What is Cranial Cruciate Ligament Disease

• ~ Cranial cruciate important stabilizer in the stifle, it prevents the movement of the tibia on the femur during weight bearing.
• ~ It is a degenerative condition – due to long term over use and stain of the ligament.
• ~ Tears can be full or partial
• ~ Although uncommon – acute traumatic tears are also seen
• ~ Osteoarthritis starts developing soon after the initial injury due to the instability in the joint caused by the sliding of the tibia on the femur. The instability causes cartilage damage and eventually formation of osteoarthritis.
• ~ Osteoarthritis is a lifelong progressive disease and it is therefore crucial that these injuries are addressed as soon as possible to minimize the abnormal forces in the stifle.
• ~ Osteoarthritis starts developing soon after the initial injury due to the instability in the joint caused by the sliding of the tibia on the femur. The instability causes cartilage damage and eventually formation of osteoarthritis.
• ~ Osteoarthritis is a lifelong progressive disease and it is therefore crucial that these injuries are addressed as soon as possible to minimize the abnormal forces in the stifle.

Predisposing factors:

• ~ Conformation- poor stifle angulation
• ~ Overweight
• ~ Poor physical condition – lack of muscle mass and strength
• ~ Breed
• ~ Age/aging of ligament

Signs and Symptoms:

• ~ Decreased activity level
• ~ Difficulty rising/ jumping onto things
• ~ Obvious lameness/ limping
• ~ Often non-weight bearing on the affected limb
• ~ Often toe touches with the affected limb when standing
• ~ Pain associated with the stifle/knee joint
• ~ Atrophy of hind limb muscles
• ~ Swelling on stifle/knee joint
• ~ Decreased flexion of stifle/knee joint

Treatment Options and Conservative Management:

Conservative management is usually only successful in the following cases:

1. Partial tears
2. When no meniscal tears are involved
3. Smaller dogs = less than 15kg

Treatment Options Surgical Intervention:

Surgical intervention is usually indicated in the following cases:

1. Complete tears
2. When meniscal tears are involved
3. Bigger dogs = more than 15kg

Goals of Physiotherapy in the Treatment of Conservative Cruciate Ligament Disease Management:

1. Strict rest, confinement and activity restriction
2. Decrease pain levels
3. Decrease compensatory muscle pain and tightness
4. Maintain function and range of motion of the stifle joint
5. Prevent muscle atrophy and increase muscle mass and strength
6. Provide a structured exercise plan
7. Provide advice regarding home modification, diet changes and weight management

General Goals of Post-Operative Physiotherapy?

• ~ Decrease pain levels
• ~ Decrease swelling
• ~ Encourage weight-bearing
• ~ Prevent and/or detect complications
• ~ Decrease compensatory muscle pain and tightness
• ~ Maintain function and range of motion of the stifle
• ~ Prevent muscle atrophy and increase muscle mass
• ~ Provide a structured exercise plan
• ~ Provide advice regarding home modification, diet changes and weight management

What is it?

1. The common calcanean tendon is made up the tendons of 5 hind limb muscles.
2. Injury to the common calcanean tendon can be complete or partial.

Treatment Options:

Goals of Physiotherapy:

• ~ Maintain ROM
• ~ Decrease pain and/or inflammation
• ~ Decrease compensation
• ~ Increase muscle mass and strength
• ~ Prevent complications
• ~ Provide a structured exercise plan
• ~ Provide advice regarding home modification, diet changes and weight management

What is it?

• ~ Found that there was a higher rate of digit injuries than fractures in racing grey hounds
• ~ Found that there was a higher rate of fractures than digit injuries in agility dogs
• ~ Mostly found on the RF, 2^nd, 5^th and 3^rd digit

Signs and Symptoms:

• ~ Pain on palpation
• ~ Can do flexion test like in horses to isolate which digit. So flex one digit and do gait analysis and repeat
• ~ For radiographs it may be easier to tape the nail and pull it into extension to have a better view radiographically
• ~ Can use US

Treatment options - mainly conservative:

1. Rest
2. Pain medication and NSAID’s
3. Intra-articular steroids if needed
4. Rehabilitation of digit injuries include
   • Manual therapy including mobilisation, traction and range of motion
   • Laser therapy
   • Ultrasound
   • Therapeutic exercises include
   • Hydrotherapy
5. Buddy taping in humans
   • Reduce pain and stiffness
   • Earlier return to function
   • Increased blood flow
   • Increased healing
   • Decrease swelling
   • Problems we face sores from splints and laxity
   • In some cases unavoidable to splint
   • Appropriate for grade 1 or 2 sprains and after the initial fracture splinting for additional support

Goals of Physiotherapy:

1. Decrease pain and inflammation
2. Maintain ROM
3. Decrease compensation
4. Increase strength
5. Provide a structured exercise plan
6. Provide advice regarding home modification, diet changes and weight management

Types of Fractures

• ~ Incomplete
• ~ Complete
• ~ Transverse
• ~ Oblique
• ~ Comminuted
• ~ Butterfly
• ~ Open/ closed – whether there is an open wound or not
• ~ Inter-articular – affecting a joint

Causes:

• Trauma

Signs and Symptoms:

• ~ Depended on fracture
• ~ Unable to bear weight
• ~ Unable to stand
• ~  Swelling
• ~ Pain
• ~ Movement at fracture ends

Healing Factors:

• ~ Age
• ~ Disruption of muscle and blood vessels
• ~ Surgical trauma
• ~ Stabilization of fracture ends

Recover Time:

• ~ Young puppies - minumum of 4 weeks
• ~ Adults - minimum of 8 weeks
• ~ It is NB that there is a slow return to function over the course of 12 weeks depending on the case

Treatment Options:

• Depends on the type of fracture and the severity thereof

Common Complications Associated with Hind Limb Fractures!

Goals of Post-Operative Physiotherapy:

1. Maintain joint ROM
2. Decrease pain and/or inflammation
3. Decrease compensation
4. Encourage weight bearing
5. Increase muscle mass and strength
6. Prevent complications
7. Provide a structured exercise plan – slow return to function

Muscle: Quadriceps Contracture

What is it?

1. A pathological process where the muscle tissue is replaced by fibrous tissue.
2. This results in permanent shortening of the muscles, loss or range of motion and loss of function.
3. quadriceps contracture is commonly seen in puppies who had a distal femoral fracture.

 Causes:

• ~ Trauma
• ~ Fractures
• ~ Repetitive strain
• ~ Immune mediated
• ~ Infection
• ~ Following prolonged immobilization or disuse

Signs and Symptoms:

• ~ Lameness 3-5 weeks after distal femoral fracture repair
• ~ Atrophy of the quadriceps muscle
• ~ Very limited stifle flexion

Treatment Options:

1. The treatment options for m. quadriceps contracture are limited.
2. Surgery can be done to remove the adhesions formed between the muscle and the bone – but it is often unsuccessful
3. The best treatment is to prevent it – NB physiotherapy post femoral fracture

Goals of physiotherapy to help prevent m. quadriceps contracture post femoral fracture repair?

1. Maintain stifle ROM – very regular stifle PROM
2. Maintain m. quadriceps muscle length – prolonged stretches
3. Decrease pain
4. Decrease compensation
5. Increase early weight bearing post operatively – this will promote correct use of m. quadriceps
6. Increase muscle mass and strength
7. Prevent complications
8. Provide a structured exercise plan
9. Provide advice regarding home modification, diet changes and weight management

Hamstring Muscles: Gracillis and Semimembranosus Contracture:

What is it?

1. A pathological process where the muscle tissue is replaced by fibrous tissue.
2. This results in permanent shortening of the muscles, loss or range of motion and loss of function.
3. gracillis and m. semimembranosus contracture is commonly seen in sporting dogs.
4. Common breeds affected is GSD, Dobermans and Belgian shepherds

Causes:

• ~ Trauma
• ~ Fractures
• ~ Repetitive strain
• ~ Immune mediated
• ~ Infection
• ~ Following prolonged immobilization or disuse

Signs and symptoms?

• ~ Lameness + strange gait
• ~ Shortened stride.
• ~ Characteristic gait m. semimembranosus – slap down of paw and swivel action
• ~ Characteristic gait m. gracillis – slap down of paw
• ~ Lameness is worse at the trot

Treatment options:

1. The treatment options are limited.
2. It is usually unresponsive to conservative management
3. Surgical management provides temporary improvement in gait – but it often returns on 2-4 weeks

Goals of physiotherapy?

1. Maintain hind limb ROM
2. Maintain and increase muscle length
3. Decrease pain
4. Decrease compensation
5. Increase muscle mass and strength
6. Provide a structured exercise plan
7. Prevent progression of disorder
8. Provide advice regarding home modification, diet changes and weight management

What is it?

~ Severe hip dysplasia or osteoarthritis
~ Severe trauma

Signs and symptoms:

~ Severe lameness
~ Non- weight bearing
~ Osteoarthritis is a common side effect of hip dislocation due to the instability in the area – leading to abnormal forces in the hip joint and eventually cartilage damage.

Laxity vs luxation/dislocation vs sub-luxation:

1. Laxity is increased instability/ movement in a joint due to lax of ligament strength
2. Luxation or dislocation is where the joint is forced out of its normal position and there is no contact between the two joint surfaces. It needs to be returned to its normal position by veterinary professionals
3. Sub-luxation is where the joint is partially out of its normal position and it usually returns to its normally position by itself.

Treatments options:

General goals of post-operative and post immobilization physiotherapy?

1. Decrease pain levels
2. Decrease swelling
3. Encourage weight-bearing
4. Prevent and/or detect complications
5. Decrease compensatory muscle pain and tightness
6. Maintain function and range of motion of the hip joint
7. Prevent muscle atrophy and increase muscle mass
8. Provide a structured exercise plan
9. Provide advice regarding home modification, diet changes and weight management

CONSERVATIVE MANAGEMENT AND SURGICAL INTERVENTION

What is hip dysplasia?

• ~ Hip dysplasia is a developmental orthopedic disease, meaning there is an abnormality in the development of the hip joint.
• ~ This leads to an incongruent hip joint and laxity.
• ~ This ultimately leads to pain and development of osteoarthritis.
• ~ Due to the incongruent joint and laxity there is abnormal forces on the hip joint – leading to increase wear and tear – leading to cartilage damage and ultimately the formation of new bone = osteoarthritis.

Causes:

• ~ Genetics
• ~ Environmental
  • Slippery floors and stairs
• Nutrition
  • Excess energy or calcium in diet - causing rapid growth rates
  • Overweight
• Exercise
  • Excessive concussive exercise at a young age
• Trauma

Signs and symptoms:

• ~ Decreased activity level
• ~ Difficulty rising/ jumping onto things
• ~ Lameness/ limping
• ~ Bunny hopping gait with hind limbs
• ~ Pain associated with hip

Treatment options for Conservative Management:

Goals of physiotherapy in the treatment of hip dysplasia conservatively:

1. Decrease pain levels
2. Decrease compensatory muscle pain and tightness
3. Maintain function and range of motion of the hip joint
4. Prevent muscle atrophy and increase muscle mass
5. Provide a structured exercise plan
6. Provide advice regarding home modification, diet changes and weight management

Treatment options for Surgical Intervention:

General Goals of Post-Operative Physiotherapy:

1. Decrease pain levels
2. Decrease swelling
3. Encourage weight-bearing
4. Prevent and/or detect complications
5. Decrease compensatory muscle pain and tightness
6. Maintain function and range of motion of the hip joint
7. Prevent muscle atrophy and increase muscle mass
8. Provide a structured exercise plan
9. Provide advice regarding home modification, diet changes and weight management

TARSUS INJURIES
CONSERVATIVE MANAGEMENT AND SURGICAL INTERVENTION

What is it?

• Tarsal injuries can be divided into sprains, luxations and fractures.

Causes:

• ~ Trauma
• ~ Overuse

Signs and symptoms?

• Depends on the type of injury and the severity thereof
• Lameness or non- weight bearing on the affected limb
• Pain associated with the tarsus/ankle joint

Conservative treatment options:

• ~ Depends on the type of injury and the severity thereof
• ~ Conservative management is usually only indicated for partial/mild tears!

Goals of Physiotherapy in Conservative Management:

1. Strict rest
2. Maintain stifle ROM of the tarsal joint
3. Decrease pain and/or inflammation
4. Decrease compensation
5. Encourage weight bearing
6. Increase muscle mass and strength
7. Prevent complications
8. Provide a structured exercise plan – slow return to function
9. Provide advice regarding home modification, diet changes and weight management

Surgical treatment options:

• ~ Depends on the type of injury and the severity thereof
• ~ Conservative management is usually indicated for severe sprains/tears, luxations and fractures!

Goals of post- operative physiotherapy!

1. Maintain stifle ROM of the tarsal joint as well as the stifle/knee joint and digits/toes
2. Decrease pain and/or inflammation
3. Decrease compensation
4. Encourage weight bearing
5. Increase muscle mass and strength
6. Prevent complications
7. Provide a structured exercise plan – slow return to function
8. Provide advice regarding home modification, diet changes and weight management

What is it?

1. It is commonly seen in working or sporting dogs.
2. Usually associated with overuse and overstrain of the muscle in a lengthened position.
3. Seen in dogs with poor dynamic control and core activation.

Causes:

• ~ Overuse
• ~ Overstrain
• Overload – often secondary to another hind limb pathology
• ~ Poor conditioning for sport

Signs and symptoms:

• ~ Loss of speed and impulsion
• ~ Struggles on turns
• ~ Decreased performance
• ~ Intermitted lameness
• ~ Pain associated with iliopsoas muscle – on palpation and stretch

Treatment options:

Usually responds very well to conservative management.

Goals of Physiotherapy:

1. Maintain iliopsoas muscle length
2. Decrease pain and/or inflammation
3. Prevent re-injury
4. Decrease compensation
5. Increase muscle mass and strength
6. Provide a structured exercise plan – to ensure a slow return to function
7. Provide advice regarding home modification, diet changes and weight management

What is Legg Calves Perthes Disease?

• ~ An avascular necrosis of the femoral head and neck
• ~ This means that the femoral head and neck starts to die due to a disruption in the blood supply

Causes:

• ~ Genetics
• ~ Small breed, young dogs (6-10months)
• ~ The exact cause of the condition is unknown

Signs and symptoms:

• ~ Lameness (gradual onset over two to three months)
• ~ Carrying of affected limb(s)
• ~ Pain when moving hip joint
• ~ Atrophy of hind limb muscles

Treatment options:

• ~ Surgery is indicated – Femoral head and neck osteotomy
• ~ Pain management is important

General Goals of Post-Operative Physiotherapy:

1. Decrease pain levels
2. Decrease swelling
3. Encourage weight-bearing
4. Prevent and/or detect complications
5. Decrease compensatory muscle pain and tightness
6. Maintain function and range of motion of the hip joint
7. Prevent muscle atrophy and increase muscle mass
8. Provide a structured exercise plan
9. Provide advice regarding home modification, diet changes and weight management

What is it?

The meniscus is the connective tissue structure located within the stifle/knee joint that helps to make the stifle joint more congruent and acts as a shock absorber.

Causes:

• ~ Trauma
• ~ Often secondary to cranial cruciate ligament disease

Signs and symptoms:

• ~ Lameness and often non-weight bearing on affected limb
• ~ Audible clicking from stifle/knee
• ~ Very painful

Treatment Options:

• ~ Does not respond to conservative management
• ~ Surgical removal of torn meniscus is usually indicated – often done concurrently with cranial cruciate ligament surgery.

Goals of physiotherapy:

1. Maintain stifle ROM
2. Decrease pain and inflammation
3. Decrease compensation
4. Increase weight bearing post operatively
5. Increase muscle mass and strength
6. Prevent complications
7. Provide a structured exercise plan
8. Provide advice regarding home modification, diet changes and weight management

What is it?

• ~ Is an avulsion fracture of the tibial tuberosity in young dogs
• ~ The tibial tuberosity has a separate growth plate that only fuses to the tibia around 4-5 months of age - his is a potential area of weakness.
• ~ An avulsion fracture means that the ligament/tendon fractures/pulls the tibial tuberosity from the bone.
• ~ This is usually a traction injury – eg. A back leg getting caught in a fence and dog trying to pull it out.

Causes:

• ~ Trauma

Signs and Symptoms:

• ~ Severe lameness
• ~ Non- weight bearing on the affected limb
• ~ Pain, heat and swelling associated with the affected knee/stifle
• ~ Associated with a traumatic event

Treatment Options:

• Surgery is indicated to re-attach the tibial tuberosity.

Goals of post-operative physiotherapy?

1. Decrease pain levels
2. Encourage weight bearing on the affected limb
3. Decrease compensatory muscle pain and tightness
4. Maintain spinal ROM
5. Address hind limb weakness if present
6. Prevent muscle atrophy and increase muscle mass
7. Provide a structured exercise plan
8. Provide advice regarding home modification, diet changes and weight management

What is it?

• ~ The patella (knee cap) is situated in the trochlear groove on the femur.
• ~ In the case of patella luxation – the patella slips out of the groove
• ~ This is often painful
• ~ Medial more common than lateral
• ~ Often bilateral (50%)
• ~ Very rarely traumatic

Laxity vs Sub-Luxation vs Luxation:

1. Laxity is increased instability/ movement in a joint due to lax of ligament strength – the patella moves within the groove, but does not move out of the groove.
2. Sub-luxation is where the joint is partially out of its normal position – the patella partially moves out of the groove and returns by itself
3. Luxation or dislocation is where the joint is forced out of its normal position and there is no contact between the two joint surfaces – the patella moves out of the groove completely

Causes:

• ~ Genetics
• ~ Related to overall conformation on hind limbs
• ~ Medial malalignment of quadriceps muscles – pulls the patella out of the groove
• ~ Weakness or atrophy of the quadriceps muscle
• ~ Shallow trochlea groove
• ~ Malformation of femur (bow-legged)

Signs and symptoms:

• ~ Decreased activity level
• ~ Skipping, intermittent lameness
• ~ Hesitant to jump
• ~ Poor flexion through hind limb joints – very stilted action
• ~ Muscle atrophy
• ~ Reluctant to sit square
• ~ Pain associated with knee joint

Conservative Treatment options:

Conservative management is only be attempted for Grade 1 and 2 luxations.

Goals of conservative physiotherapy management in the treatment of patella luxation?

1. Decrease pain levels
2. Decrease compensatory muscle pain and tightness
3. Maintain function and range of motion of the stifle joint
4. Prevent muscle atrophy and increase muscle mass and strength
5. Provide a structured exercise plan
6. Provide advice regarding home modification, diet changes and weight management

Surgical Treatment options:

Surgery is usually indicated for:
~ Grade 3 and 4 luxations
~ Lateral luxations
~ Some Grade 2 luxations

General goals of post-operative physiotherapy?

1. Decrease pain levels
2. Decrease swelling
3. Encourage weight-bearing
4. Prevent and/or detect complications
5. Decrease compensatory muscle pain and tightness
6. Maintain function and range of motion of the stifle joint
7. Prevent muscle atrophy and increase muscle mass and strength
8. Provide a structured exercise plan
9. Provide advice regarding home modification, diet changes and weight management

What is it?

• ~ Inflammation of the patella tendon
• ~ Often seen post stifle surgery
• ~ Can also be a overuse or over strain injury

Signs and symptoms?

• ~ Lameness
• ~ Swelling or heat on the stifle/knee joint

Treatment options:

• ~ Rest
• ~ Pain medication and NSAID’s
• ~ Physiotherapy and rehabilitation

Goals of physiotherapy?

1. Decrease pain and inflammation
2. Maintain ROM
3. Decrease compensation
4. Increase muscle mass and strength
5. Provide a structured exercise plan
6. Provide advice regarding home modification, diet changes and weight management