How to Prevent The #1 Cranial Cruciate Ligament (CCL) Complication
We’ve been talking about issues related to and how to prevent cranial cruciate ligament (CCL) tears. Today, we’re continuing the CCL discussion, but I want to introduce the number one complication related to CCL surgery that is overlooked.
If I were to ask you to list the most common surgical complications, you’d likely come up with infection, hemorrhage, shock, blood clots. These are common and problematic. But when we talk about cranial cruciate injury or surgery, there is something we must specifically look for because unless we do something to stop it, every dog that has a cranial cruciate injury or surgery has this happen. And when it does, it increases the chances that the other cranial cruciate ligament will be injured.
The #1 cranial cruciate injury or surgery Complication is Range of Motion Loss
The most common things we see with CCL injury or surgery is loss of flexion of the hock and extension of the stifle. This may not seem like a big issue, but it can lead to something much worse. It can be a factor in the tearing of the opposite CCL. Remember, 25-50% of dogs that tear one cruciate will tear the other in the next 16 months.
It makes sense, every time a dog sits, they flex their hock. When they flex the hock, the tibia is pushed forward, straining the cranial cruciate ligament fibers. If some of the fibers are torn, it puts added stress on the remaining fibers, causing pain. If the whole ligament is torn, it puts abnormal stress on the joint capsule as the tibia slides forward, also causing pain.
To prevent the pain, dogs will decrease the amount they are willing to flex their hock. To keep the hock at 90 degrees instead of 30-45 degrees of flexion, they will hold the limb forward as seen by the tip of the toes being ahead of the other side. They will hold the leg out to the side, and they may externally rotate the leg with their toes pointing out. They then shift their weight off of the leg which had the cruciate injury onto the other side. The healthier leg is held medially, or toward midline when standing, has added weight on it when they are sitting and laying down, and has added stress at the joint when they rise into a stand. This puts added stress on the knee on the good side, causing inflammation. It is the inflammation that causes stress to the cruciate ligament that can then cause the sprain or tear on the good side.
Early warning signs of trouble in the “good” knee
Thinning synovial fluid and then effusion. In this series we will discuss how anyone can check for effusion and the most sensitive way to assess for thin joint fluid. Watch for that post.
How to Assess and Treat Range of Motion IssueS
Assessing a dog’s range of motion is easy with a Goniometer. With some specific manual therapy and/or some passive range of motion exercises, we can keep available motion in the normal range or return it to normal quickly when it is lost. I touch on this briefly in this video, but will go more in depth in a couple weeks.
How to perform passive range of motion correctly
It is super important to work on flexion and extension of each joint independently to prevent putting excessive strain on some of the joints without benefiting the restricted joints. Some joints may be hypermobile (having too much motion) and they can actually become even more hypermobile or overstretched, to compensate for the hypomobile joint (a joint that has restricted motion) when several joints are motioned at the same time. This can lead to an injury at the hypermobile joint and not change the range of motion of the restricted joint. We never want to stretch a joint in the direction of its hypermobility. We do want to perform passive range of motion if there is restricted motion, to normalize it.
We always want to work within the dog’s comfort level.
There are rare instances that we want to increase tarsal extension. If this is done indiscriminately, we can cause irreversible damage.
The 90 Second Rule
To increase flexibility (muscle related) or range of motion (joint related), we stick to the 90-second rule. That means flex or extend the joint that has lost flexion or extension in either two sets of 45 seconds, three sets of 30 seconds, or my favorite, 10 sets of 10 seconds. I know this adds up to 100, but it’s easy to remember and works really well.
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