Cranial Cruciate Ligament Disease

Happy February everyone!  I figured that it was time to talk about one of the most common orthopedic issues in veterinary practice...Cruciate Ligament Tears!

Cranial cruciate ligament (CCL) disease is one of the most common and debilitating orthopedic diseases seen in dogs. The CCL (also called the anterior cruciate ligament or ACL) is an important ligament in the stifle (knee) of the dog that stabilizes the joint. Stretching and rupture of the ligament leads to instability in the stifle joint, which in turn leads to lameness, osteoarthritis and possible damage to the menisci (knee cartilages).

In human medicine, rupture of the anterior cruciate ligament (ACL) is a common sporting injury associated with overextension of the knee joint. While this is occasionally seen in dogs, (such as after jumping to catch a frisbee or rough play), the more typical presentation is a gradual onset of lameness that gets worse with exercise and over time. Often there is stretching or micro-tearing of the CCL over time leading to osteoarthritis and thickening of the joint, often already present by the time the pet first presents for lameness. As the damage progresses, it can lead to complete rupture of the CCL and injury to other structures such as the menisci (cartilages that cushion the joint).

While CCL tears have been linked to obesity, high carbohydrate diets, early spaying and neutering, and many other risk factors, fundamentally the underlying cause of canine CCL tear is biomechanical stress on the ligament. Humans also suffer from ACL tears, but the anatomy and mechanics of the human and canine knee (or stifle joint) are very different. In dogs, the weight bearing surface of the knee joint – the tibial plateau- slopes backwards. This leads to an inherent force within the knee whenever the limb is weight-bearing called the cranial tibial thrust. Once rupture has taken place, there is very little capacity for healing of the cranial cruciate ligament, partly due to poor blood supply to the ligament, and partly due to ongoing shear forces within the joint. Due to these factors, both stifle joints will eventually become affected in approximately 50-70% of patients with CCL disease.

Clinical signs for dogs with CCL tears can be variable. The dogs with a true traumatic injury to the CCL will present with acute onset of hind limb lameness, swelling, instability and pain on flexion and extension of the stifle, often with a palpable ‘clunk’ if meniscal injury is present. However, some patients may only exhibit lameness when first getting up in the morning. The lameness may subside with rest but recurs with activities like hiking or ball playing. However, other dogs have persistent, moderate to severe lameness. The degree of lameness is influenced by the amount of osteoarthritis, as well as the degree of tearing of the ligament and the meniscus, and may and may wax and wane for several months.

Almost all dogs with ACL problems will also show an altered sit posture. In many cases, dogs sit to the side, but in others they will slide their legs forward to sit on the tail base or pelvis rather than being centered over their tarsi (ankles).

Any dog suspected to be suffering from a CCL tear will require a thorough veterinary examination and often radiographs to determine the extent of the disease or injury and to determine the best treatment. Depending on the patient's lifestyle and the level of instability in the joint, surgery may be required to prevent rapid progression of arthritis, reduce pain and restore mobility. The most common methods of surgical repair are a TPLO (tibial plateau leveling osteotomy) or extracapsular stabilization procedure. In other cases, conservative management (assisted by an appropriate rehabilitation protocol) can be adequate to stabilize the joint and allow return to function.

Recently, stifle braces have become more widely available to assist in the management of dogs with CCL disease that not being managed by surgery. These can prevent some of the instability in the stifle that occurs during weight bearing, but can only be worn part of the day, so exercise would still need to be restricted.

Physiotherapy and rehabilitation are imperative to the success of either surgical or conservative management of cranial cruciate ligament disease. At Back on Track, we will work with you and your referring veterinarian to provide your pet with a tailored rehabilitation program, specific to your pet’s individual needs and goals.

Treatment ideally starts 5 -7 days after injury or surgery, but is beneficial at any point. Rehabilitation therapy may include manual therapy techniques such as massage and joint mobilizations, modalities such as heat and ice, LASER therapy, Acupuncture for pain relief, or the prescription of a custom stifle brace. Advice on appropriate bedding will be provided to ensure your pet is well supported.

Hydrotherapy, specifically underwater treadmill, also plays an important role in the rehabilitation program for patients with CCL disease. The buoyancy of the water means that strengthening can commence earlier while still protecting healing structures. This is ideally performed 2-3 times per week for best effects. Strengthening of the surrounding muscles is critical to help support the stifle, improve weight-bearing, and reduce pain as exercise increases.

A customized home exercise program allows you to continue therapy at home on a daily basis as well as addressing exercise restrictions specific to your pet’s stage of healing and your home environment. Regular reviews with your rehabilitation veterinarian are important to ensure your pet is progressing correctly and modify the home exercise plan accordingly.

Overall, the prognosis in most cases of CCL disease or injury is good once the stifle is stabilized adequately. Rehabilitation back to normal function can take from 3-6 months depending on severity and duration of injury and compliance with the rehabilitation program. As always, please feel free to contact Back on Track by phone or email to learn more about managing CCL disease in your pet.


Head and Jaw Shape

The amazing variation of skull shapes in dogs!

The amazing variation of skull shapes in dogs!

Happy New Year all!  I hope everyone had a lovely holiday and is feeling energized for 2016!  Today I am marveling at the variety of patients we see here at Back on Track.  We have French Bulldogs, Great Danes, Papillons, Mastiffs, Corgis....dogs come in so many shapes!  While most wild dogs look relatively similar (medium sized body and hair length, long bushy tail, and cone shaped head), centuries of selective breeding and domestication of dogs have resulted in a wide variety of face and head shapes in our pets today.  Along with this variation comes a wide range of issues affecting the nose, eyes, brain, teeth, and airway, not to mention overall balance and coordination. 

There are three basic skull types in domestic breeds: long nosed (dolichocephalic), short-nosed (brachiocephalic) and medium (mesocephalic). Mesocephalic dogs tend to have the fewest head and neck related issues, which is probably why most wild dogs fall in this category.  Dolichocephalic breeds, like Greyhounds and Borzois, tend to have very narrow skulls, and may have problems with eye formation, overbites and not enough room for incisor teeth to fit properly. Brachiocephalic breeds, like Pugs and Bulldogs, often have exaggerated underbites. Whether lengthened or shortened, if the shape of the skull is distorted, the space into which the teeth erupt can be distorted as well. This results in teeth that don’t fit together properly, or “malocclusions.”

Besides being interesting, evaluation of bite and skull shape is important to appropriate posture and gaiting, because the teeth and temporomandibular joints (TMJ) are giving critical postural information to the brain. A well aligned bite results in neutral TMJs, which allow neutral posture.

Try this exercise: Stand on level ground with easy neutral stance, arms at your sides. Feel how your weight is centered between your feet. Thrust your lower jaw forward as far as you can voluntarily, creating an underbite. Wait, and feel the postural changes. Now pull the jaw back as far as you can. Most people will feel their bodies pitch forward and back with the movement of the jaw. You can experiment with side to side as well, and feel your weight shift from foot to foot. This is a cool “trick,” but it also illustrates how jaw position helps determine weight-bearing, because the top priority of the nervous system is to keep the brain safe by making sure the nearby TM joints are symmetrically stimulated, indicating that the head is level and symmetrically supported. When a dog has a congenital or genetic malocclusion, the rest of the body may have an altered posture-- which may make them susceptible to injuries over time.

Long term assymetric posture and gait leads to musculoskeletal problems like hip dysfunction, ACL tears, arthritis, and disc disease.  Besides that, a truly functional bite is also self-cleaning and evenly wearing, requiring less dental intervention over the lifetime of the dog and minimizing periodontal inflammation and infections. Take a look at your dog's head shape and bite and think about how it may affect his or her posture or balance.  As always, feel free to ask me questions too - I love this stuff!


Dr. G




Shaving your dog for summer - do or don't?

Shaving your dog for the summer – do or don’t?


Structure of the coat on a double coated dog (Image created by Brook Wilkins)

Structure of the coat on a double coated dog (Image created by Brook Wilkins)

There are several different types of textures on dog’s fur, but in a general breakdown there are two coat types; single coated and double coated.  A single coat means that there is only a top (or over) coat that grows all over the body with no different undercoat.  Breeds such as Shih Tzus, Poodles, Bichons, for example, are ones with a single coat.  These breeds can be shaven generally with the only thing potentially occurring to the coat is over time it may become softer or it may have a slight colour change.  Even with only a single coat you want to be careful on when you shave them, especially if you shave them right down, as this, although may appear to feel cooler, leaves the dog exposed to the possibility of sunburn.  A dog with a coat shaved right down in the height of summer should not spend any length of time in direct sunlight.  With the simple fact that there is only one coat the hair grows back normally and even after a shaving.

A double coat means there is both a top (or over) coat made of tougher guard hairs and a bottom or (under) coat that is thick and soft.  Breeds such as Pomeranians, Shetland Sheepdogs, Siberian Huskies, Samoyeds, are examples of double coated dogs.  With a double coated dog they need to be groomed by brushing throughout the year but most heavily done  in the spring when a major shedding period occurs.  As the weather warms up the thick undercoat starts to do a complete shed, it detaches from the body and is often described as molting.  When you look at a dog in shed, they have “tufts” of fur that is soft and dense peaking through the longer guard hairs of the topcoat, this is called molting.


A double coated dog in a full blown shed

All this dense undercoat needs to be brushed out of the dog or Stage 3  from the top image above occurs.  The coat becomes impacted and matted, preventing air from being able to move between the dog’s topcoat and their skin.   Once all this undercoat is removed the air can circulate between and through the hairs of the topcoat keeping the dog cool, while the topcoat keeps the skin protected from the sun.  This topcoat can also protect the dog’s skin from fly and mosquito bites.

The question still remains then, why not shave them and just keep them out of the sun?  For one, they may not actually be cool even if they are out of the sun, the topcoat can help to keep the heat off the skin itself  and unlike people, dogs do not sweat through their skin.  Dogs sweat by panting and in all but northern breeds, through the pads of the feet.  Shaving them actually removes some of their natural ability to stay cool.  Another reason is that when the hair does begin to grow back it tends to do strange things.  For some, it may mean having patches that don’t grow at all, or that don’t grow both types of coat layers (top and under), older dogs often have issues with proper regrowth and then for others (which happens most often) the undercoat grows in faster than the topcoat (since the topcoat isn’t meant to shed extensively it grows extremely slowly) so now that protective topcoat is matted into the undercoat.  Dogs like this generally appear as though they have thyroid issues.  The hair looks fuzzy and varies in length all over the body.  This doesn’t mean the coat will forever stay this way.   Most of the time with regular brushing and the next shed cycle the topcoat will get longer while the undercoat sheds away, eventually leaving the coat the way it once was with long topcoat guard hairs and a thick shorter undercoat.  One other thing to note about those topcoat guard hairs – they actually prevent the dog from getting wet.  Due to the coarseness of the guard hairs water rolls off of this topcoat keeping the undercoat dry, which in the winter is important to keeping the dog warm and dry.

All of this being said there may be times where it is necessary to shave a double coated dog.  In surgical/medical situations the coat must be shaved or if the undercoat has become so matted it can not be combed out, shaving is the only solution.  Once the coat begins to grow in, keeping them brushed and free of matting will prevent the need to shave them in the future.

Bottom line?

The ideal situation: Keep the hair brushed, remove all the undercoat and allow the dog to remain with their natural ability to keep themselves cool and protected from the sun and some bug bites in the summer and warm and dry in the winter.

Additional sources of information:

Do CATS go in the water treadmill?

I get asked this question, and the answer is...YES, but...

We have done pretty much every treatment option available on cats, but most will respond well with just manual therapy and modified exercise plans. It is tricky to get cats to perform specific exercises, so we try to adapt things to get them to practice stretching, loading or pulling, depending on the issues. They also have a very short attention span, so 2-3 repetitions of something may be all that is needed, or possible. So generally, for cats, less is more.

But, our cat patients usually love the hands-on treatment and stretching here in the clinic. And about half of them were the type of cat that didn't like handling before we started therapy. Their backs hurt, or they were unstable or stiff in their joints so quick escapes were uncomfortable. Avoidance was their rule of thumb until they found someone to help them move again and reduce their pain. We check very cautiously to find the areas of pain, looking for skin and muscle tension around the site and approaching the area slowly.

We handle cats very gently and work with their bodies in ways that relax their muscles and allow for better joint movement. First, we check for which movement is painful (for instance, straightening the elbow if it is arthritic), stopping as their muscles start to react and feeling for the slightest resistance throughout the body. Then, we find the comfortable directions of movement, holding the body part and moving in three dimensions (like rotation, sideways motion, and gliding of the joint surfaces), working our way around until we reach the desired goal. We teach the body to move more appropriately in response to injury, until we get the injury healed. And we teach the cats which movements are tolerable, or use what treatment option is needed to reach comfortable movement.

Cats do well with acupuncture generally, as well as LASER. They like anything having to do with warmth. The warm water in the pool and treadmill can work in our favor. Usually, we resort to water therapy if we need specific strengthening or endurance. Most cats will not need this kind of work because they don't go on long walks or chase balls for long periods. Cats are also usually not so heavy that we can't support them on dry land or a land treadmill.

Often the first things people notice is that their cat doesn't climb up or jump anymore. Many of the cats we treat have back pain or spinal injuries. Some have arthritis in their hips, knees or elbows, especially if they were climbers and jumpers. We have worked with paralyzed cats after trauma or saddle thrombi (blood clots in the aorta) and they can learn to use carts or wheelchairs like dogs. Cats also injure their cranial cruciate ligaments like dogs and people, although not nearly as often. We also see cats with oddball genetic issues that limit their mobility.

The Occipital-Atlantal Joint

The OA joint may be the area that gets the most attention in my patients, and often shows up on my reports to referring vets, in some cryptic form, or on the insurance form as a dysfunction or subluxation. Today I saw a dog with ear pain, which the regular vet had had a hard time examining yesterday because of guarding and tension in the neck (okay, the owner said he was shrieking and wouldn't let them look deep in the ears). The OA joint was rotated, and after mobilization, I was able to see all the way to the eardrums, as well as the amount of debris that was causing irritation.

I often describe OA problems as feeling like tension headaches that arise from muscle tightness at the base of the skull and may radiate up around the ears and over the brow, where heat may be evident. It can result in tightness in the back of the throat, pressure or ringing in the ears. The dogs often yawn or shake the head after the joint tension is released.

Chronic ear problems or ear canal redness without discharge may be an indicator. These dogs may have a slight imbalance in the set of their ears, and if observed closer, their eyes and their whole head is slightly askew. Cavalier King Charles Spaniel dogs with Chiari-like malformations are the classic cases of this dysfunction, but any dog may be affected.

The most common cases observed in general practice will be geriatric vestibular syndrome (GVS) dogs. The primary problem is usually in the inner ear, but the muscle tension through the neck, combined with the dog’s desire to rotate the head to find balance, results in a secondary, fixed rotation at the OA joint, as well as increased muscle tension along one side of the neck, which exacerbates the wry neck and inability to stand or walk straight. If a current rehab patient is subsequently afflicted with GVS, I will encourage owners to bring them in for manipulation in the first couple of days to break the OA dysfunction component.

What is actually going wrong with the OA joint? It is a combination of bone slippage (subluxation of the rounded base of the skull in the cup of the first cervical vertebra) in one direction, instead of the normal rolling motion, then increased muscle and ligament tension (reflex inhibition , an unconscious protective mechanism) to prevent further slippage. This pinches the first cervical nerve, which affects the muscles along the back of the throat, front of the neck, inside of the jaw, back and sides of the head, and the ears. Also affected are very important muscular proprioceptors in the neck which provide postural feedback and affect overall muscle tone throughout the body. The dogs can no longer move fluidly to adjust for slight imbalances and use gross motor movements rather than finer movements to adapt. This leads to more jerking of the neck and head and a continual vicious cycle.

The cycle can be initiated by a variety of insults to the body. An illness with generalized muscle weakness or fever with muscle stiffness may be the cause. Lameness with a persistent head bob in one direction may lead to an OA problem, and the problem may continue as long as the lameness does, or until a better gait develops. Animals get whiplash from being in or being hit by vehicles. Even slipping or tripping can cause a dysfunction when the head jerks at the end of the neck.

Big dogs need strong necks to hold their heads steady, but it is the relative velocity of the head at the end of the neck, and the relative size of the head to the neck, so small dogs and cats are at risk as well. The other cause is compressive injury where the animal runs head-on into something or someone, or has a glancing blow off something, causing the head to bend tightly at the OA joint and pressing the bones to slide across each other instead rolling.

So the next time your pet seems to be looking at you sideways, or from under raised brows, look again. Is that dog able to move its’ head fully, or is it moving just the neck? Are those eyes and ears level? What about the line of the nose?

New and Newer at Back on Track

We've been busier than ever here at Back on Track. We have hired a second veterinary therapist, Dr. Jonit Greenberger, and are happily providing more services and time slots for the pets of the Pacific Northwest. We are training new staff to assist or veterinarians, so you can look forward to more new faces, with the same personal care and attention.

As you can see, our new website is functional, although still being updated. We switched platforms and software as well as updating some of our photos. Look for us on Facebook as well!

We are busy expanding into our extended space and hours. You can now drop off your pet as early as 7:30am, and pickup as late as 7:30pm. We have added a 3rd water treadmill in a separate room for those less-than-social dogs.

We also have a semi-self-serve bathing facility with a jetted hose called a HydroSurge, and a high-velocity dryer to reduce the drip factor (although my dog thinks the dryer is a vacuum and attacks it, luckily it has a rubber nozzle). Our staff can bathe your pets (scheduled in advance) or you can do it yourself, and we have a medicated shampoo option as well.