Pain Management Case of the Month: Golden Retriever with a CCL Tear

by Paul Brumett, DVM, CCRP, cAVCA, HTAP

Signalment and History

Josie is an 11-year-old spayed female golden retriever who enjoyed an active lifestyle and routinely walked 5 to 6 miles a day with her owners. In mid-January 2020, the owners heard Josie yelp on a walk and noted she was carrying her left rear leg. She was subsequently diagnosed with a left cranial cruciate ligament (CCL) tear by her regular veterinarian, who discussed surgical correction as well as conservative care with them. Josie was placed on 100 mg of carprofen once daily for pain and a joint health supplement by label. After a brief phone visit with the owner, Josie presented to my clinic at the end of February 2020 for consultation on stifle bracing and rehabilitation therapy.

Physical Examination and Diagnostics

On physical exam, Josie had a grade 2/5 limp on her left rear leg with decreased muscle mass. She externally rotated the left rear leg and had mild to moderate weight bearing in standing. At times she would toe touch with her left rear leg. Thigh girth in standing at the groin was 34 centimeters on the left and 39 centimeters on the right. The left iliopsoas was tender on palpation and the left stifle painful on extension with positive drawer and moderate e–usion. Neurological exam was normal. Radiographs taken at initial diagnosis by the referring veterinarian showed e–usion in both stifle joints, with the left being worse than the right. The owners were educated on the possibility of the right stifle having a CCL rupture in the future, which did happen about five months later. The rest of the exam was within normal limits.

Treatment and Outcome

A discussion on surgical correction of CCL tears as the current standard of care in veterinary medicine, the use of custom stifle orthotics/braces (knee braces), conservative care, and possible outcomes/expectations was undertaken with Josie’s owners.

They decided to move forward with a custom stifle orthotic (brace) for the left stifle and rehabilitation therapy. Josie received veterinary chiropractic, laser therapy (Class 3b) of her stifles and lower back, targeted pulsed electromagnetic field therapy for her stifles and lower back, and targeted exercises at each therapy session.

The custom stifle orthotic was cast per manufacturer instructions as follows: Josie was placed in right lateral recumbency without sedation. A veterinary nurse and the owner assisted in restraint. Stockinette was placed over the limb extending from the groin to the foot. A cutting strip was placed on the lateral side of the left pelvic limb with the ends through a small hole in either end of the stockinette.

As the limb was held in extension, casting material was wrapped snuggly, starting just below the ankle and wrapping up high into the groin with a 50% overlap.

The casting material was then spiraled back down at approximately a 45-degree angle to create three layers of material ending at the ankle. Reduction of drawer was accomplished by the wrap of the casting tape and gently pulling perpendicular to the hip at the ankle. As the casting material became firm, pictures were taken of the cast on the limb from the front, side, and rear for reference at the lab.

As the cast hardens, take pictures of the cast on the limb from the front, side, and rear. Note the placement of the cutting strip. These pictures were taken during Josie’s right stifle casting.

The cast was removed using a hook blade carpet knife with the cutting strip as both protection and guide. The underlying stockinette was cut off and the cast removed with the edges realigned to fully set. Measurements were taken per manufacturer instructions.

After making the casting/impression, Josie was sent home with instructions to perform targeted exercises at home, continue leash walks for bathroom breaks, and continue the pain and joint medications previously prescribed by her regular veterinarian.

Approximately three weeks later, Josie was fitted with her custom left stifle brace.The owners were instructed on proper donning and dožng as well
as proper break-in/wearing schedule.

Josie in her first stifle brace.	Josie in both braces.

Josie was to work up to 8 to 12 hours of wear time during the day over 7 to 10 days. She received another round of laser therapy, tPEMF, vet  chiropractic, and new exercises that could be performed in her brace to enhance use and regain muscle mass.

Normally, Josie would have had a two-week follow-up, but the COVID-19 pandemic began to restrict movement and the owners kept in touch by phone and email. Josie was doing well. At six weeks after brace fitting, Josie was back up to walking two miles a day and was tolerating the brace well. On exam, her thigh girth in standing had increased by four centimeters on the left side. At 10 weeks after brace fitting, Josie was walking two miles twice a day and thigh girth had increased by two more centimeters in both rear limbs. Josie’s owners were instructed to continue rehabilitation exercises at home.

Discussion and Conclusion

Josie’s case is typical of what I see in my rehabilitation practice: owners who are looking for treatment options  other than surgery, such as those with older pets and comorbidities. In Josie’s case, like 50% to 60% of dogs who rupture one CCL, she ruptured her right CCL five months after the
left. After additional consultation we placed her in a right custom stifle
orthotic. Josie has done well and is back to three- to four-mile walks daily
with her owners in her braces. 

Custom stifle orthotics are still controversial in some circles and need to be applied for the right reasons. Although the custom stifle brace is designed to manage drawer and support the stifle, it is more diffcult to manage patella luxation and collateral ligament damage. The degree of medial meniscal damage and coping ability of the pet can also affect how well a stifle brace can help. Each bracing company has its own thoughts and approaches to these issues, and I encourage anyone considering a brace to consult with the company they are working with. The casting process presented for Josie is similar between companies, but each has its own variation. Check with them to see exactly what techniques, measurements, and labeling they require.

Custom stifle orthotics are relatively new to veterinary medicine, having only been in use the last two decades. As veterinarians, physical therapists, and clients begin to understand and use these devices more, we will get better at applying them to specific cases. Research on custom orthotics and braces is ongoing and needs to continue so that we can understand more about the biomechanics, proper application of corrective forces, design, and use for our patients in the future.

Paul Brumett DVM, CCRP, cAVCA, HTAP, practices in Grand Junction, Colorado. He is a Healing Touch for Animals Practitioner, certified in Canine Rehabilitation, and certified by the American Veterinary Chiropractic Association in Animal Chiropractic. He is also a Hero Braces consultant and representative, and performs site visits, presentations, and CE events across the country.

 

Photo credits: Photos courtesy of Paul Brumett, Photos courtsey of David Karisny