When you are all grown up

One of the most common orthopedic problems in dogs is a torn cranial cruciate ligament (CCL). A ligament connects one bone to another, often allowing for movement and stabilization of a joint. People have this ligament also. We call it our ACL, or anterior cruciate ligament. The difference in names between dogs and people is due to nomenclature but they’re essentially the same ligament.

As the weather gets nicer, people and dogs are more active. It is this time of year that I see more injuries to this ligament. As in people, it may just be a strain, or it can be completely torn. If a strain is not given the appropriate time to heal, it will tear. a ligament usually takes 2-6 weeks.

If the problem is severe, there are a number of surgical techniques to correct it. However, in cases of less severity, I try to tailor a rehab plan (with or without surgery) to each patient’s (and client’s) needs and situation. This particular case, as you will see, tailored the plan for me.

Dexter is a very cute Golden Retriever puppy, long on looks and sweetness but short on common sense. He is your typical pup, an active and happy new soul. He was about 3 months old the first time I met him. I had been seeing him for his vaccines and wellness visits. He had always had very nice conformation and movement. When he came in a month later holding up his left hind leg completely, I was worried.

He had been playing with his dad, Mr. Miller, out on the dock at their lake house. Dad was in the kayak when Dexter decided he should join him. Good intention, bad outcome. Dexter slipped off the dock and kayak, and landed in the lake. Dad got him right out, but the pup was very tender in his back leg.

In normal growing puppies, there is a certain bit of laxity in the knee-joint. This is because the ligaments are growing, and are not completely taut yet. This “puppy drawer” goes away around 8-12 months of age. While Dexter had this in the right knee, there was definitely more laxity in the left. The left knee was also very swollen and painful.

Good dog that he was, I was able to take x-rays (radiographs) of him awake to make sure there was no fracture. Going on the principle that puppies are made out of rubber, I hoped for just a bad strain and started Dexter on oral anti-inflammatories and pain relievers. That, in combination with icing of the left knee and strict crate rest for 1 week, I hoped would reduce the swelling and give me a better understanding of what damage was done.

If a person has this type of injury, they can have an MRI done. In dogs, this is possible too, but requires general anesthesia and costs around $1600 all by itself. Needless to say, we usually hold off on that.

One week later, I saw Dexter again. Mom and Dad have been very careful with Chip. The swelling reduced, but while he is placing the leg on the ground some of the time, he is definitely not healed. We continue the oral medications and add in an injection series that goes under his skin and gets into the damaged joint. We also begin laser treatments to help stimulate the ligament to heal. The restricted activity is also continued – not fun for 4-month-old puppies. We will re-convene in 2 weeks this time.

I had avoided surgery since Dexter and his knee-joint is still growing. The established surgical protocol requires that bones and joints be fully grown. This usually happens around 1 year of age. I reviewed Dexter’s case with an orthopedic surgical specialist, and there was an experimental technique for growing dogs, but it had only been done in 6 dogs in Europe, and none in the states yet. I offered it to the Millers, but they didn’t want to pursue it.

2 weeks later he is doing a fair bit better. We continue the twice-weekly laser treatments and injections, and add in underwater treadmill therapy to strengthen the muscles of the leg. This also allows for some exercise, which is needed for Dexter and the Millers mental health.

While some of the laxity in Dexter’s knee has decreased, I am not confident that the ligament is going to heal completely on its own. I prepare the owners that we may need to tread water with Dexter until he is done growing, and then surgically repair the problem. They understood and were okay with it.

Over the next few months Dexter does pretty well. The knee does bother him some days, but a combination of continued rehab, laser treatments, and anti-inflammatory medications keep him comfortable and happy. We take new radiographs for his first birthday, and see that the bones are done growing. I also see why he had such a problem.

We all have growth plates at the top and bottom of our long bones (tibia, femur, humerus, etc.), and when Dexter fell the previous summer, he damaged the growth plate at the top of his left tibia. The fall did initially damage his cruciate ligament, but as he grew the tibia grew with an angle that constantly pulled on the ligament. It was this angle that didn’t allow his ligament to heal properly.

We prepped Dexter for surgery and corrected the inappropriate angle of his tibia. The surgery was a success. After the healing process and rehabilitation, he was running and jumping safely at the lake the next summer.

Normally, when conservative therapy doesn’t work after a few weeks on a strain or partial tear, I will recommend surgery. In this case I had to wait for Dexter’s body to give me the green light. And it was the patience and dedication of mom and dad that made him such a success.

We can always do that later

When I look at my schedule on the computer for any given day, there will be a variety of patients and ailments. Peppers the poodle for vaccines, Momma Kitty for “limping on and off for 6 months.” Some just say “2nd opinion having issues – wants to talk to doctor”.

This was the case with Matilda. A 12 year old yellow Labrador Retriever. Once the client and patient are in an exam room, the technician takes a detailed history, along with a baseline temperature, pulse, respiration, etc. They then leave the chart outside the closed door and it is my turn.

I always try and read the history before I go in, to get a jump on what problems may be going on. The owner notes difficulty with stairs, trouble rising, reluctance to go outside. The weight, temp, pulse all look good. At the end of this history there is a spot for other comments, and the technician had written “owner considering euthanasia, pet just not herself.”

This makes me pause, and I try to imagine what else is going on. Are there other issues at home, other stresses? I also respect the human-animal bond and if an owner says it is time to stop, they spend their whole lives with their pet. I sometimes only see them once a year for 30 minutes.

I head into the room, and am greeted by a middle age woman, her teenage son and the woman’s mother, hunched over from chronic back pain. Matilda is lying on the floor, smiling away and tail thumping. I squat down and begin to pet her as I talk with everyone.

Matilda hasn’t wanted to play as much, she likes to lie around a lot, she fell down the 3 steps going outside last week. Once they found her lying in her own urine by the back door. They had taken her to their regular vet a few months ago, she was diagnosed with arthritis, and was started on an anti-inflammatory.

They had seen improvement, but then she started having diarrhea and her liver values went up, so they had to stop the drug. That was 3 months ago, and they have seen her slide downward ever since. Mom says she doesn’t know what else to do. They love her, but they are wondering if it is time to put her to sleep.

I say that we can discuss that in a minute, after I examine her. I run my hands all up and down Matilda’s coat, note the little bit of tartar on her teeth, feel the creaky stiff elbow joints up from and note the lack of muscle tone and hip extension in both of her back legs. However, her heart and lungs sound good, her pulses are strong, and the rest of her is pretty good.

I ask her to stand up and she definitely has difficulty rising on the slippery exam room floor, but she can do it. We take her outside for a walk on the pavement, and although gingerly, she does take good strides and goes up and down the parking lot twice. At the end, I can see she is tired, so I carry her back in.

I speak with the owners, agreeing with the likely diagnosis of multi-site arthritis. There are some good things here: no neurological problems, no torn ligaments. The lack of muscle tone and creaky joints are the telltale signs for arthritis, and I doubt it is something more serious than that. Arthritis can be tough, painful, and especially when it is affecting each of Matilda’s four legs. Some days, one leg may hurt more than the others, and it does explain why she would have a hard time getting up. Do we need radiographs (X-rays) to confirm this? Not necessarily but, if we wanted to, we could. However, if things continue to progress poorly, we should definitely take a look.

Arthritis is a very common diagnosis in dogs, and, more often than not, it will be in more than one joint. This can make these cases challenging. The first line class of drugs we use are the NSAIDs. The Non-Steroidal Anti Inflammatory Drugs. Dogs need to take ones designed for dogs, and people take ones for people.

The vast majority of the time these drugs are very safe, but nothing is 100%. Problems can range from stomach ulcers to kidney and liver problems. With careful dosing and monitoring via blood tests, these drugs can be a great asset in the battle against arthritis.

The chances for severe problems with these drugs are slim, but when your pet is the one with a reaction, slim doesn’t matter. In Matilda ‘s case, she didn’t handle one of the medications well. That’s why it is necessary to carefully monitor for problems and perform follow-up blood work.

I discussed our options with the owners. To answer their question about putting her to sleep, I tell them “I don’t see her day in and day out, and if you feel she is suffering, we can talk about that. But why not discuss other options and see how she does? If she does not improve, then we can revisit euthanasia.” That seems to make the son and grandmother a bit comfortable, but I see hesitancy on Mom’s face.

Then I notice the lack of a wedding band. Now I start to see it: single mom, has her mother living with her, and raising her teenage son. And then there is Matilda, now having issues. This cannot be easy. I also do not want them to feel rushed or pushed in to a decision, one way or the other.

We review some practical options for them. Oral supplements like Glucoasamine and Chondroitin can take weeks to see improvement, and may not work for every patient. The same can be said for fish oil supplementation. In the long term, these are helpful, but I know we need to give this family a time frame to see which way Matilda is going.

The difficult thing about arthritis is that it can take months and years to come on and show signs. So, expecting an overnight quick fix doesn’t happen. Knowing that she had a reaction to one of the NSAIDs, I am hesitant to have her on another one long-term. However, it is this class of drugs that we often see the fastest response to, often in 1-2 weeks. And they are different enough that a pet can have problems with one and be fine with another. But if she is on a new one long term and then has issues, we will be back revisiting this same issue.

Ultimately, we agree to start Matilda on a new NSAID, but they won’t start it until I get the blood work back tomorrow. Then I will see her in 1 week and 4 weeks after today for a follow up.

As a rehab practitioner, I also lay out a plan for daily massage and passive range of motion exercises for Matilda, any of the family members can do. We also talk about providing some traction on the kitchen floor to aid in her getting up. We also talk about making some laps in the backyard to get her some exercise.

Keeping arthritic joints moving definitely helps. When we do not move as much, we lose muscle mass, which then puts more strain on the joints to bear the body weight when we do move. Simple exercises help painful joints and also decrease the need for pain medications.

Knowing that her mobility improved with the first drug, I am expecting her to improve again on the new one. As long as her body is handling the new drug well, I plan to not have her on it every day long-term. At the one-week check we repeat blood work to make sure she is tolerating them.

The owners do not notice much improvement with her mobility, but the blood work shows she is handling the new drug well. At this point, I prescribe my long-term plan. Adequan is an injectable medication of polysulfated glycoaminoglycans. These are the building blocks to healthy joints, and also have anti-inflammatory properties. It also has 1/10 the risk of side effects as the NSAID’s.

The catch, you ask? We have to give injections twice a week for 4 weeks, then about once a month. They need time to build up in the body, so it can take 3-4 weeks to see improvement. Also, the first month can be expensive, just because of the number of injections. I have tried to make this easier by teaching the majority of owners to give the injections under the skin at home, to save time and money in the commute. It also allows them to escape having to wait in the lobby for 15 minutes for a 1 minute visit. This also saves the arthritic dog multiple car rides, which can be tough on them. Some owners are a little hesitant to give injections, but since most pets do not have a fear of needles, the injections usually go well.

As the Adequan builds up in their system, I usually find I can wean the patient down on the NSAID, therefore minimizing our chances of side effects. I find that most pets do need some oral pain relief from time to time. Adequan works only on joints, and if we slip and fall we can strain a muscle or tendon, and NSAIDs are also great to reduce that inflammation.

Mom is still hesitant, but she does start the Adequan, and I plan to see them in 3 weeks. At the next recheck, I was running late, so I didn’t read the history. I just went into the exam room and was greeted by Matilda at the door, smiling, wagging and leaning into me. Smiles abound on Mom, son and Grandma too.

Matilda is much more comfortable, and she is only taking the oral NSAID every other day. Grandma asks me if she can take Adequan herself, I smile and tell her to ask her doctor. (To my knowledge, Adequan is not used in people).

They agree to keep up with monthly injections, and eventually Matilda is only taking an NSAID on an as needed basis, which turns out to be about once a week. They have also kept up with daily massage and range of motion exercises. As they head out to the exam room, Mom stays back to thank me for not putting Matilda to sleep a few weeks ago. “I really didn’t want to, but I didn’t know what else to do.”

As a veterinarian, we have to not only examine the patient but the client. It turns out that most of the time it’s all about listening, and just presenting practical options.