, and signs of more ligament tears existed in the original “bad” one. She was amazing nonetheless, and a pioneer for me regarding non-surgical helps for knee damage, since nothing more could be done given her dynamics and dramatic damage. With her immune system and other medical history, she probably would not have been a candidate for the knee replacement studies that were going on at the time.
And Grace’s situation is likely not the complication your dog/animal will encounter. I welcome stories of problem and resolution. I am only relaying these few stories to allow for the fact that other things do happen outside of the first three most common incidents I outlined, however the reason for lameness/limping after surgery is usually one (hopefully one) of the more simple-to-resolve first three situations I cited. !
The most updated version of this post is now available from Amazon.com through Kindle, under
Rehabilitation and Conditioning for Animals
Guidelines for Home Rehabilitation of Your Dog
After Surgery for Torn Knee Ligament,
First Four Weeks, Basic Edition