Specialty Spotlight: Is Conservative Management of Cruciate Disease a Viable Option for Your Patient…or Owner?
Is Conservative Management of Cruciate Disease a Viable Option for Your Patient…or Owner?
Laura Perez, DVM, CVA, CCRT
At the risk of opening an enormous can of worms, I’ve decided to give my 2 cents on conservative management of cruciate disease. Ask many vets and most surgeons and they are going to tell you that surgery is the only viable option. Ask another group of vets or those that strictly do complementary therapy and they are likely going to tell you otherwise. Truthfully, I find myself somewhere in between and do my best to present both sides to clients coming to see our rehab service for this issue with their dog. By talking owners through what both scenarios are generally going to look like, it allows them to make a more educated decision and do what is best for their dog and their situation. Unfortunately, there is a perception with conservative management that one or two strolls in the underwater treadmill and the occasional laser session and the dog should be good to go. Well, not exactly. There is also the perception that conservative management is a less expensive option. Potentially. The cost of surgery might be more upfront, but conservative management can add up overtime and over the life of the pet. When a young, large, goofy, athletic (fill in the blank) Lab, Rottweiler, Pit Bull, etc., comes limping into our rehab room and the owners tell me that they want the dog to go back to living a full tilt life, I’m going to strongly encourage them to consider surgery. Ultimately, assuming everything goes well, it is going to be the shorter path to recovery, result in less severe arthritis, and ideally prolong the time to when the arthritis gets significant enough to impact mobility and quality of life. If there is a high suspicion of a meniscal tear, than I will usually push for surgery even harder. Can a dog go through conservative management with a meniscal tear? Potentially, but it is a much longer process, the dog will be lame for a lot longer and it requires a lot more dedication on the owner’s end to the process. It is also not a guarantee. Ultimately, these dogs just don’t do as well. What I will always emphasize with any owner is that once the cruciate ligament is damaged, an inflammatory process has been set into motion in the joint and will result in arthritis. The time to be proactive about it is before it impacts the dog’s ability to do daily activities (go for walks, jump in/out of the car, do stairs). Across the board, one of the most consistently recognized and proven ways to do this in both human medicine and veterinary medicine is weight loss and maintaining a healthy body weight. In human studies, people report improved comfort and energy with just a 3-5% loss of body weight. At a recent CE lecture I attended by Dr. Marcellin-Little, he reported that owners will start to notice an improvement in their dog’s comfort and energy when they lose about 8% of their body weight. For that 90 pound Lab, that’s just 7 pounds. I find owners think I’m going to make really dramatic recommendations and are often relieved to hear a number like 7 to 10 pounds. Dogs can safely lose 1-2% of their body weight per week. That same 90 pound Lab can take almost 2 months to lose that weight. I find when you break it down a bit, it can seem less daunting to owners. If they see the improvement with just those 7 pounds, I am hopeful that it will motivate them to continue to work on weight loss. Does that mean we get 100% compliance with weight loss? No, but the results are obvious in the ones that do, so I will continue to encourage owners and be supportive.
What does conservative management look like? Successful conservative management centers around activity modification (definitely in the early stages and potentially long term), pain management, proprioceptive training and strength training. While I usually give owners averages of time to progress through the different stages of conservative management, every dog is different. It is more important to focus on how the patient is progressing before introducing the next stage. In the beginning, this means no off leash time outside, no running, no jumping, or playing with other dogs. When not directly observed, they should be kept in a small area with good footing and no furniture, stairs, etc. For some dogs, variations of these activity restrictions will need to be in place for 6 to 9 to sometimes 12 months. The big concerns are if it is a partial tear, that it becomes a complete tear and if it is a complete tear, that they then tear their meniscus. Sometimes owners just need this time to accept what has happened to their dog and realize that true conservative management is harder to do than they think and not the right choice for them or their dog. They try it for the first 4-6 weeks and then come into their appointment tired of the restrictions. Or they come in frustrated that it isn’t “working” for their dog. More often than not, with a few questions, it comes out that they have been letting the dog jump on/off of furniture or play with another dog, etc. If non-compliance becomes an obvious reoccurring theme, I will revisit the idea of surgery. Those that stick to the plan will progressively see their dog get more comfortable and we progress from the protection and pain management phase into early strength training and eventually more intense strength training. Contrary to what many think, the dog is not just crate rested for 2-3 months. With each stage comes more activity (specific, targeted exercises and activities), less restrictions and a gradual return to normal activities by ideally 3-4 months post injury, assuming everything goes to plan. Generally, by 6 months there is enough fibrosis to limit drawer in extension. Drawer in flexion may not be reduced until 9 months or more. However, depending on the dog, I still recommend not allowing unrestricted running, jumping, play, squirrel chasing, etc. for 9 months to a year and often long term modifications to activity need to be made. Conservative management can and should also include the use of the underwater treadmill, modalities (laser, acupuncture, EStim, etc.), NSAIDs, and nutraceuticals to support the dog in their recovery. There is also the potential use of a brace. This leads to entirely separate conversation regarding the pros and cons, what the brace looks like and what it will require of the owner, among other things. The successful use of a brace is also very dependent on owner compliance. If owners are interested, I recommend the use of a custom brace that after casting, fabrication and fitting and rechecks will usually cost $800-1000 for the average medium to large breed dog.
While you must obviously take into account what other comorbities your patient has when considering surgery, it is just as important for the owner to consider what the decision, surgery or not, means for them. In order for surgery to be successful, post-op instructions need to be followed. Similarly, in order for conservative management to be successful, owners need to be active participants in their dog’s recovery and recognize they are in it for the long haul.
-Laura Perez, DVM, CVA, CCRT